hesi maternity 55 questions quizlet HESI Maternity 55 Questions Quizlet - Nursing Elites
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HESI Maternity 55 Questions Quizlet

1. To confirm respiratory distress syndrome (RDS) in a newborn, what should the nurse assess?

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.

2. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?

Correct answer: D

Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.

3. A two-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take is to administer the scheduled dose of digoxin. A heart rate of 128 bpm in a two-year-old child with heart failure falls within the safe range for digoxin administration. It indicates that the child's heart rate is not excessively low, which could be a concern for administering digoxin. Therefore, proceeding with the scheduled dose is appropriate in this scenario. Determining the pulse deficit (Choice A) is not necessary in this situation as the heart rate is already obtained. Calculating the safe dose range (Choice C) is not required as the heart rate is within the safe range. Reviewing the serum digoxin level (Choice D) is not needed at this point since the heart rate indicates that administering the next dose is appropriate.

4. A 4-year-old boy presents with a rash and is diagnosed with varicella (chickenpox). What is the most appropriate intervention to manage this condition?

Correct answer: B

Rationale: The most appropriate intervention for managing varicella (chickenpox) in a 4-year-old child is to apply calamine lotion to soothe itching. Calamine lotion helps alleviate the itching associated with the chickenpox rash, providing relief to the child. It is important to discourage scratching to prevent complications such as scarring or secondary bacterial infections. Encouraging bed rest can be beneficial for comfort but is not the primary intervention to manage chickenpox.

5. The nurse is caring for a postpartum client who is exhibiting symptoms of a spinal headache 24 hours following the delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should the nurse perform?

Correct answer: A

Rationale: In a postpartum client exhibiting symptoms of a spinal headache, applying an abdominal binder is a priority action. The abdominal binder can help reduce the severity of a spinal headache by increasing intra-abdominal pressure, which may relieve pressure on the dural sac and alleviate symptoms. This intervention can be performed promptly by the nurse to provide immediate relief while waiting for further evaluation and management by the anesthesiologist. Cleansing the spinal injection site (Choice B) is not the priority in this situation as the headache is likely due to a dural puncture during epidural anesthesia rather than infection. Inserting an indwelling Foley catheter (Choice C) and placing procedure equipment at the bedside (Choice D) are not the appropriate actions to address a spinal headache and should not take precedence over applying an abdominal binder.

Similar Questions

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