HESI RN
HESI Maternity Test Bank Questions
Question 1 of 5
The healthcare provider is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg. Which action is the highest priority?
Correct Answer: B
Rationale: Having calcium gluconate readily available is crucial when administering magnesium sulfate, as it serves as the antidote in case of magnesium toxicity. Magnesium sulfate can lead to respiratory depression and cardiac arrest in cases of overdose or toxicity, making the prompt availability of calcium gluconate essential for immediate administration to counteract these effects.
Question 2 of 5
At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?
Correct Answer: A
Rationale: In this scenario, the nurse should prioritize obtaining information about the color and consistency of the amniotic fluid. This is crucial as it helps assess for signs of infection or meconium staining, which can impact the management of labor and delivery. Meconium-stained fluid can indicate fetal distress and may require immediate intervention. Option B, estimating the amount of fluid, is not as critical at this moment compared to assessing for signs of infection or fetal distress. Option C, noting any odor, while important, is secondary to assessing for potential complications such as infection or meconium staining. Option D, recording the time of membrane rupture, is also important but does not take precedence over evaluating the characteristics of the amniotic fluid for immediate clinical decision-making. Educationally, this question highlights the importance of prioritizing information gathering in obstetrical emergencies. Understanding the significance of different assessment parameters in such situations is crucial for providing safe and effective care to both the mother and the baby during labor and delivery.
Question 3 of 5
A 34-week primigravida woman with preeclampsia is receiving Lactated Ringer's 500ml with magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the infusion pump?
Correct Answer: A
Rationale: To calculate the infusion rate, divide the total quantity to be infused (500ml) by the total time (1 hour) which equals 500ml/hr. Since the magnesium sulfate is being given at 3g/hr, and 1g of magnesium sulfate is in 5ml of solution, the rate will be 3g/hr x 5ml/g = 15ml/hr. Therefore, the total infusion rate should be 500ml/hr + 15ml/hr = 515ml/hr. Hence, the nurse should program the infusion pump to deliver 75ml/hr (515ml/hr total - 500ml/hr Lactated Ringer's rate).
Question 4 of 5
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care?
Correct Answer: A
Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA.
Question 5 of 5
At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?
Correct Answer: B
Rationale: The correct answer is B) Chorioamnionitis. Chorioamnionitis is an infection of the amniotic fluid and fetal membranes, typically caused by ascending bacteria from the vagina. In the scenario described, the client's complaint of pain with fetal movements, elevated temperature, and severe abdominal tenderness are indicative of an intrauterine infection. Chorioamnionitis can lead to serious complications for both the mother and the baby if not promptly treated with antibiotics and possibly early delivery. Option A) Round ligament strain is incorrect because it does not present with fever or uterine tenderness. Round ligament pain is common in pregnancy and is typically sharp, intermittent pain in the lower abdomen due to the stretching of the ligaments supporting the uterus. Option C) Abruptio placenta is incorrect as it presents with sudden onset of dark vaginal bleeding, along with severe abdominal pain and uterine tenderness. This condition involves the premature separation of the placenta from the uterine wall. Option D) Viral infection is incorrect in this context because the symptoms described are more indicative of a bacterial infection rather than a viral one. Viral infections in pregnancy may present with a different set of symptoms and do not typically cause severe uterine tenderness. In an educational context, understanding the signs and symptoms of common pregnancy complications like chorioamnionitis is crucial for nurses and healthcare providers working in maternity care. Early recognition and intervention can significantly impact maternal and fetal outcomes. Nurses must be vigilant in assessing pregnant clients for any concerning symptoms and implementing appropriate interventions promptly to ensure the best possible outcomes for both mother and baby.