Maternity HESI Quizlet

HESI RN

1. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?

A. Allow the child to eat any food desired and tolerated.
B. Provide small, frequent meals that are high in protein and calories.
C. Offer the child preferred foods and avoid foods that are not well-tolerated.
D. Consult with a dietitian to provide appropriate nutritional support.

Correct answer: B

Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.

2. During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

A. Observe the urethral opening on the surface of the penis when the newborn voids.
B. Perform transillumination of the scrotal sac to visualize shadows of the testes.
C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis.
D. Measure the size of the scrotal sac for length and width.

Correct answer: C

Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.

3. A 38-week primigravida who works at a desk job and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities?

A. Wear support stockings.
B. Reduce salt in her diet.
C. Move about every hour.
D. Avoid constrictive clothing.

Correct answer: C

Rationale: During pregnancy, especially in the third trimester, it is common for women to experience swelling due to decreased circulation. Encouraging the patient to move about every hour helps prevent blood pooling in the lower extremities by promoting circulation. This simple activity can help alleviate swelling and discomfort associated with prolonged sitting.

4. In which chromosome pattern is Duchenne disease inherited?

A. Autosomal dominant
B. Autosomal recessive
C. X-linked recessive
D. Mitochondrial

Correct answer: C

Rationale: Duchenne disease is caused by a mutation in the DMD gene located on the X chromosome, leading to an X-linked recessive inheritance pattern. Males are typically affected by this disorder as they have only one X chromosome, while females are carriers with one normal and one affected X chromosome.

5. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?

A. Turn the client to her left side
B. Contact the healthcare provider
C. Assess the fetal heart rate
D. Check the cervical dilation

Correct answer: C

Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.