HESI RN
HESI Maternity 55 Questions Quizlet
1. A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm, and tender upon palpation. What action should the LPN/LVN take?
- A. Apply cold compresses to both breasts for comfort.
- B. Instruct the client to run warm water on her breasts.
- C. Wear a loose-fitting bra to prevent nipple irritation.
- D. Express small amounts of milk to relieve pressure.
Correct answer: A
Rationale: After childbirth, engorgement of the breasts can occur, leading to swelling and discomfort. Applying cold compresses helps reduce swelling and provides comfort for engorged breasts. This action can also help with pain relief and promote milk flow regulation. Instructing the client to run warm water on her breasts (Choice B) is incorrect as warm water can increase blood flow and exacerbate swelling. Wearing a loose-fitting bra (Choice C) may provide some comfort, but it does not address the swelling effectively. Expressing small amounts of milk (Choice D) may provide temporary relief but does not address the underlying issue of engorgement.
2. A client has just taken a dose of trimethobenzamide (Tigan). The nurse plans to monitor this client for relief of:
- A. Heartburn
- B. Constipation
- C. Abdominal pain
- D. Nausea and vomiting
Correct answer: D
Rationale: The correct answer is D: Nausea and vomiting. Trimethobenzamide (Tigan) is an antiemetic medication used to treat nausea and vomiting. Therefore, the nurse would monitor the client for relief of nausea and vomiting after taking this medication.
3. A client with hypothyroidism is being treated with levothyroxine. Which of the following symptoms would indicate that the client may be receiving too much medication?
- A. Bradycardia
- B. Weight gain
- C. Tachycardia
- D. Cold intolerance
Correct answer: C
Rationale: Tachycardia is a sign of excessive thyroid hormone replacement. Levothyroxine is used to treat hypothyroidism by supplementing thyroid hormone levels. If a client with hypothyroidism experiences symptoms of tachycardia, it suggests that they may be receiving an excessive amount of levothyroxine, causing hyperthyroidism. Bradycardia (Choice A) is more commonly associated with hypothyroidism, not excessive levothyroxine. Weight gain (Choice B) and cold intolerance (Choice D) are also typical symptoms of hypothyroidism and would not typically indicate overmedication.
4. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?
- A. request transport of the child to his pediatrician's office
- B. call the child's parents and send him home for the day
- C. compare the child's body mass index to normal values
- D. measure the child's pulse and blood pressure every 15 minutes
Correct answer: D
Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.
5. Which of the following is NOT a strategy for family planning?
- A. Integrating family planning services with other Reproductive Health programs
- B. Expanding access to family planning through non-public delivery systems
- C. Targeting family planning services to priority groups
- D. Expanding programs of immunization
Correct answer: D
Rationale: The correct answer is D. Expanded programs of immunization are not considered a strategy for family planning. Immunization programs focus on preventing diseases through vaccines and are distinct from family planning strategies, which aim to help individuals and couples plan their desired family size and spacing of children. Choices A, B, and C are all valid strategies for family planning. Integrating family planning services with other reproductive health programs, expanding access to family planning through non-public delivery systems, and targeting family planning services to priority groups are common approaches to improve the availability and effectiveness of family planning services.