HESI RN
Maternity HESI Quizlet
1. A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:
- A. Prevent eye infection.
- B. Dilate the pupil so the red reflex can be visualized.
- C. Clear the infant's vision.
- D. Prevent herpes infection.
Correct answer: A
Rationale: The correct answer is A: Prevent eye infection. Eye ointment, usually containing erythromycin, is applied to prevent neonatal conjunctivitis, which can be caused by bacteria present in the birth canal. It is not used to dilate the pupil, clear the infant's vision, or prevent herpes infection.
2. The client with DM is being instructed by the nurse about the importance of controlling blood glucose levels. The nurse should emphasize that uncontrolled blood glucose can lead to:
- A. Increased risk of heart disease and stroke.
- B. Improved wound healing.
- C. Reduced need for medication.
- D. Decreased risk of infection.
Correct answer: A
Rationale: The correct answer is A: Increased risk of heart disease and stroke. Uncontrolled blood glucose levels in clients with diabetes mellitus (DM) can lead to cardiovascular complications, such as heart disease and stroke. High blood glucose levels can damage blood vessels over time, increasing the risk of atherosclerosis and cardiovascular events. Choices B, C, and D are incorrect because uncontrolled blood glucose levels do not improve wound healing, reduce the need for medication, or decrease the risk of infection. In fact, uncontrolled blood glucose levels can impair wound healing, require more medications to manage symptoms, and increase the risk of infections due to compromised immune function.
3. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?
- A. Use a mechanical lift to transfer the client from the bed to a chair.
- B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
- C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
- D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.
Correct answer: D
Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.
4. A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?
- A. Support the infant as it emerges.
- B. Review prenatal laboratory results.
- C. Obtain fetal heart tones.
- D. Apply suprapubic pressure.
Correct answer: A
Rationale: When the fetal head is visible at the perineum, the priority is to support the infant's birth to prevent injury. Providing support as the infant emerges helps ensure a safe delivery process and reduces the risk of complications associated with rapid or uncontrolled birth.
5. After a lumbar puncture, a client reports a severe headache. What is the nurse's priority intervention?
- A. Administer a dose of acetaminophen.
- B. Elevate the head of the bed.
- C. Encourage the client to rest in a dark room.
- D. Administer caffeine to relieve the headache.
Correct answer: B
Rationale: After a lumbar puncture, a severe headache is often caused by cerebrospinal fluid leakage. Elevating the head of the bed or having the client lie flat can reduce cerebrospinal fluid pressure and alleviate the headache. These positions help prevent further fluid loss and relieve discomfort. While acetaminophen or caffeine may help in relieving the headache, changing the client's position is the priority to address the underlying cause. Resting in a dark room may be beneficial for headache relief but is not the priority intervention compared to adjusting the position to manage cerebrospinal fluid pressure.