HESI RN
HESI Maternity Test Bank
1. A 34-week primigravida woman with preeclampsia is receiving Lactated Ringer’s 500ml with magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the infusion pump?
- A. 75ml/hr
- B. 100ml/hr
- C. 50ml/hr
- D. 25ml/hr
Correct answer: A
Rationale: To calculate the infusion rate, divide the total quantity to be infused (500ml) by the total time (1 hour) which equals 500ml/hr. Since the magnesium sulfate is being given at 3g/hr, and 1g of magnesium sulfate is in 5ml of solution, the rate will be 3g/hr x 5ml/g = 15ml/hr. Therefore, the total infusion rate should be 500ml/hr + 15ml/hr = 515ml/hr. Hence, the nurse should program the infusion pump to deliver 75ml/hr (515ml/hr total - 500ml/hr Lactated Ringer's rate). This choice is correct because it accounts for both the Lactated Ringer's and magnesium sulfate rates. Choice B, 100ml/hr, is incorrect as it does not consider the additional magnesium sulfate infusion rate. Choice C, 50ml/hr, is incorrect because it does not account for the magnesium sulfate infusion. Choice D, 25ml/hr, is incorrect as it is too low and does not consider the magnesium sulfate being infused concurrently.
2. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?
- A. Initiate an intravenous infusion.
- B. Observe the FHR pattern for 30 more minutes.
- C. Schedule a biophysical profile.
- D. Place an acoustic stimulator on the abdomen.
Correct answer: D
Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.
3. During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
- A. Recommend explaining the normal physiological changes during pregnancy.
- B. Notify the healthcare provider of the complaint.
- C. Inform her that this is a normal physiological change.
- D. Prepare to provide education on vaginal health.
Correct answer: C
Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.
4. The nurse is conducting postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy?
- A. Breastfeed exclusively at least every 3 to 4 hours.
- B. Condoms and contraceptive foam or gel.
- C. Rhythm method (natural family planning).
- D. Combined estrogen-progesterone oral contraceptives.
Correct answer: B
Rationale: Condoms and contraceptive foam or gel are safe options for breastfeeding mothers and do not affect milk supply.
5. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
- A. Notify the healthcare provider immediately.
- B. Suction the infant's nares, then the oral cavity.
- C. Check the infant's oxygen saturation rate.
- D. Position the infant on the right side.
Correct answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.
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