HESI RN
Maternity HESI 2023 Quizlet Questions
Question 1 of 5
A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Use an alternative form of contraception until a new diaphragm is obtained. Breastfeeding can delay the return of ovulation, but it is not a reliable form of contraception. Using the same diaphragm as before pregnancy may not provide effective contraception due to changes in the cervix and vaginal walls postpartum. Option B is incorrect because the diaphragm should be resized not only after weaning but also after childbirth due to potential changes in the cervix and vaginal size. Option C is incorrect because avoiding intercourse during ovulation is not a reliable method of contraception, and waiting to reassess the diaphragm size could lead to unintended pregnancies. Option D is incorrect because weight gain during pregnancy is not a reliable indicator of whether the diaphragm will fit properly postpartum. Educationally, this question highlights the importance of counseling postpartum clients on appropriate contraceptive methods and the need for reassessment of contraceptive devices after pregnancy to ensure their effectiveness. It emphasizes the role of healthcare providers in promoting safe and effective family planning practices.
Question 2 of 5
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Correct Answer: D
Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.
Question 3 of 5
A primipara has delivered a stillborn fetus at 30 weeks gestation. To assist the parents in the grieving process, which intervention is most important for the nurse to implement?
Correct Answer: A
Rationale: The most important intervention for the nurse to implement in this situation is option A, which is to provide an opportunity for the parents to hold their infant in privacy. This intervention is crucial as it allows the parents to create memories with their stillborn baby, fostering a sense of connection and closure. It also validates the reality of their loss, enabling them to begin the grieving process and start the healing journey. Option B, assisting the couple in completing a request for autopsy, may not be the most important intervention at this moment. While obtaining information about the cause of fetal demise can be valuable for closure and future family planning, the immediate emotional needs of the parents should take precedence. Option C, encouraging the couple to seek family counseling within the next few weeks, is also important for long-term support. However, in the immediate aftermath of the stillbirth, providing emotional support and facilitating the grieving process should be the primary focus. Option D, explaining the possible causes of fetal demise, is not the most appropriate intervention at this time. The parents may not be ready to process detailed medical information while they are grieving the loss of their baby. Prioritizing emotional support and allowing them to process their feelings should come first before discussing medical specifics.
Question 4 of 5
A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
Correct Answer: C
Rationale: In this scenario, the correct intervention for the nurse to implement is to assess bilateral lung sounds (Option C). This is crucial because a 6-year-old with heart failure who has gained 2 pounds in the last 24 hours may be experiencing fluid overload, leading to pulmonary congestion and potentially exacerbating the heart failure. Assessing bilateral lung sounds allows the nurse to determine if there are any signs of pulmonary edema or congestion, which are common complications of heart failure. Early detection of these issues through lung auscultation can prompt timely interventions to prevent respiratory distress and further deterioration of the child's condition. The other options are not as pertinent in this situation: - Option A, graphing the daily weight for the past week, while important for monitoring trends in weight gain or loss, does not address the immediate concern of potential respiratory distress. - Option B, decreasing the IV flow rate, could be considered if there were signs of fluid overload, but assessing lung sounds would provide more direct information about the child's respiratory status. - Option D, restricting intake of oral fluids, may be necessary in some cases of fluid overload, but assessing lung sounds would provide more immediate information about the child's respiratory status and guide further interventions. In an educational context, this question highlights the importance of clinical assessment skills in pediatric nursing, especially in managing children with complex conditions like heart failure. Nurses must be able to recognize subtle signs and symptoms of complications early to provide timely and appropriate care to pediatric patients.
Question 5 of 5
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
Correct Answer: B
Rationale: The correct answer is B) Change to latex-free gloves when handling the infant. This is the most important action for the nurse to take because the child is showing signs of an allergic reaction, likely due to a latex allergy. Given that the child has myelomeningocele, which is a neural tube defect, they may have a higher risk of developing allergies. Using latex-free gloves will help prevent further exposure to latex and reduce the risk of exacerbating the allergic symptoms. Option A) Auscultate the lungs for respiratory pneumonia is incorrect because the symptoms described are indicative of an allergic reaction, not respiratory pneumonia. Option C) Draw blood to analyze for streptococcal infection is incorrect because the symptoms are not suggestive of a streptococcal infection but rather an allergic reaction. Option D) Apply zinc oxide to the perineum with each diaper change is incorrect because it addresses diaper rash, which is not the primary concern in this scenario. In an educational context, it is important for healthcare providers to be aware of common allergies, such as latex, especially when caring for vulnerable populations like infants with myelomeningocele. Understanding the signs and symptoms of allergic reactions and knowing how to manage them is crucial in providing safe and effective care.