HESI RN
HESI Maternity 55 Questions Quizlet
1. A 4-year-old boy presents with a rash and is diagnosed with varicella (chickenpox). What is the most appropriate intervention to manage this condition?
- A. Administer oral acyclovir.
- B. Apply calamine lotion to soothe itching.
- C. Encourage scratching to relieve itching.
- D. Encourage bed rest to avoid spreading the rash.
Correct answer: B
Rationale: The most appropriate intervention for managing varicella (chickenpox) in a 4-year-old child is to apply calamine lotion to soothe itching. Calamine lotion helps alleviate the itching associated with the chickenpox rash, providing relief to the child. It is important to discourage scratching to prevent complications such as scarring or secondary bacterial infections. Encouraging bed rest can be beneficial for comfort but is not the primary intervention to manage chickenpox.
2. At 40-weeks gestation, a client presents to the obstetrical floor indicating that the amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. Which information is most important for the nurse to obtain?
- A. Color and consistency of fluid.
- B. Estimated amount of fluid.
- C. Any odor noted when membranes ruptured.
- D. Time the membranes ruptured.
Correct answer: A
Rationale: The color and consistency of the amniotic fluid are crucial to assess for the presence of meconium, which may indicate fetal distress. Meconium-stained amniotic fluid can suggest fetal compromise and the need for further evaluation and monitoring. The estimated amount of fluid is less critical than assessing for meconium. While noting any odor when the membranes ruptured may provide some information, it is not as crucial as assessing for meconium. The time the membranes ruptured is important for documenting the timeline but does not directly impact immediate patient care like assessing for fetal distress.
3. The nurse is caring for a client who experienced fetal demise at 32 weeks' gestation. After the fetus is delivered vaginally, the nurse implements fetal demise protocol and identification procedures. Which action is most important for the nurse to take?
- A. Create a memory box with the baby's footprint and photographs.
- B. Determine if the mother desires a visit from her clergy.
- C. Encourage the mother to hold and spend time with her baby.
- D. Explain the reasons for obtaining consent for an infant autopsy.
Correct answer: C
Rationale: Encouraging the mother to hold and spend time with her baby is crucial after a fetal demise at 32 weeks' gestation. This action can support the mother in the grieving process, facilitate bonding, and provide closure, helping her cope with the loss of the baby. Creating a memory box with the baby's footprint and photographs could be emotionally comforting but not as immediate and impactful as encouraging direct physical contact. While offering a visit from her clergy may provide spiritual support, the immediate need is to address the physical and emotional aspects of the situation. Explaining the reasons for obtaining consent for an infant autopsy is important, but it is secondary to the immediate emotional support needed by the mother.
4. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan?
- A. Keep airway equipment at the bedside.
- B. Allow liberal family visitation.
- C. Monitor blood pressure, pulse, and respirations q4h.
- D. Assess temperature q1h.
Correct answer: A
Rationale: In a client with eclampsia, the priority intervention is to keep airway equipment at the bedside to manage potential convulsions effectively. This proactive measure is essential to ensure rapid response and intervention in case of convulsions, which can occur in clients with eclampsia.
5. Using Nägele's rule, what is the estimated date of delivery for a pregnant client who reports that the first day of her last menstrual period was August 2, 2006?
- A. April 25, 2007.
- B. May 9, 2007.
- C. May 29, 2007.
- D. June 2, 2007.
Correct answer: B
Rationale: Nägele's rule is used to estimate the date of delivery. It involves adding 7 days to the first day of the last menstrual period (August 2), which gives August 9. Then, subtracting 3 months from August 9, we arrive at May 9 of the following year as the estimated date of delivery. This makes choice B, 'May 9, 2007,' the correct answer. Choices A, C, and D are incorrect as they do not follow the correct calculation based on Nägele's rule.
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