HESI RN
HESI Maternity Test Bank
1. A woman who delivered a 9-pound baby via cesarean section under spinal anesthesia is recovering in the post-anesthesia care unit. Her fundus is firm at the umbilicus, and a continuous trickle of bright red blood with no clots is observed by the nurse. Which action should the nurse implement?
- A. Assess her blood pressure.
- B. Apply an ice pack to the perineum.
- C. Allow the infant to breastfeed.
- D. Massage the fundus vigorously.
Correct answer: A
Rationale: In this situation, continuous bleeding despite a firm fundus suggests a possible laceration. The appropriate action for the nurse to take is to assess the woman's blood pressure. This helps determine the severity of blood loss and guides further interventions, such as identifying the need for additional assessments or interventions to control bleeding. Applying an ice pack to the perineum (choice B) would not address the ongoing bleeding issue. Allowing the infant to breastfeed (choice C) may not be safe if there is significant bleeding. Massaging the fundus vigorously (choice D) is contraindicated when there is continuous bleeding as it can worsen the bleeding or cause further harm.
2. During a woman's first prenatal visit, the nurse reviews her health care record, noting a history of chickenpox as a child and syphilis as a teenager. Which action is most important for the nurse to take?
- A. Obtain blood and urine for prenatal screens.
- B. Schedule prenatal visits to occur monthly.
- C. Explain common complications of pregnancy.
- D. Obtain baseline blood pressure and weight.
Correct answer: A
Rationale: Obtaining blood and urine for prenatal screens is crucial in identifying any potential infections or conditions that may require monitoring throughout the pregnancy. Screening for infections such as syphilis is essential to ensure appropriate management and prevent adverse outcomes. This action helps in early detection and timely intervention, promoting the health and well-being of both the mother and the developing fetus. The other options, while important during prenatal care, are not as critical as obtaining prenatal screens to assess for any existing infections that could impact the pregnancy.
3. What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?
- A. Maternal blood pressure.
- B. Level of pain sensation.
- C. Station of presenting part.
- D. Variability of fetal heart rate.
Correct answer: A
Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia. The other options, such as assessing the level of pain sensation, station of presenting part, and variability of fetal heart rate, are important in obstetric care but are not as critical as monitoring maternal blood pressure to prevent complications related to epidural anesthesia administration.
4. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
- A. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on.
- B. Use a nipple shield to help the baby latch on.
- C. Try a different breastfeeding position.
- D. Have another person help the mother with breastfeeding.
Correct answer: A
Rationale: In this scenario, the best intervention is to ask the mother to stop feeding, comfort the infant, and then assist her in helping the baby latch on. Stopping the feeding and providing comfort can reduce the infant's frustration and create a calmer environment for successful breastfeeding. Choice B, using a nipple shield, may not address the underlying issue causing the baby's difficulty latching. Choice C, trying a different breastfeeding position, can be attempted after the baby is calm and ready to latch. Choice D, having another person help, may not be necessary if the mother can be guided effectively on latching techniques.
5. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?
- A. Slowly increasing urinary output over the last week.
- B. Respiratory rate changes from the 40s to the 60s.
- C. Changes in apical heart rate from the 180s to the 140s.
- D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
Correct answer: C
Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99