which information regarding the care of antepartum women with cardiac conditions is most important for the nurse to understand
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HESI LPN

HESI Focus on Maternity Exam

1. Which information regarding the care of antepartum women with cardiac conditions is most important for the nurse to understand?

Correct answer: B

Rationale: Class II cardiac disease is symptomatic with ordinary activity. Women in this category need to avoid heavy exertion and limit regular activities as symptoms dictate. Stress is greatest between weeks 28 and 32 of gestation, when hemodynamic changes reach their maximum. Class III cardiac disease is symptomatic with less-than-ordinary activity. These women need bed rest most of the day and face the possibility of hospitalization near term. Class I cardiac disease is asymptomatic at normal levels of activity. These women can perform limited normal activities with discretion, although they still need a good amount of sleep.

2. During a prenatal visit, for which of the following clients should the nurse auscultate the fetal heart rate?

Correct answer: D

Rationale: The correct answer is D because feeling quickening typically occurs around 18-20 weeks of gestation, indicating fetal movement. This is an appropriate time to auscultate the fetal heart rate. Choice A is incorrect because a molar pregnancy is not a viable pregnancy, and auscultating the fetal heart rate in this case is not applicable. Choice B is incorrect because a crown-rump length of 7 weeks gestation is too early for fetal heart rate auscultation. Choice C is incorrect because a positive urine pregnancy test alone does not indicate the appropriate timing for fetal heart rate auscultation.

3. The nurse is receiving a report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?

Correct answer: C

Rationale: The priority nursing action when a client with ruptured membranes is admitted to the labor and delivery suite is to take the client's temperature. This is crucial to assess for infection, especially when the duration of membrane rupture is unknown. Beginning a pad count, preparing to start an IV, and monitoring amniotic fluid for meconium are important actions but are not as immediate or critical as assessing for infection through temperature measurement.

4. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.

5. Which of the following statements is true of menstruation?

Correct answer: B

Rationale: The correct statement regarding menstruation is that during this time, an unfertilized egg is discharged along with the shedding of the uterine lining. Choice A is incorrect because the endometrium is shed during menstruation. Choice C is incorrect as menstruation does not prevent a female from engaging in sexual activity with her partner. Choice D is incorrect as a fertilized egg does not undergo mitosis during menstruation but rather implants in the uterine lining for further development.

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