HESI RN
HESI Maternity Test Bank
1. What action should be implemented when preparing to measure the fundal height of a pregnant client?
- A. Have the client empty her bladder.
- B. Request the client lie on her left side.
- C. Perform Leopold's maneuvers first.
- D. Give the client some cold juice to drink.
Correct answer: A
Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.
2. A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which question is most important for the LPN/LVN to ask this client?
- A. Which symptom did you experience first?
- B. Are you consuming large amounts of salty foods?
- C. Have you traveled to a foreign country recently?
- D. Do you have a history of rheumatic fever?
Correct answer: D
Rationale: The correct answer is D. Rheumatic fever can lead to rheumatic heart disease, which may be exacerbated during pregnancy, causing symptoms like pedal edema and dyspnea. Asking about a history of rheumatic fever is crucial in this case to assess the potential impact on the client's current symptoms. Choices A, B, and C are less relevant in this scenario as they do not directly relate to the presenting symptoms and history of rheumatic fever.
3. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?
- A. Bathe the infant with an antimicrobial soap.
- B. Measure the head and chest circumference.
- C. Obtain the infant's footprints.
- D. Administer vitamin K (AquaMEPHYTON).
Correct answer: A
Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.
4. 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.
5. A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion?
- A. 3+ deep tendon reflexes and hyperreflexia.
- B. Periorbital edema, flashing lights, and aura.
- C. Epigastric pain in the third trimester.
- D. Recent decreased urinary output.
Correct answer: A
Rationale: In a client with preeclampsia, 3+ deep tendon reflexes and hyperreflexia are indicative of severe preeclampsia. These neurological signs suggest an increased risk for seizures, making option A the most indicative of an impending convulsion. Choices B, C, and D are not directly associated with an impending convulsion in a client with preeclampsia.
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