HESI RN
Maternity HESI 2023 Quizlet
1. The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
- A. Urinary output and fluid intake.
- B. Hemoglobin and hematocrit.
- C. Abdominal contour and bowel sounds.
- D. Heart rate and blood pressure.
Correct answer: D
Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.
2. Upon admission, a 77-year-old female client presents with confusion, loss of appetite, nausea, vomiting, and headache, with a pulse rate of 43 beats per minute. Which question should the nurse prioritize asking the client or her family?
- A. Does the client have her own teeth or dentures?
- B. Does the client take aspirin, and if so, what is the dosage?
- C. Does the client take nitroglycerin?
- D. Does the client take digitalis?
Correct answer: D
Rationale: The correct answer is D. The client's symptoms suggest digitalis toxicity, a potentially life-threatening condition that requires immediate attention. Digitalis toxicity can present with symptoms such as anorexia, nausea, vomiting, headache, and bradycardia (low pulse rate). Given the client's presentation, it is crucial to assess for digitalis use as elderly individuals are more susceptible to this type of intoxication. Choices A, B, and C are important aspects to consider during the assessment, but in this scenario, the priority lies in identifying and addressing the potential digitalis toxicity due to the severity of symptoms and the need for prompt intervention.
3. A woman has been scheduled for a routine mammogram. What should the nurse tell the client?
- A. That mammography takes about 1 hour
- B. Not to eat or drink on the morning of the test
- C. That there is no discomfort associated with the procedure
- D. That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
Correct answer: D
Rationale: The correct answer is D. The nurse should instruct the client to avoid using deodorants, powders, or creams on the day of the mammogram. These products used in the axillary or breast area can interfere with the mammogram results and must be washed off before the test. Choices A, B, and C are incorrect because mammography typically takes less than 30 minutes, there is no need for fasting before the test, and some discomfort may be experienced during the procedure.
4. The nurse is caring for a client with a nasogastric tube to continuous suction. Which electrolyte imbalance should the nurse monitor for?
- A. Hypercalcemia.
- B. Hypokalemia.
- C. Hyponatremia.
- D. Hypomagnesemia.
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. When a client has a nasogastric tube to continuous suction, potassium loss through gastric fluids can lead to hypokalemia. Hypercalcemia (Choice A) is not typically associated with continuous suction. Hyponatremia (Choice C) involves sodium imbalance and is not directly related to nasogastric suction. Hypomagnesemia (Choice D) is not the primary concern in this situation, as potassium loss is more significant with gastric suction.
5. In the past, when was a woman only allowed to access Family planning methods?
- A. when she was married
- B. when she had more than four children
- C. when she produced a letter of consent from the husband
- D. when the doctors recommended
Correct answer: C
Rationale: In the past, women were often required to produce a letter of consent from their husband to access family planning services. This requirement stemmed from traditional beliefs and societal norms that placed men in control of such decisions. Choice A is incorrect because marital status alone did not determine access to family planning. Choice B is incorrect because the number of children a woman had did not dictate her access to family planning. Choice D is incorrect because medical recommendations alone did not influence a woman's access to family planning services in the past.