a nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to 10 which of the following acti
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HESI Maternal Newborn

1. 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.

2. A healthcare professional is caring for a client who is 14 weeks of gestation. At which of the following locations should the healthcare professional place the Doppler device when assessing the fetal heart rate?

Correct answer: A

Rationale: At 14 weeks of gestation, the uterus is still relatively low in the abdomen. Placing the Doppler midline 2 to 3 cm above the symphysis pubis is appropriate for assessing the fetal heart rate. This location allows for better detection of the fetal heart tones as the uterus is at a lower position during this stage of pregnancy. Placing the Doppler on the left upper abdomen would not be ideal at 14 weeks gestation as the uterus is not yet at that level. Placing it two fingerbreadths above the umbilicus or lateral at the xiphoid process would also not be accurate for locating the fetal heart rate at this stage of gestation.

3. What determines a child’s sex?

Correct answer: D

Rationale: The correct answer is the sex chromosome received from the father. The father contributes either an X or Y chromosome, which determines the child's sex. This occurs at the moment of fertilization when the sperm carrying either an X (resulting in a female) or Y (resulting in a male) chromosome fertilizes the egg. Choices A, B, and C are incorrect because the presence of teratogens at the time of conception or ovulation does not determine the child's sex. While the sex chromosome received from the mother is important, it is the father's contribution that ultimately determines the child's sex.

4. Following an amniocentesis, a nurse is caring for a client. The nurse should observe the client for which of the following complications?

Correct answer: D

Rationale: After an amniocentesis, the nurse should monitor the client for potential complications, with hemorrhage being a significant concern due to the invasive nature of the procedure. Hyperemesis (severe vomiting), proteinuria (excessive protein in the urine), and hypoxia (low oxygen levels) are not typically associated with amniocentesis and are less likely to occur compared to hemorrhage, which is a more common complication that requires prompt recognition and intervention.

5. A client experiencing preterm labor is being taught about terbutaline by a nurse. Which statement by the client indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A. Terbutaline is a beta-adrenergic agonist used to stop preterm labor. One of its common side effects is heart palpitations due to its action on beta receptors in the heart. Choices B and C are incorrect because blurred vision and ringing in the ears are not common side effects of terbutaline. Choice D is irrelevant to the side effects of terbutaline.

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