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?
- A. Use a sterile item to tie off the umbilical cord.
- B. Provide privacy for the woman.
- C. Reassure the husband and try to keep him calm.
- D. Put the newborn to breast.
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. The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag
- B. Perform a quick assessment of the client's condition
- C. Call the respiratory therapist for help
- D. Press the alarm reset button on the ventilator
Correct answer: B
Rationale: The correct answer is to perform a quick assessment of the client's condition when the high-pressure alarm goes off on the ventilator. This assessment is crucial to determine the cause of the alarm and the client's current status. Option A is incorrect because disconnecting the client from the ventilator without assessing the situation can be harmful. Option C is incorrect as the nurse should first assess the client before seeking additional help. Option D is incorrect because resetting the alarm without understanding the underlying issue may lead to potential risks to the client.
3. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?
- A. Obtain informed consent from the client for the PRBC transfusion
- B. Review the client’s medical history for a history of transfusion reactions
- C. Assess the client’s baseline vital signs before starting the transfusion
- D. Verify the blood type and crossmatch with another licensed nurse
Correct answer: D
Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.
4. The nurse is preparing to administer digoxin to a patient who is newly admitted to the intensive care unit. The nurse reviews the patient’s admission electrolytes and notes a serum potassium level of 2.9 mEq/L. Which action by the nurse is correct?
- A. Administer the digoxin and monitor the patient’s electrocardiogram closely.
- B. Hold the digoxin dose and notify the provider of the patient’s lab values.
- C. Request an order for an intravenous bolus of potassium.
- D. Request an order for oral potassium supplements.
Correct answer: B
Rationale: In the scenario presented, the patient has a low serum potassium level, which can predispose the patient to digoxin toxicity. It is essential for the nurse to hold the digoxin dose and promptly notify the healthcare provider of the abnormal lab values. Option A is incorrect because administering digoxin without addressing the low potassium level can potentiate toxicity. Option C is inappropriate as potassium should not be given as an IV bolus, especially in the case of hypokalemia. Option D is incorrect because oral potassium supplements may not be sufficient for rapidly correcting severe hypokalemia in an acute care setting.
5. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?
- A. Elevated blood pressure must be anticipated and identified quickly
- B. Frequent monitoring helps ensure the medication is effective
- C. It is standard protocol for all hospitalized children
- D. We need to monitor for any potential kidney damage
Correct answer: A
Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.