an unlicensed assistive personnel uap reports to the charge nurse that a client who delivered a 7 pound infant 12 hours ago is reporting severe headac
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Nursing Elites

HESI RN

Maternity HESI 2023 Quizlet

1. An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound infant 12 hours ago is reporting a severe headache. The client’s blood pressure is 110/70 mmHg, respiratory rate is 18 breaths/min, heart rate is 74 beats/min, and temperature is 98.6°F (37°C). What action should the charge nurse implement first?

Correct answer: A

Rationale: A severe headache post-delivery could indicate a serious condition such as preeclampsia or a spinal headache, which requires immediate medical attention. Notifying the healthcare provider of the assessment findings allows for prompt evaluation and appropriate management of the client's condition.

2. Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the healthcare provider take?

Correct answer: C

Rationale: Placing the woman in a lateral position is the appropriate action to improve venous return and cardiac output, helping to stabilize the blood pressure. This position can alleviate pressure on the inferior vena cava, reducing the risk of hypotension associated with epidural anesthesia. Turning off the continuous epidural would not be the initial action as it may not be necessary and could lead to inadequate pain relief for the client. Notifying the healthcare provider or anesthesiologist immediately is premature and should be done after attempting non-invasive interventions. Continuing to assess the blood pressure every 5 minutes is important, but placing the woman in a lateral position should be the first intervention to address the hypotension.

3. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the

Correct answer: D

Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.

4. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?

Correct answer: B

Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.

5. During an examination for possible cryptorchidism in an infant, what technique should be used?

Correct answer: D

Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.

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