a client with no prenatal care arrives at the labor unit screaming the baby is coming the nurse performs a vaginal examination that reveals the cervix
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Nursing Elites

HESI RN

HESI Maternity Test Bank

1. A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?

Correct answer: C

Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus. Choices A, B, and D are important in labor assessment, but in this scenario, the most crucial information needed is the date of the last normal menstrual period to estimate the gestational age.

2. The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

Correct answer: B

Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.

3. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?

Correct answer: A

Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.

4. A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?

Correct answer: C

Rationale: Assessing bilateral lung sounds is crucial in this scenario as it can provide essential information about potential fluid accumulation in the lungs, indicating worsening heart failure. This assessment can guide immediate interventions to prevent further deterioration in the patient's condition.

5. During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct answer: C

Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.

Similar Questions

The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?
What action should be implemented when preparing to measure the fundal height of a pregnant client?
A client addicted to heroin and newly pregnant asks a nurse about ensuring her baby's health while on methadone. What should the nurse advise?
A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?
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?

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