Maternity HESI 2023 Quizlet

HESI RN

Maternity HESI 2023 Quizlet

1. 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.

2. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

A. Notify the healthcare provider of the assessment findings.
B. Administer analgesics as prescribed.
C. Increase the client’s fluid intake.
D. Monitor the client’s vital signs every hour.

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

3. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?

A. Jaundice.
B. Poor feeding.
C. Brain injury.
D. Hypoglycemia.

Correct answer: A

Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.

4. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

A. Urinary output and fluid intake.
B. Hemoglobin and hematocrit.
C. Abdominal contour and bowel sounds.
D. Heart rate and blood pressure.

Correct answer: D

Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.

5. When assessing a child with HIV, which system should the nurse assess first?

A. Assess the respiratory system.
B. Assess the gastrointestinal system.
C. Assess the cardiovascular system.
D. Assess the neurological system.

Correct answer: A

Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.