HESI RN
HESI Maternity 55 Questions Quizlet
1. 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. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
- B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
- C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
- D. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection.
Correct answer: B
Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.
2. A client addicted to heroin and newly pregnant asks a nurse about ensuring her baby's health while on methadone. What should the nurse advise?
- A. Sign up for group therapy sessions.
- B. Discontinue the methadone right away.
- C. Start prenatal care as soon as possible.
- D. Describe genetic testing protocol.
Correct answer: C
Rationale: Initiating prenatal care promptly is essential for monitoring the well-being of both the mother and the fetus, particularly in high-risk pregnancies involving substance use. Early prenatal care allows for timely interventions, education, and support to promote a healthier pregnancy and birth outcomes. Choice A is incorrect because while group therapy may be beneficial, initiating prenatal care is more crucial at this stage. Choice B is incorrect as abrupt discontinuation of methadone can be harmful and should be managed under medical supervision. Choice D is incorrect as genetic testing is not the immediate priority in this scenario.
3. A client is prescribed metformin for type 2 diabetes. What should the nurse emphasize in the client's teaching?
- A. Take the medication with meals to reduce the risk of GI upset.
- B. Report any muscle pain to the healthcare provider promptly.
- C. Avoid alcohol consumption while taking this medication.
- D. Monitor blood sugar levels regularly to prevent hypoglycemia.
Correct answer: C
Rationale: The correct answer is to avoid alcohol consumption while taking metformin. Alcohol can increase the risk of lactic acidosis when combined with metformin. Choice A is incorrect because metformin is usually recommended to be taken with meals to reduce GI upset. Choice B is important but not the priority; muscle pain is more commonly associated with other diabetes medications. Choice D is incorrect because metformin typically does not cause hypoglycemia but rather helps control blood sugar levels in type 2 diabetes.
4. The client with congestive heart failure has been educated about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct answer: B
Rationale: The correct answer is B: Sliced turkey sandwich and canned pineapple. This lunch choice is suitable for a client with congestive heart failure as it is low in sodium. Sliced turkey is a lean protein choice, and canned pineapple is a low-sodium fruit option. Choice A contains high-sodium items like cheese and 2% milk. Choice C includes a cheeseburger, which is typically high in sodium, and a baked potato could also be high in sodium depending on preparation. Choice D consists of mushroom pizza and ice cream, both of which can be high in sodium, especially in processed or restaurant-prepared forms.
5. Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that the primary action of this medication is to:
- A. Increase DNA and RNA synthesis.
- B. Promote the biosynthesis of nucleic acids.
- C. Increase estrogen concentration and estrogen response.
- D. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.
Correct answer: D
Rationale: The primary action of tamoxifen, an antineoplastic medication used in metastatic breast carcinoma, is to compete with estradiol for binding to estrogen receptors in tissues with high receptor concentrations. By doing so, tamoxifen reduces DNA synthesis and estrogen response, leading to its therapeutic effect in inhibiting the growth of estrogen-sensitive breast cancer cells.