HESI RN
Maternity HESI Quizlet
1. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?
- A. Body temperature.
- B. Level of pain.
- C. Time of first void.
- D. Number of vessels in the cord.
Correct answer: D
Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.
2. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
- A. Unless your sister has a medical education, ignore her comments.
- B. I can hear that your sister comments are over-whelming you.
- C. Do you think it’s possible that you might be a hypochondriac?
- D. Besides your sister’s comments, what in your life is troubling you?
Correct answer: B
Rationale: Acknowledging the impact of the sister's comments on the client helps validate the client's feelings and supports therapeutic dialogue.
3. The healthcare provider is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information?
- A. A review in the Cochrane Library.
- B. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL).
- C. An online nursing textbook.
- D. The policy and procedure manual at the healthcare agency.
Correct answer: A
Rationale: The Cochrane Library provides systematic reviews of primary research in healthcare, making it a reliable resource for evidence-based practice. Choice B, a literature search in a database like CINAHL, may also be useful but does not guarantee the same level of systematic review and reliability as the Cochrane Library. Choice C, an online nursing textbook, may offer information but might not provide the most current or evidence-based practices. Choice D, the policy and procedure manual at the healthcare agency, is unlikely to offer the comprehensive evidence-based information needed for developing standards of care.
4. The nurse is assessing a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which clinical finding requires immediate intervention?
- A. Increased fatigue
- B. Elevated blood pressure
- C. Headache
- D. Elevated hemoglobin
Correct answer: A
Rationale: The correct answer is A, 'Increased fatigue.' In a client with CKD receiving erythropoietin therapy, increased fatigue can be a sign of polycythemia, a condition characterized by an elevated red blood cell count. This can lead to increased blood viscosity and raise the risk of thromboembolic events, necessitating immediate intervention. Elevated blood pressure (choice B) is a common concern in CKD but does not require immediate intervention in this context. Headache (choice C) may be related to elevated blood pressure but is not the most critical finding requiring immediate attention. Elevated hemoglobin (choice D) is an expected outcome of erythropoietin therapy and does not require immediate intervention unless excessively high.
5. During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while holding the infant
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct answer: B
Rationale: Auscultating the heart and lungs while the infant is held is the most appropriate intervention to assess his current condition. This action allows the nurse to gather important information regarding the cardiovascular and respiratory status of the infant, which is crucial in evaluating his post-surgical recovery and overall well-being. Option A is incorrect as stimulating the infant to cry intentionally is not necessary and could cause distress. Option C is incorrect as the infant's growth is within the expected range, indicating no signs of failure to thrive. Option D is incorrect as obtaining a 12-lead electrocardiogram is not the initial intervention needed in this situation; assessing the heart and lungs through auscultation is more immediate and informative.