HESI RN
HESI RN Maternal Newborn I Questions
Question 1 of 5
A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?
Correct Answer: B
Rationale: Fundal height of 30 cm is below the expected range (32-36 cm) for 34 weeks gestation, suggesting possible intrauterine growth restriction (IUGR) or oligohydramnios, which requires further evaluation. Mild edema is common, weight gain is normal, and a fetal heart rate of 110 bpm is within the acceptable range.
Extract:
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
Question 2 of 5
Select the findings that will help the nurse determine what is causing the client's symptoms.
| Rupture of membranes for 16 hours |
| Normal spontaneous vaginal birth |
| Breastfeeding 7 to 8 times a day for 10 minutes |
| Discharge hemoglobin of 9.2 g/dL (92 g/L) |
| Current vital signs |
| Shopping yesterday for 5 hours |
| Foul-smelling lochia rubra |
Correct Answer: A,D,E,F,G
Rationale: Prolonged rupture of membranes, low hemoglobin, fever, tachycardia, prolonged shopping, and foul-smelling lochia suggest postpartum infection risks like endometritis or mastitis. These findings indicate systemic inflammation, anemia, and potential milk stasis.
Question 3 of 5
For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions.
| Options | Mastitis | Endometritis | Both mastitis and endometritis |
|---|---|---|---|
| Pulse of 105 beats/minute - Both mastitis and endometritis | |||
| Feeling chilled, achy, and fatigued - Both mastitis and endometritis | |||
| Baby fed pumped breast milk - Mastitis | |||
| Pain rating of 4 on a 0 to 10 scale - Mastitis | |||
| Foul-smelling lochia rubra at 2 weeks postpartum - Endometritis | |||
| Temperature of 101.2° F (38.4°C) - Both mastitis and endometritis |
Correct Answer: B,D
Rationale: Tachycardia, chills, aches, fatigue, and fever are systemic signs of infection in both mastitis and endometritis. Feeding pumped milk and localized breast pain suggest mastitis due to milk stasis. Foul-smelling lochia is specific to endometritis, indicating uterine infection.
Question 4 of 5
Which education by the nurse will help resolve the issue for the client? Select all that apply.
Correct Answer: B,C,E,G
Rationale: Warm compresses, pumping to prevent milk stasis, completing antibiotics, hand hygiene, starting on the unaffected side, and varying positions promote milk flow, reduce infection risk, and ensure effective breastfeeding. Underwire bras and avoiding rest are not recommended.
Question 5 of 5
The nurse knows that the mastitis in this scenario is most likely caused by... as evidenced by...
| Plugged duct |
| Breast abscess |
| Engorgement |
| Nipple trauma with cracked skin |
| Firm, red, warm area on the right breast |
| Pus draining from the nipple |
| Generalized swelling of the entire breast |
Correct Answer: A,E
Rationale: A plugged duct, evidenced by a firm, red, warm area, is the likely cause of mastitis due to milk stasis from missed feedings. Abscess, engorgement, or nipple trauma are less likely without pus, generalized swelling, or reported cracks.