HESI RN
Maternity HESI 2023 Quizlet
1. A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.
2. After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?
- A. Check the differential, as the WBC count can be normal for this client.
- B. Assess the client's temperature, pulse, and respirations every 4 hours.
- C. Notify the healthcare provider, as this finding may indicate infection.
- D. Assess the client's perineal area for signs of a perineal hematoma.
Correct answer: A
Rationale: In postpartum clients, a white blood cell count of 15,000/mm3 can be within normal limits due to physiological changes that occur after childbirth. Checking the differential count would provide a more detailed analysis of the specific types of white blood cells present, helping to differentiate between normal postpartum changes and potential infection. This action allows the nurse to gather more information before escalating the situation to the healthcare provider or initiating other assessments. Assessing vital signs and the perineal area are important aspects of postpartum care but may not be the priority in this scenario where the white blood cell count can be influenced by normal physiological changes.
3. The nurse is caring for a client who experienced fetal demise at 32 weeks' gestation. After the fetus is delivered vaginally, the nurse implements fetal demise protocol and identification procedures. Which action is most important for the nurse to take?
- A. Create a memory box with the baby's footprint and photographs.
- B. Determine if the mother desires a visit from her clergy.
- C. Encourage the mother to hold and spend time with her baby.
- D. Explain the reasons for obtaining consent for an infant autopsy.
Correct answer: C
Rationale: Encouraging the mother to hold and spend time with her baby is crucial after a fetal demise at 32 weeks' gestation. This action can support the mother in the grieving process, facilitate bonding, and provide closure, helping her cope with the loss of the baby. Creating a memory box with the baby's footprint and photographs could be emotionally comforting but not as immediate and impactful as encouraging direct physical contact. While offering a visit from her clergy may provide spiritual support, the immediate need is to address the physical and emotional aspects of the situation. Explaining the reasons for obtaining consent for an infant autopsy is important, but it is secondary to the immediate emotional support needed by the mother.
4. A child with glomerulonephritis is asking for strawberries. What should the nurse do?
- A. Allow the child to eat strawberries.
- B. Restrict the child's diet.
- C. Give the child a low-protein diet.
- D. Increase the child's fluid intake.
Correct answer: B
Rationale: In glomerulonephritis, it is crucial to restrict the child's diet, particularly avoiding foods high in potassium like strawberries. Potassium restriction is essential because impaired kidney function in glomerulonephritis can lead to potassium retention, potentially causing hyperkalemia. Therefore, the nurse should restrict the child's diet to manage their condition effectively.
5. The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take?
- A. Administer oxygen by face mask.
- B. Notify the healthcare provider of the client's symptoms.
- C. Have the client breathe into her cupped hands.
- D. Check the client's blood pressure and fetal heart rate.
Correct answer: C
Rationale: Tingling fingers and dizziness are symptoms of hyperventilation, which can occur with accelerated-blow breathing. Instructing the client to breathe into her cupped hands can help rebreathe exhaled carbon dioxide, which can alleviate the symptoms by restoring the proper balance of oxygen and carbon dioxide in the blood. This intervention can be effective in managing the client's hyperventilation without the need for additional medical interventions at this point.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access