HESI RN
Maternity HESI Quizlet
1. While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a 'V' shaped appearance. What action should the nurse take first?
- A. Change the maternal position.
- B. Administer oxygen at 10 L by mask.
- C. Prepare for a potential cesarean.
- D. Allow the client to begin pushing.
Correct answer: A
Rationale: In cases of fetal heart rate patterns showing abrupt falls and rises with a 'V' shaped appearance, it indicates possible cord compression. Changing the maternal position, such as moving the mother onto her side, can relieve the pressure off the cord and help improve fetal oxygenation, making it the priority intervention to address the decelerations.
2. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?
- A. Body temperature.
- B. Level of pain.
- C. Time of first void.
- D. Number of vessels in the cord.
Correct answer: D
Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.
3. The LPN/LVN should explain to a 30-year-old gravida client that alpha fetoprotein testing is recommended for which purpose?
- A. Detect cardiovascular disorders.
- B. Screen for neural tube defects.
- C. Monitor placental functioning.
- D. Assess for maternal pre-eclampsia.
Correct answer: B
Rationale: The correct answer is B: Screen for neural tube defects. Alpha fetoprotein testing is primarily used to screen for neural tube defects and other fetal abnormalities. It is not used to detect cardiovascular disorders, monitor placental functioning, or assess for maternal pre-eclampsia.
4. 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.
5. Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Unilateral lower leg pain.
- B. Saturating two perineal pads per hour.
- C. Pulse rate of 56 bpm.
- D. Soft, spongy fundus.
Correct answer: C
Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.
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