HESI RN
HESI Maternity 55 Questions Quizlet
1. The healthcare provider receives a newborn within the first minutes after vaginal delivery and intervenes to establish adequate respirations. What priority issue should the healthcare provider address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct answer: A
Rationale: Corrected Rationale: Immediately after birth, newborns are at high risk for heat loss, which can lead to cold stress and associated complications. Maintaining thermal regulation is crucial to prevent hypothermia and ensure the newborn's survival. By addressing heat loss as a priority issue, the healthcare provider can help stabilize the newborn's temperature and support overall well-being. Choices B, C, and D are not the priority issues immediately after birth. While fluid balance, bleeding tendencies, and hypoglycemia are important considerations in newborn care, heat loss is the primary concern right after delivery to prevent complications related to thermal regulation.
2. A postpartum client who is Rh-negative refuses to receive RhoGAM after the delivery of an infant who is Rh-positive. Which information should the nurse provide this client?
- A. RhoGAM prevents maternal antibody formation for future Rh-positive babies.
- B. RhoGAM is not necessary unless all of her pregnancies are Rh-positive.
- C. The Rh-positive factor from the fetus threatens her blood cells.
- D. The mother should receive RhoGAM when the baby is Rh-negative.
Correct answer: A
Rationale: The correct answer is A. RhoGAM is administered to Rh-negative individuals after exposure to Rh-positive blood to prevent the development of antibodies that could harm future Rh-positive babies during subsequent pregnancies. By refusing RhoGAM after the delivery of an Rh-positive infant, the mother risks developing these antibodies, which could lead to hemolytic disease in future pregnancies with Rh-positive babies. Therefore, it is crucial for the nurse to explain to the client that receiving RhoGAM prevents the formation of maternal antibodies against Rh-positive blood, safeguarding the health of future babies. Choices B, C, and D are incorrect. Choice B is incorrect because RhoGAM is necessary after exposure to Rh-positive blood, regardless of the Rh status of future pregnancies. Choice C is incorrect as it does not accurately convey the purpose of RhoGAM administration. Choice D is incorrect because RhoGAM is specifically given after exposure to Rh-positive blood, not when the baby is Rh-negative.
3. The LPN/LVN assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement?
- A. Insert an internal fetal monitor.
- B. Assess for cervical changes q1h.
- C. Monitor bleeding from IV sites.
- D. Perform Leopold's maneuvers.
Correct answer: C
Rationale: Monitoring for bleeding from IV sites is the priority intervention in this situation. The dark red vaginal bleeding, uterine tension, and other assessment findings suggest a potential placental abruption. Monitoring bleeding from IV sites can help detect coagulopathy, which may be associated with placental abruption. Options A, B, and D are not the most appropriate interventions in this scenario. Inserting an internal fetal monitor, assessing for cervical changes, and performing Leopold's maneuvers are not the priority actions when dark red vaginal bleeding and uterine tension are present, indicating a potential emergency situation.
4. The nurse is caring for a client who experienced fetal demise at 32 weeks' gestation. After the fetus is delivered vaginally, the nurse implements fetal demise protocol and identification procedures. Which action is most important for the nurse to take?
- A. Create a memory box with the baby's footprint and photographs.
- B. Determine if the mother desires a visit from her clergy.
- C. Encourage the mother to hold and spend time with her baby.
- D. Explain the reasons for obtaining consent for an infant autopsy.
Correct answer: C
Rationale: Encouraging the mother to hold and spend time with her baby is crucial after a fetal demise at 32 weeks' gestation. This action can support the mother in the grieving process, facilitate bonding, and provide closure, helping her cope with the loss of the baby. Creating a memory box with the baby's footprint and photographs could be emotionally comforting but not as immediate and impactful as encouraging direct physical contact. While offering a visit from her clergy may provide spiritual support, the immediate need is to address the physical and emotional aspects of the situation. Explaining the reasons for obtaining consent for an infant autopsy is important, but it is secondary to the immediate emotional support needed by the mother.
5. What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?
- A. Administer prescribed IV solution.
- B. Give oral rehydration solution.
- C. Encourage small, frequent meals.
- D. Offer ginger tea to reduce nausea.
Correct answer: A
Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.
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