HESI RN
Maternity HESI Quizlet Questions
Question 1 of 5
A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
Correct Answer: C
Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.
Question 2 of 5
A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?
Correct Answer: A
Rationale: In this scenario, the correct action for the nurse to take is option A) Support the infant as it emerges. This is the right choice because the client is involuntarily pushing and the fetal head is presenting at the perineum, indicating imminent birth. By supporting the infant as it emerges, the nurse can ensure a safe delivery and prevent any potential complications. Option B) Review prenatal laboratory results is incorrect because in this urgent situation, the focus should be on the imminent birth rather than reviewing lab results which do not impact immediate care. Option C) Obtain fetal heart tones is also incorrect as the fetal head is already presenting at the perineum, indicating the need for immediate action to support the delivery rather than assessing fetal heart tones. Option D) Apply suprapubic pressure is not the appropriate action in this situation as the client is already involuntarily pushing and the fetal head is presenting, indicating that delivery is imminent and the focus should be on supporting the baby as it emerges. Educationally, it is crucial for nurses to be prepared to provide immediate care in emergent childbirth situations like this. Understanding the stages of labor and delivery, as well as knowing appropriate interventions for each stage, is essential for maternal and newborn safety. Nurses should be trained to act quickly and decisively in such scenarios to ensure positive outcomes for both the mother and baby.
Question 3 of 5
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
Correct Answer: C
Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.
Question 4 of 5
During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?
Correct Answer: A
Rationale: In a newborn assessment, the presence of flaring of the nares would indicate respiratory distress. This is the correct answer because in a newborn, flaring of the nares is a sign of increased work of breathing and the body's attempt to get more oxygen. It indicates that the baby is struggling to breathe and needs immediate attention. Option B, shallow and irregular respirations, while abnormal, may not necessarily indicate respiratory distress as newborns can have irregular breathing patterns. Option C, a respiratory rate of 50 breaths per minute, is within the normal range for a newborn and does not specifically point to respiratory distress. Option D, abdominal breathing with synchronous chest movement, can be a normal finding in newborns due to their immature respiratory systems and does not solely indicate respiratory distress. Educationally, understanding the signs of respiratory distress in newborns is crucial for healthcare professionals to provide timely interventions and prevent complications. Recognizing subtle cues like flaring of the nares can make a significant difference in the management of newborns with respiratory issues.
Question 5 of 5
The healthcare provider is providing preconception counseling. Which supplement should the provider recommend to help prevent the occurrence of anencephaly?
Correct Answer: A
Rationale: Folic acid supplementation before and during early pregnancy is crucial for reducing the risk of neural tube defects, including anencephaly. Anencephaly is a severe birth defect in which a baby is born without parts of the brain and skull. Folic acid plays a key role in neural tube development and can significantly lower the chances of such defects when taken prior to conception and in early pregnancy.