HESI RN
Maternity HESI 2023 Quizlet
1. While preparing a 10-year-old with a lacerated forehead for suturing, the nurse notices both parents and a 12-year-old sibling at the child’s bedside. Which instruction best supports the family's involvement?
- A. While waiting for the healthcare provider, only one visitor may stay with the child.
- B. All of you should leave while the healthcare provider sutures the child’s forehead.
- C. It is best if the sibling goes to the waiting room until the suturing is completed.
- D. Please decide who will stay when the healthcare provider begins suturing.
Correct answer: D
Rationale: Involving the family by letting them decide who will stay during the suturing process promotes family engagement and comfort, ensuring the presence of a familiar person for the child during the procedure.
2. A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?
- A. Turn off the oxytocin infusion.
- B. Reposition the fetal monitor transducers.
- C. Decrease the rate of the oxytocin infusion.
- D. Alert the charge nurse about the patient's condition.
Correct answer: A
Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.
3. A 28-year-old client in active labor complains of cramps in her leg. What intervention should be implemented?
- A. Massage the calf and foot.
- B. Extend the leg and dorsiflex the foot.
- C. Lower the leg off the side of the bed.
- D. Elevate the leg above the heart.
Correct answer: B
Rationale: During active labor, if a client complains of leg cramps, extending the leg and dorsiflexing the foot can help relieve the muscle cramps by stretching the affected muscles. This intervention promotes circulation and can alleviate discomfort associated with leg cramps.
4. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.
5. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first?
- A. Alert the neonatal team and prepare for neonatal resuscitation
- B. Notify the healthcare provider from the client’s bedside
- C. Obtain written consent for an emergency cesarean section
- D. Draw a blood sample for stat hemoglobin and hematocrit
Correct answer: B
Rationale: In this scenario, the priority action for the nurse is to notify the healthcare provider from the client's bedside. The clinical presentation of severe abdominal pain, bright red vaginal bleeding, rigid and tender abdomen, along with fetal bradycardia (FHR 90 bpm) and maternal tachycardia (120 bpm) indicates an urgent need for medical intervention. Notifying the healthcare provider promptly allows for immediate assessment and decision-making to address the critical condition and ensure timely and appropriate management for both the mother and fetus.
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