HESI RN
Maternity HESI 2023 Quizlet
1. A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema.
- B. Ascertain the frequency of headaches.
- C. Evaluate for a history of cluster headaches.
- D. Observe and time the client's contractions.
Correct answer: A
Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.
2. In caring for a 4-year-old boy recently diagnosed with Duchenne muscular dystrophy (DMD), which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
- A. Lower legs become progressively weaker, causing a waddling, unsteady gait.
- B. Growth and development have been abnormal since birth.
- C. Muscular strength can be regained with physical exercise and therapy.
- D. Respiratory dysfunction and aspiration are prime concerns at this stage of the disease.
Correct answer: A
Rationale: In Duchenne muscular dystrophy, a key characteristic is the progressive weakness in the lower legs, leading to a waddling, unsteady gait. The nurse should focus on teaching about this aspect as it helps in understanding the disease's progression and managing the symptoms effectively.
3. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant’s head-to-heel length
- B. Observe the infant for sunsetting eyes
- C. Palpate the anterior fontanel for tension and bulging
- D. Plot the measurement on the infant’s growth chart
Correct answer: C
Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.
4. 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.
5. What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?
- A. Inform and assure the mother that this is normal weight loss.
- B. Encourage the mother to increase the frequency of breastfeeding.
- C. After verifying the accuracy of weight, notify the healthcare provider.
- D. Monitor the stool and urine output of the neonate for the last 24 hours.
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.
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