HESI RN
Maternity HESI 2023 Quizlet
1. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?
- A. Weak cry without tears.
- B. Bulging fontanel.
- C. Visible peristaltic wave.
- D. Palpable mass in the right upper quadrant.
Correct answer: A
Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.
2. A pregnant woman in her first trimester is experiencing watery vaginal discharge. What should the nurse tell her?
- A. Inform her that it is normal.
- B. Advise her to see a doctor immediately.
- C. Suggest using panty liners.
- D. Suggest a change in diet.
Correct answer: A
Rationale: Informing the pregnant woman that watery vaginal discharge is normal during the first trimester is crucial to providing reassurance and reducing anxiety. This discharge, known as leukorrhea, is common during pregnancy due to increased estrogen levels and increased blood flow to the pelvic area. It helps maintain a healthy balance of bacteria in the vagina and protects the birth canal from infection. Advising the woman to see a doctor immediately may cause unnecessary alarm, while suggesting the use of panty liners can help manage the discharge comfortably. Suggesting a change in diet is not relevant to addressing watery vaginal discharge in this scenario.
3. A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
- A. Provide an opportunity for the parents to hold their infant in privacy.
- B. Assist the couple in completing a request for autopsy.
- C. Encourage the couple to seek family counseling within the next few weeks.
- D. Explain the possible causes of fetal demise.
Correct answer: A
Rationale: Allowing the parents to hold their infant in privacy is crucial for facilitating the grieving process after the loss of a stillborn child. This intimate moment can help the parents create memories, bond with their baby, and start the healing process.
4. A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?
- A. Obtain the healthcare provider’s advice as to when the restraints should be removed.
- B. Remove restraints one at a time to provide range of motion exercises.
- C. Record observation of the restraints q2h and ensure that they are in place at all times.
- D. Remove restraints q4h for 30 minutes and place gloves on the child’s hands.
Correct answer: B
Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.
5. 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.
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