HESI RN
Maternity HESI Quizlet
1. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?
- A. Perform a gestational age assessment.
- B. Obtain a drug screen for cocaine.
- C. Determine reactivity of neonatal reflexes.
- D. Weigh and measure the newborn.
Correct answer: B
Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.
2. Which of the following is used to differentiate abdominal mass from pelvic mass on clinical examination?
- A. Size
- B. Site
- C. Margins
- D. Lower border
Correct answer: D
Rationale: The lower border is used to differentiate between an abdominal mass and a pelvic mass during clinical examination. The lower border of the mass provides important information about its location and origin. The size (Choice A) alone may not always clearly distinguish between abdominal and pelvic masses. The site (Choice B) and margins (Choice C) are also important factors, but they are not as specific in differentiating between abdominal and pelvic masses as the lower border.
3. Septic abortion is characterized by:
- A. Backache.
- B. Os open.
- C. Heavy bleeding.
- D. Maternal pyrexia.
Correct answer: D
Rationale: Septic abortion is characterized by maternal pyrexia. Maternal pyrexia, or fever, is a hallmark sign of septic abortion due to infection. Backache and heavy bleeding can be present in abortion but are not specific to septic abortion. 'Os open' does not directly characterize septic abortion.
4. The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which clinical finding is most concerning?
- A. Blood pressure of 110/70 mmHg
- B. Heart rate of 110 beats per minute
- C. Fever of 100.4°F
- D. Respiratory rate of 24 breaths per minute
Correct answer: C
Rationale: The correct answer is C. A fever of 100.4°F is most concerning in a client with ESRD scheduled for hemodialysis because it may indicate an underlying infection that requires immediate attention. Elevated body temperature can be a sign of systemic infection, which can quickly worsen in individuals with compromised renal function. Monitoring for infection is crucial in ESRD patients to prevent complications. Choices A, B, and D are not as immediately concerning in this context. While variations in blood pressure, heart rate, and respiratory rate should be monitored, they are not as indicative of a potentially severe issue as an unexplained fever in this scenario.
5. When reviewing laboratory results for a client receiving tacrolimus (Prograf), which laboratory result would indicate to the nurse that the client is experiencing an adverse effect of the medication?
- A. Blood glucose of 200 mg/dL
- B. Potassium level of 3.8 mEq/L
- C. Platelet count of 300,000 cells/mm³
- D. White blood cell count of 6000 cells/mm³
Correct answer: A
Rationale: An elevated blood glucose level of 200 mg/dL indicates an adverse effect of tacrolimus. This finding suggests hyperglycemia, which is a known adverse effect of the medication. Other potential adverse effects of tacrolimus include neurotoxicity and hypertension. Monitoring blood glucose levels is crucial to detect and manage this adverse effect promptly. Choices B, C, and D are not directly associated with adverse effects of tacrolimus. Potassium, platelet count, and white blood cell count are important parameters to monitor for other reasons but not specifically for detecting adverse effects of tacrolimus.