a multiparous client at 36 hours postpartum reports increased bleeding and cramping on examination the nurse finds the uterine fundus 2 centimeters ab
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HESI LPN

HESI Focus on Maternity Exam

1. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

Correct answer: C

Rationale: Encouraging the client to void is the priority action in this scenario. A distended bladder can prevent the uterus from contracting properly, leading to increased bleeding and a high uterine fundus. By encouraging the client to void, the nurse can help the uterus contract effectively, reducing bleeding. Increasing intravenous fluids or administering ibuprofen would not address the immediate concern of a distended bladder affecting uterine contraction. While it may be necessary to involve the healthcare provider, addressing the bladder distention promptly is crucial to prevent further complications.

2. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?

Correct answer: A

Rationale: During the first stage of labor, effective uterine contractions lead to cervical dilation. Dilation of the cervix is a key indicator that uterine contractions are progressing labor. Descent of the fetus to -2 station (Choice B) is related to the fetal position in the pelvis and not a direct indicator of uterine contraction effectiveness. Rupture of the amniotic membranes (Choice C) signifies the rupture of the fluid-filled sac surrounding the fetus and does not directly reflect uterine contraction effectiveness. An increase in bloody show (Choice D) can be a sign of impending labor, but it is not a direct indicator of uterine contraction effectiveness.

3. A client is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM every 12 hours. The available concentration is dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)

Correct answer: A

Rationale: Calculation: (6 mg/dose) / (10 mg/mL) = 0.6 mL per dose. The correct answer is 0.6 mL. This calculation is obtained by dividing the dose needed (6 mg) by the concentration available (10 mg/mL). The resulting value is 0.6 mL per dose. Choices B, C, and D are not applicable as the correct answer has been calculated accurately.

4. A client is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Ensuring the newborn's mouth is wide open before latching is crucial for achieving a proper latch, which can help reduce nipple soreness. Placing a snug dressing on the nipple when not breastfeeding (choice A) can lead to further irritation and hinder healing. Encouraging the client to limit the newborn’s feeding to 10 minutes on each breast (choice C) may not be adequate for effective feeding as infants should feed until they are satisfied. Instructing the client to begin feeding with the most tender nipple (choice D) can worsen the soreness as it may not allow the baby to feed effectively.

5. Which of the following is a sexually transmitted infection that, in advanced stages, can attack major organ systems?

Correct answer: B

Rationale: Syphilis is the correct answer. Syphilis is a sexually transmitted infection caused by the bacterium Treponema pallidum. If left untreated, it can progress through various stages and potentially attack major organ systems, causing severe complications. Rubella, Cystic fibrosis, and Phenylketonuria are not sexually transmitted infections. Rubella is a viral infection, Cystic fibrosis is a genetic disorder affecting the lungs and digestive system, and Phenylketonuria is a genetic metabolic disorder. These conditions do not typically affect major organ systems in the same way as untreated syphilis.

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