HESI RN
Maternity HESI Quizlet
1. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
- A. Turn the client to her left side
- B. Contact the healthcare provider
- C. Assess the fetal heart rate
- D. Check the cervical dilation
Correct answer: C
Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.
2. The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which intervention should the nurse implement first?
- A. Encourage fluid intake to thin secretions.
- B. Administer a mucolytic agent.
- C. Increase humidity in the client's room.
- D. Perform deep suctioning as needed.
Correct answer: C
Rationale: Increasing humidity in the client's room is the first priority in managing thick, tenacious secretions in a client with a tracheostomy to facilitate airway clearance. This intervention helps to moisten secretions, making them easier to clear. Encouraging fluid intake (Choice A) can be beneficial, but increasing humidity should be addressed first. Administering a mucolytic agent (Choice B) and performing deep suctioning (Choice D) are interventions that can be considered after addressing humidity if necessary, but they are not the initial priority.
3. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain a sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw the catheter in a circular motion
Correct answer: A
Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.
4. 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?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The lack of the protein dystrophin in the mother can impact the XXX muscle groups of males.
- D. Spinal cord damage due to birth trauma during a breech vaginal birth weakens the muscles.
Correct answer: A
Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder, meaning the gene mutation causing DMD is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if the X chromosome they inherit from their mother carries the mutated gene, they will develop DMD. Females have two X chromosomes, so they are carriers of the gene but are usually not affected by the disease. Therefore, the nurse should explain to the parents that DMD is an inherited X-linked recessive disorder that primarily affects male children in the family.
5. What is the estimated percentage of deaths due to unsafe abortions from 591 maternal deaths per 100,000 live births?
- A. 0.1
- B. 0.2
- C. 0.3
- D. 0.4
Correct answer: D
Rationale: To calculate the estimated percentage of deaths due to unsafe abortions, you divide the number of deaths due to unsafe abortions by the total number of maternal deaths and then multiply by 100 to get the percentage. In this case, with 591 maternal deaths and 40% estimated to be due to unsafe abortions, the calculation is (591 * 0.4) / 100, which equals 2.36. Therefore, the estimated percentage of deaths due to unsafe abortions from 591 maternal deaths per 100,000 live births is 0.4 or 40%. Choices A, B, and C are incorrect percentages that do not reflect the provided information.