a young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family how should the nurse interven
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Nursing Elites

HESI RN

Maternity HESI Quizlet

1. A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?

Correct answer: A

Rationale: Post-liver transplant pregnancy is high-risk due to potential complications associated with immunosuppressive therapy and the transplanted organ's health. Providing information about the risks involved allows the client to make an informed decision regarding family planning.

2. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?

Correct answer: D

Rationale: The correct answer is D: Reduction of edema. Albumin helps reduce edema by increasing oncotic pressure, drawing fluid back into the blood vessels. In nephrotic syndrome, there is an abnormal loss of protein in the urine, leading to decreased oncotic pressure and fluid shifting into the interstitial spaces, causing edema. Administering albumin helps restore the oncotic pressure, reducing edema, which is a desirable effect of the medication.

3. The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant’s care?

Correct answer: C

Rationale: A high respiratory rate in a newborn is concerning as it may indicate respiratory distress, which requires immediate attention to ensure adequate oxygenation. Monitoring and addressing respiratory issues take precedence over other parameters in the initial assessment of a newborn. The blood pressure, heart murmur, and blood glucose levels are important but not as urgent as addressing potential respiratory distress in a newborn.

4. A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?

Correct answer: B

Rationale: The correct answer is B. Adequate voiding is a sign that the baby is receiving enough milk. Pale straw-colored urine 6 to 10 times a day indicates proper hydration and nutrition. This is a reliable indicator of adequate breast milk intake for the infant. Choice A is incorrect because weight gain alone may not always indicate sufficient milk intake. Choice C is incorrect because supplementing with bottle milk can interfere with establishing breastfeeding. Choice D is incorrect as it suggests switching to bottle feeding, which is not necessary if the baby is latching and voiding well.

5. What action should be implemented when preparing to measure the fundal height of a pregnant client?

Correct answer: A

Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.

Similar Questions

A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?
A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?
A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?
The client is 24 weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

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