the nurse is preparing to administer phytonadione to a newborn which statement made by the parents indicates understanding why the nurse is administer
Logo

Nursing Elites

HESI RN

HESI Maternity 55 Questions Quizlet

1. The healthcare provider is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the healthcare provider is administering this medication?

Correct answer: A

Rationale: The correct answer is A: 'Prevent hemorrhagic disorders.' Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease by promoting blood clotting. Newborns are born with low levels of vitamin K, which is essential for blood clotting, hence the administration to prevent hemorrhagic disorders. Choice B is incorrect because phytonadione is not given to help an immature liver but to supply vitamin K. Choice C is incorrect as phytonadione is not administered to improve dietary intake but to provide essential vitamin K. Choice D is incorrect as phytonadione does not stimulate the immune system but helps with blood clotting.

2. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

3. After a full-term vaginal delivery, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first?

Correct answer: A

Rationale: In postpartum clients, a white blood cell count of 15,000/mm3 can be within normal limits due to physiological changes that occur after childbirth. Checking the differential count would provide a more detailed analysis of the specific types of white blood cells present, helping to differentiate between normal postpartum changes and potential infection. This action allows the nurse to gather more information before escalating the situation to the healthcare provider or initiating other assessments. Assessing vital signs and the perineal area are important aspects of postpartum care but may not be the priority in this scenario where the white blood cell count can be influenced by normal physiological changes.

4. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

Correct answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

5. The healthcare provider is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the healthcare provider withhold the drug?

Correct answer: C

Rationale: A blood pressure of 149/90 is an indication to withhold Methergine due to its potential to further increase blood pressure. Methergine is a medication that can cause vasoconstriction, leading to elevated blood pressure. In this case, administering Methergine could exacerbate the elevated blood pressure, posing a risk to the patient. Therefore, it is crucial to withhold the medication in the presence of hypertension to prevent adverse effects. The other options are not directly related to the administration of Methergine. A respiratory rate of 22 breaths/min is within the normal range. A large amount of lochia rubra may indicate normal postpartum bleeding. A positive Homan’s sign is associated with deep vein thrombosis, which is not a contraindication for administering Methergine.

Similar Questions

Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client?
The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?
The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant’s care?
A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses