Maternity HESI 2023 Quizlet

HESI RN

Maternity HESI 2023 Quizlet

1. 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.

2. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

A. Graph the daily weight for the past week.
B. Decrease IV flow rate.
C. Assess bilateral lung sounds.
D. Restrict intake of oral fluids.

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

3. After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?

A. The new formula is a coconut milk formula used with babies with impaired fat absorption.
B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea.
C. The new formula is a casein protein source that is low in phenylalanine.
D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

Correct answer: D

Rationale: The LPN/LVN should inform the mother that Similac® Soy Isomil® Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.

4. 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.

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.