HESI RN
HESI Maternity 55 Questions Quizlet
1. The healthcare provider is preparing to give an enema to a laboring client. Which client requires the most caution when carrying out this procedure?
- A. A gravida 6, para 5 who is 38 years of age and in early labor.
- B. A 37-week primigravida who presents at 100% effacement, 3 cm cervical dilation, and a -1 station.
- C. A gravida 2, para 1 who is at 1 cm cervical dilation and a 0 station admitted for induction of labor due to postdates.
- D. A 40-week primigravida who is at 6 cm cervical dilation and the presenting part is not engaged.
Correct answer: D
Rationale: The client at 40 weeks of gestation with a 6 cm cervical dilation and a presenting part that is not engaged requires the most caution during an enema procedure. An unengaged presenting part increases the risk of cord prolapse, which can be a serious complication during the procedure. This situation demands careful attention to prevent potential complications and ensure the safety of the client and fetus. Choice A is incorrect as being in early labor does not pose the same level of risk as an unengaged presenting part. Choice B describes a client at 37 weeks with signs of early labor but does not indicate the same level of risk as an unengaged presenting part. Choice C involves a client at 1 cm cervical dilation and a 0 station with no mention of an unengaged presenting part, making it a less critical situation compared to an unengaged presentation, as in Choice D.
2. The nurse is performing an admission assessment of an older client who has difficulty swallowing and has a history of aspiration pneumonia. Which action should the nurse implement first?
- A. Obtain a speech therapy consult
- B. Elevate the head of the bed
- C. Check the client's lung sounds
- D. Implement aspiration precautions
Correct answer: B
Rationale: The correct action for the nurse to implement first is to elevate the head of the bed. Elevating the head of the bed helps prevent aspiration in clients with swallowing difficulties by reducing the risk of food or fluids entering the airway. While obtaining a speech therapy consult (Choice A) is important, the immediate priority is to ensure the client's safety by positioning them properly. Checking the client's lung sounds (Choice C) and implementing aspiration precautions (Choice D) are also essential steps but should follow the immediate intervention of elevating the head of the bed to prevent aspiration.
3. A client is prescribed phenytoin (Dilantin) for seizure control. Which statement by the client indicates an understanding of the medication?
- A. I should brush and floss my teeth regularly.
- B. I should take the medication with antacids.
- C. I can stop taking the medication once my seizures are controlled.
- D. I should avoid drinking milk while taking this medication.
Correct answer: A
Rationale: The correct statement is 'I should brush and floss my teeth regularly.' Phenytoin (Dilantin) can cause gingival hyperplasia, so maintaining good oral hygiene is essential. Taking the medication with antacids can affect its absorption, so it should not be done. It is crucial not to stop taking the medication abruptly, even if seizures are controlled. There is no specific requirement to avoid milk while taking phenytoin (Dilantin).
4. The nurse is providing discharge instructions to a client who has had a stroke. Which intervention should the nurse recommend to prevent aspiration during meals?
- A. Encourage the client to take large bites of food
- B. Advise the client to eat quickly to prevent fatigue
- C. Offer the client thin liquids with meals
- D. Instruct the client to sit upright while eating
Correct answer: D
Rationale: Instructing the client to sit upright while eating is crucial to prevent aspiration in stroke clients. This position helps in safe swallowing and reduces the risk of food or liquid entering the airway. Encouraging the client to take large bites of food (Choice A) can increase the risk of choking and aspiration. Advising the client to eat quickly (Choice B) may lead to fatigue and compromise safe swallowing. Offering thin liquids (Choice C) can also increase the risk of aspiration in stroke clients, as thicker liquids are usually recommended to prevent aspiration.
5. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
- A. Auscultate the lungs for respiratory pneumonia.
- B. Change to latex-free gloves when handling infant.
- C. Draw blood to analyze for streptococcal infection.
- D. Apply zinc oxide to perineum with each diaper change.
Correct answer: B
Rationale: Latex allergy is a concern in patients with myelomeningocele, so switching to latex-free gloves is important.