HESI RN
HESI Maternity Test Bank
1. What is the most important assessment for the healthcare provider to conduct before the administration of epidural anesthesia to a client at 40 weeks' gestation?
- A. Maternal blood pressure.
- B. Level of pain sensation.
- C. Station of presenting part.
- D. Variability of fetal heart rate.
Correct answer: A
Rationale: Assessing maternal blood pressure is crucial before administering epidural anesthesia because it can cause hypotension, affecting both the mother and the fetus. Hypotension can lead to decreased placental perfusion, potentially compromising the fetal oxygen supply. Monitoring and maintaining maternal blood pressure within a safe range are essential to ensure the well-being of both the mother and the fetus during the administration of epidural anesthesia. The other options, such as assessing the level of pain sensation, station of presenting part, and variability of fetal heart rate, are important in obstetric care but are not as critical as monitoring maternal blood pressure to prevent complications related to epidural anesthesia administration.
2. 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?
- A. Respiratory rate of 22 breaths/min
- B. A large amount of lochia rubra
- C. Blood pressure 149/90
- D. Positive Homan’s sign
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.
3. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?
- A. Balance and coordination
- B. Cognitive status
- C. Level of pain
- D. Upper body muscle strength
Correct answer: D
Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.
4. A client with Addison's disease is experiencing an Addisonian crisis. The nurse should expect to administer which of the following medication?
- A. Insulin
- B. Hydrocortisone
- C. Levothyroxine
- D. Methimazole
Correct answer: B
Rationale: During an Addisonian crisis, the adrenal glands are not producing enough cortisol, leading to a life-threatening situation. Hydrocortisone, a glucocorticoid, is the medication of choice in managing an Addisonian crisis. It helps replace deficient cortisol levels, stabilize blood pressure, and prevent further complications. Insulin (Choice A) is not indicated in Addison's disease unless specifically needed for diabetes management. Levothyroxine (Choice C) is used in hypothyroidism, not in Addison's disease. Methimazole (Choice D) is used to manage hyperthyroidism, which is not related to Addison's disease or its crisis.
5. The healthcare provider is providing dietary instructions to a client with hyperthyroidism. Which of the following foods should the client avoid?
- A. Seafood
- B. Spinach
- C. Bananas
- D. Oatmeal
Correct answer: A
Rationale: The client with hyperthyroidism should avoid foods high in iodine, as it can exacerbate the condition by increasing thyroid hormone production. Seafood, particularly ocean fish, is rich in iodine, making it a food to avoid. Spinach, bananas, and oatmeal do not contain high levels of iodine and are generally safe for individuals with hyperthyroidism.