HESI RN
Maternity HESI 2023 Quizlet
1. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?
- A. Reduce cerebral edema and lower intracranial pressure
- B. Avert hypotension and septic shock
- C. Prevent cardiac arrhythmias and heart failure
- D. Promote kidney perfusion and normal blood pressure
Correct answer: A
Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.
2. A primipara patient asks what is the best pet to have at home to share time with. Which pet is not recommended?
- A. Dog
- B. Cat
- C. Bird
- D. Fish
Correct answer: C
Rationale: Birds are not recommended as pets for a primipara patient due to potential health risks associated with bird droppings, feathers, and dander. These factors may pose a risk to the newborn's health and the mother's well-being. Additionally, some birds can be loud, which may disrupt the baby's sleep patterns. Therefore, it is advisable for primipara patients to consider pets like dogs, cats, or fish as they generally have lower associated risks in a household with a newborn. Dogs, cats, and fish are relatively safer options compared to birds for primipara patients due to their lower risk of transmitting infections, allergens, or causing disturbances that could affect the newborn or the mother.
3. A client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. What intervention should the nurse recommend to help prevent hypoglycemia while the client is sleeping?
- A. Eat a bedtime snack.
- B. Avoid physical activity.
- C. Take half the usual dose of insulin.
- D. Discontinue insulin until the next meal.
Correct answer: A
Rationale: Eating a bedtime snack is the most appropriate intervention to prevent hypoglycemia during the night when NPH insulin peaks. This snack helps maintain blood glucose levels and counteracts the risk of hypoglycemia. Avoiding physical activity is not recommended as it can further lower blood sugar levels. Taking half the usual dose of insulin can lead to inadequate control of blood sugar levels. Discontinuing insulin until the next meal can result in uncontrolled hyperglycemia, especially during the peak action of NPH insulin.
4. What should be included in the differential diagnosis of ectopic pregnancy?
- A. Inevitable abortion
- B. Dysmenorrhea
- C. Twisted ovarian cyst
- D. Fibroids
Correct answer: C
Rationale: In the differential diagnosis of ectopic pregnancy, conditions such as twisted ovarian cysts should be considered. Twisted ovarian cysts can present with similar symptoms to ectopic pregnancy, making it important to include them in the differential diagnosis. Choices A, B, and D are not typically part of the differential diagnosis of ectopic pregnancy. Inevitable abortion refers to an imminent miscarriage, dysmenorrhea is characterized by painful menstruation, and fibroids are benign growths in the uterus, none of which are directly related to ectopic pregnancy.
5. A client with heart failure is prescribed digoxin and reports nausea. What is the nurse's first action?
- A. Administer an anti-nausea medication as prescribed.
- B. Assess the client's digoxin level immediately.
- C. Assess the client’s apical pulse and hold the next dose if it's below 60 bpm.
- D. Instruct the client to reduce their fluid intake.
Correct answer: B
Rationale: When a client on digoxin reports nausea, it can be a sign of digoxin toxicity. The priority action for the nurse is to assess the client's digoxin level immediately. This assessment will help determine if the nausea is related to digoxin toxicity, requiring a dosage adjustment. Administering an anti-nausea medication (Choice A) does not address the underlying issue of potential digoxin toxicity. Assessing the client's apical pulse (Choice C) is important in general digoxin monitoring but not the first action when nausea is reported. Instructing the client to reduce fluid intake (Choice D) is not the initial response to nausea in a client taking digoxin.