a client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit which nursing plan is best in assisting this mother
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Nursing Elites

HESI RN

Maternity HESI Quizlet

1. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

Correct answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

2. At 20 weeks gestation, a client is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

Correct answer: C

Rationale: The primary reason for an ultrasound at 20 weeks gestation is to assess fetal growth, gestational age, and anatomical development. This evaluation helps ensure the fetus is developing appropriately and can detect any potential issues that may require intervention. Choices A, B, and D are incorrect because at 20 weeks, the primary focus of the ultrasound is not to determine the sex of the fetus, detect chromosomal abnormalities, or assess the lecithin-sphingomyelin ratio. While these factors may be evaluated in pregnancy, they are not the primary reasons for an ultrasound at 20 weeks gestation.

3. A client at 32 weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved?

Correct answer: C

Rationale: A decrease in respiratory rate from 24 to 16 indicates that magnesium sulfate is effectively reducing central nervous system irritability, a desired therapeutic effect. This decrease in respiratory rate signifies that the drug has reached a therapeutic level to control symptoms of severe pregnancy-induced hypertension. Choices A, B, and D are incorrect because 4+ reflexes, urinary output, and body temperature are not direct indicators of achieving a therapeutic level of magnesium sulfate for controlling PIH symptoms.

4. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

Correct answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

5. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?

Correct answer: C

Rationale: The primary side effects of terbutaline sulfate are related to its beta-adrenergic effects. Tachycardia and nervousness are common side effects of terbutaline sulfate. Tachycardia is expected due to the drug's beta-agonist properties, while nervousness can result from the stimulation of beta-adrenergic receptors. It is crucial to monitor the client for these side effects to ensure early recognition and appropriate management.

Similar Questions

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The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
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