HESI RN
Maternity HESI Quizlet
1. A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?
- A. Support the infant as it emerges.
- B. Review prenatal laboratory results.
- C. Obtain fetal heart tones.
- D. Apply suprapubic pressure.
Correct answer: A
Rationale: When the fetal head is visible at the perineum, the priority is to support the infant's birth to prevent injury. Providing support as the infant emerges helps ensure a safe delivery process and reduces the risk of complications associated with rapid or uncontrolled birth.
2. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
- A. Administer oxygen by face mask.
- B. Notify the healthcare provider of the client's symptoms.
- C. Have the client breathe into her cupped hands.
- D. Check the client's blood pressure and fetal heart rate.
Correct answer: C
Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.
3. An expectant father tells the LPN/LVN he fears that his wife 'is losing her mind.' He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
- A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
- B. Help him understand that his wife is experiencing normal maternal behaviors and bonding with the baby, and reassure him that these actions are positive.
- C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
- D. Let him know that these behaviors are part of normal maternal-fetal bonding which occur once the mother feels fetal movement.
Correct answer: D
Rationale: The father's concerns about his wife's behaviors can be addressed by explaining that behaviors like talking to the baby and responding to fetal movements are part of normal maternal-fetal bonding. These actions indicate that the mother is connecting with the baby and are positive signs of a healthy pregnancy. The nurse should reassure the father that these behaviors are common and beneficial for the mother-baby relationship during pregnancy.
4. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the
- A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
- B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
- C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
- D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
Correct answer: D
Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.
5. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
- A. Use a sterile item to tie off the umbilical cord.
- B. Provide privacy for the woman.
- C. Reassure the husband and try to keep him calm.
- D. Put the newborn to breast.
Correct answer: D
Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.
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