an off duty lpnlvn finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife which i
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Nursing Elites

HESI RN

Maternity HESI Quizlet

1. An off-duty healthcare professional finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority?

Correct answer: D

Rationale: Putting the newborn to breast is the highest priority intervention in this scenario. It helps stimulate uterine contractions in the mother, which aids in controlling postpartum bleeding. Additionally, placing the newborn to breast promotes bonding between the mother and infant, provides comfort to the baby, and facilitates the initiation of breastfeeding. Ensuring the well-being of both the mother and the newborn is essential in this critical situation.

2. When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

Correct answer: A

Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.

3. A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?

Correct answer: D

Rationale: The correct action to take in this situation is to schedule a test for Lyme disease if a rash appears. Lyme disease can be transmitted through tick bites, and a rash is a common early symptom of the disease. Testing for Lyme disease is crucial for timely diagnosis and treatment to prevent complications. Referring the mother to the Centers for Disease Control and Prevention (Choice A) is not necessary at this point, as immediate testing for Lyme disease is more appropriate. Reporting the incident to the school principal (Choice B) is not the most direct action to address the potential health concern. Culturing the bite site when the child returns to school (Choice C) may not be as effective as scheduling a test for Lyme disease if a rash appears, as the latter is a more specific diagnostic measure for Lyme disease.

4. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

5. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?

Correct answer: A

Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.

Similar Questions

The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?
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?
A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?
A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
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?

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