HESI RN
HESI Maternity Test Bank Questions
Question 1 of 9
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 9
What action should be implemented when preparing to measure the fundal height of a pregnant client?
Correct Answer: A
Rationale: Having the client empty her bladder before measuring the fundal height is essential to ensure an accurate measurement. A full bladder can impact the fundal height measurement by displacing the uterus and affecting the accuracy of the assessment.
Question 3 of 9
Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
Correct Answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation.
Question 4 of 9
The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
Question 5 of 9
The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?
Correct Answer: A
Rationale: If the client experiences a return to red bleeding after transitioning to pink and white, it may indicate possible complications like hemorrhage or retained placental fragments. Instructing the client to reduce activity level and promptly notify the healthcare provider is crucial for timely evaluation and management of these potentially serious postpartum complications.
Question 6 of 9
What maternal behavior is typically observed when a new mother first receives her infant?
Correct Answer: B
Rationale: When a new mother first receives her infant, a common behavior is to use her arms and hands to receive the infant and then trace the infant's profile with her fingertips. This behavior helps facilitate bonding and aids in the recognition of the newborn.
Question 7 of 9
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should you share with her?
Correct Answer: B
Rationale: The diaphragm should be refitted after childbirth to ensure proper fit and effectiveness, as changes in the body may affect its function.
Question 8 of 9
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.
Question 9 of 9
When should the LPN/LVN encourage the laboring client to begin pushing?
Correct Answer: C
Rationale: The LPN/LVN should encourage the laboring client to begin pushing when the cervix is completely dilated to 10 centimeters. Pushing before full dilation can lead to cervical injury and ineffective labor progress. By waiting for complete dilation, the client can push effectively, aiding in the descent of the baby through the birth canal.