a client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart while the client is in the bathroom
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HESI Maternity 55 Questions

1. A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What should the nurse do first?

Correct answer: B

Rationale: Inspecting the client's perineum immediately is necessary to assess if the baby is being delivered, which would require urgent action. Pushing the call light for help (Choice A) may delay the assessment and immediate action needed. Notifying a healthcare provider (Choice C) might cause further delays, as the situation requires urgent attention. Turning on the infant warmer (Choice D) is not the priority; ensuring safe delivery and assessment of the baby's condition come first.

2. A client has active genital herpes simplex virus type 2. Which of the following medications should the nurse plan to administer?

Correct answer: C

Rationale: Acyclovir is the antiviral medication specifically used to treat herpes simplex virus infections, including genital herpes caused by herpes simplex virus type 2. Metronidazole (Choice A) is an antibiotic used for different types of infections, but not for viral infections like herpes. Penicillin (Choice B) is an antibiotic effective against bacterial infections, not viruses like herpes. Gentamicin (Choice D) is an antibiotic mainly used to treat bacterial infections, not viral infections like herpes.

3. A client at 26 weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Correct answer: B

Rationale: An elevated AFP level during pregnancy can indicate potential fetal anomalies. Further evaluation is necessary to confirm the findings and assess the need for additional interventions. Scheduling a sonogram is the appropriate next step as it can provide more definitive results and help identify any underlying issues. Choice A is incorrect because dismissing the elevated AFP level as a false reading without further investigation can lead to missing important information about the baby's health. Choice C is not the best immediate action, as scheduling a sonogram would provide more detailed information than just repeating the AFP test. Choice D is incorrect as discussing intrauterine surgical correction is premature at this stage and not typically indicated based solely on an elevated AFP level.

4. A newborn is being assessed following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of the birth method?

Correct answer: C

Rationale: Facial palsy is a known complication of forceps-assisted birth. During forceps delivery, pressure applied to the facial nerve can result in facial palsy. The newborn may present with weakness or paralysis of the facial muscles on one side. Hypoglycemia (Choice A) is not directly related to forceps-assisted birth. Polycythemia (Choice B) is a condition characterized by an increased number of red blood cells and is not typically associated with forceps delivery. Bronchopulmonary dysplasia (Choice D) is a lung condition that primarily affects premature infants who require mechanical ventilation and prolonged oxygen therapy, not a direct outcome of forceps-assisted birth.

5. The nurse is planning discharge teaching for four mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

Correct answer: A

Rationale: A primiparous woman who has recently migrated to the US with her spouse is at the highest risk for psychological difficulties during the postpartum period. Recent migration and adjustment to a new environment can increase the risk of postpartum depression, especially when combined with the challenges of being a new mother. Choice B, a multiparous client living with her husband and his family, may have social support from family members, which can be protective against psychological difficulties. Choice C, a multiparous female with a large family living in a community, also indicates potential social support. Choice D, a primiparous adolescent living at home with her parents and significant other, may have a support system in place with her family and significant other.

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