a nurse is assessing a newborn immediately following a vaginal birth for which of the following findings should the nurse intervene
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Maternity HESI Practice Questions

1. A healthcare provider is assessing a newborn immediately following a vaginal birth. For which of the following findings should the provider intervene?

Correct answer: D

Rationale: Sternal retractions in a newborn indicate respiratory distress and require immediate intervention. This finding suggests the newborn is having difficulty breathing and needs prompt attention to ensure adequate oxygenation. Molding, the overlapping of fetal skull bones during birth, is a normal and expected process that does not require intervention. Vernix Caseosa, the protective white substance on the skin, and Acrocyanosis, the bluish discoloration of extremities, are both common and benign findings in newborns that do not necessitate immediate action. Therefore, the healthcare provider should focus on addressing sternal retractions to manage the respiratory distress effectively.

2. Most victims of _____ die of respiratory infections in their 20s.

Correct answer: B

Rationale: Individuals with cystic fibrosis have a genetic disorder that causes mucus to be thick and sticky, leading to blockages in the lungs and digestive system. This mucus buildup makes them more susceptible to severe respiratory infections, which can ultimately result in premature death in their 20s. Tay-Sachs disease (Choice A) is a genetic disorder that affects the nervous system, not typically causing respiratory infections. Turner syndrome (Choice C) and Klinefelter syndrome (Choice D) are chromosomal disorders that do not directly lead to the respiratory issues observed in cystic fibrosis.

3. What additional assessment is required for the postoperative care of a pregnant woman who undergoes abdominal surgery for appendicitis?

Correct answer: D

Rationale: The correct additional assessment for postoperative care of a pregnant woman requiring abdominal surgery for appendicitis is monitoring the fetal heart rate (FHR) and uterine activity. This is crucial due to the presence of the fetus. Continuous fetal and uterine monitoring should be prioritized to ensure the well-being of both the mother and the baby. While assessing I&O levels and the IV site are common postoperative care procedures, they are not specific to the unique needs of a pregnant woman. Evaluating for signs and symptoms of infection is important for any postoperative patient but is not the additional assessment required specifically for a pregnant woman in this scenario. Routine vital signs and incision evaluation are standard components of postoperative care but do not address the specific needs related to the fetus and the uterus in this case.

4. A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?

Correct answer: B

Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.

5. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates?

Correct answer: D

Rationale: 50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.

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