Maternity HESI Quizlet

HESI RN

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. What should the nurse recommend to a woman with mastitis?

A. Apply heat to the affected area.
B. Apply cold compresses to the affected area.
C. Use a breast pump to express milk.
D. Continue breastfeeding as usual.

Correct answer: A

Rationale: The nurse should recommend applying heat to the affected area for a woman with mastitis. Heat can help reduce pain and inflammation associated with mastitis by improving blood flow to the area and promoting healing.

3. 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.

4. 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.

5. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 g/dl and a hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet?

A. Carrots
B. Chicken
C. Yogurt
D. Cheese

Correct answer: B

Rationale: During pregnancy, it is common for women to experience a drop in hemoglobin levels, leading to anemia. Chicken is a good dietary source of iron, which is essential for increasing hemoglobin levels. Iron from animal sources, such as chicken, is more readily absorbed by the body compared to plant-based sources. Therefore, encouraging the client to include chicken in her diet can help improve her hemoglobin levels and combat anemia.