Maternity HESI Quizlet

HESI RN

1. 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.

2. During an examination for possible cryptorchidism in an infant, what technique should be used?

A. Place the infant in a warm room and use a calm approach.
B. Hold the scrotum and palpate gently.
C. Cleanse the penis with an antiseptic-soaked pad.
D. Position the infant in a warm room to prevent muscle contraction.

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

3. 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.

4. During the admission procedure of a 6-year-old, the child states, 'I’m going to have an operation.' Which response is best for the nurse to provide to this child?

A. Are you scared?
B. We’re going to do everything we can to take very good care of you.
C. Tell me what an operation is.
D. I’m glad your mother told you why you were coming to the hospital.

Correct answer: B

Rationale: In this situation, the most appropriate response for the nurse is to provide reassurance and express care to alleviate the child's anxiety about the upcoming operation. By reassuring the child that everything will be done to take very good care of them, the nurse helps build trust and comfort, creating a positive and supportive environment for the child.

5. 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.

Similar Questions

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?

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A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?

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