HESI RN
HESI Maternity 55 Questions Quizlet
1. The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?
- A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
- B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
- C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
- D. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection.
Correct answer: B
Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.
2. When a client delivers a viable infant but experiences excessive uncontrolled vaginal bleeding after the IV Pitocin infusion, what information is most important for the nurse to provide when notifying the healthcare provider?
- A. Maternal blood pressure
- B. Estimated blood loss
- C. Length of labor
- D. Amount of IV fluids administered
Correct answer: A
Rationale: In a situation where a client is experiencing excessive uncontrolled vaginal bleeding post-delivery, the most crucial information for the nurse to provide the healthcare provider is the maternal blood pressure. Maternal blood pressure can help assess the severity of the bleeding and guide immediate interventions to stabilize the client's condition. Estimated blood loss, length of labor, and amount of IV fluids administered are important pieces of information but in this scenario, maternal blood pressure takes precedence as it directly indicates the client's current hemodynamic status.
3. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?
- A. Apply cold compresses to both breasts for comfort.
- B. Instruct the client to run warm water on her breasts.
- C. Wear a loose-fitting bra to prevent nipple irritation.
- D. Express small amounts of milk to relieve pressure.
Correct answer: A
Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.
4. Why is complete bedrest necessary for a pregnant client with mitral stenosis Class III?
- A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
- B. We want your baby to be healthy, and this is the only way we can ensure that will happen.
- C. I know you're upset. Would you like to talk about some activities you could do while in bed?
- D. Labor is difficult, and you need to use this time to rest before assuming child-caring duties.
Correct answer: A
Rationale: Complete bedrest is necessary for a pregnant client with mitral stenosis Class III to reduce the workload on the heart, lower oxygen consumption, and prevent complications associated with cardiac conditions like mitral stenosis. By remaining in bed, the client can help maintain cardiac function and promote a safer pregnancy outcome. Choice B is incorrect as it does not provide a specific reason related to the client's medical condition. Choice C is not addressing the medical necessity of bedrest for this particular client. Choice D is irrelevant and does not explain the importance of bedrest for a pregnant client with mitral stenosis Class III.
5. To confirm respiratory distress syndrome (RDS) in a newborn, what should the nurse assess?
- A. Assess diaphragmatic breathing.
- B. Assess heart sounds.
- C. Monitor blood oxygen levels.
- D. Check for signs of infection.
Correct answer: A
Rationale: To confirm respiratory distress syndrome (RDS) in a newborn, the nurse should assess diaphragmatic breathing. In RDS, the baby may have difficulty breathing due to immature lungs, leading to shallow, rapid breathing movements. Assessing diaphragmatic breathing directly evaluates the respiratory effort and can help identify the presence of RDS. Choice B, assessing heart sounds, is not specific to diagnosing RDS but could be relevant for other conditions. Choice C, monitoring blood oxygen levels, is important but alone may not confirm RDS. Choice D, checking for signs of infection, is not a direct indicator of RDS but rather suggests a different issue.
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