HESI RN
Maternity HESI Quizlet
1. 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.
2. What lines the uterus?
- A. Endometrium.
- B. Myometrium.
- C. Perimetrium.
- D. Glandular tissue.
Correct answer: A
Rationale: The correct answer is A, Endometrium. The endometrium is the inner lining of the uterus where the fertilized egg implants and develops during pregnancy. Myometrium (Choice B) is the middle layer of the uterus consisting of muscle tissue. Perimetrium (Choice C) is the outer layer of the uterus. Glandular tissue (Choice D) is a broad term referring to tissue containing glands, but it does not specifically line the uterus.
3. A client with diabetes mellitus is being educated on the importance of foot care. Which of the following instructions should the nurse include?
- A. Soak your feet daily to maintain cleanliness.
- B. Wear tight-fitting shoes to protect your feet.
- C. Apply lotion between your toes to prevent dryness.
- D. Inspect your feet daily for any cuts or sores.
Correct answer: D
Rationale: The correct answer is to instruct the client to inspect their feet daily for any cuts or sores. This is crucial for individuals with diabetes as they are at a higher risk of developing foot problems. Soaking feet daily can lead to skin breakdown and infections, making choice A incorrect. Tight-fitting shoes can cause pressure points and increase the risk of foot injuries, so choice B is incorrect. Applying lotion between the toes can create a moist environment, increasing the risk of fungal infections, making choice C incorrect.
4. The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.)
- A. Litmus paper.
- B. Fetal scalp electrode.
- C. A sterile glove.
- D. An amniotic hook.
Correct answer: C,D
Rationale: For performing an amniotomy, the nurse should have a sterile glove to maintain asepsis and an amniotic hook to rupture the amniotic sac. Litmus paper is not required for this procedure, and a fetal scalp electrode is used for fetal monitoring, not for an amniotomy.
5. A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
- A. Provide an opportunity for the parents to hold their infant in privacy.
- B. Assist the couple in completing a request for autopsy.
- C. Encourage the couple to seek family counseling within the next few weeks.
- D. Explain the possible causes of fetal demise.
Correct answer: A
Rationale: Allowing the parents to hold their infant in privacy is crucial for facilitating the grieving process after the loss of a stillborn child. This intimate moment can help the parents create memories, bond with their baby, and start the healing process.