HESI RN
Maternity HESI Quizlet Questions
Question 1 of 5
The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?
Correct Answer: B
Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.
Question 2 of 5
A young woman who underwent a liver transplant one year ago tells the clinic nurse that she would like to start a family. How should the nurse intervene?
Correct Answer: A
Rationale: In this scenario, the correct intervention for the nurse is option A) Provide information about the high-risk nature of her pregnancy. This option is correct because a young woman who underwent a liver transplant is at an increased risk during pregnancy due to the immunosuppressive medications she is likely taking to prevent rejection of the transplanted organ. Pregnancy can increase the woman's need for these medications, which may pose risks to both her health and the baby's well-being. Option B) Gently remind the client that anti-rejection drugs can cause sterility is incorrect because while some medications can affect fertility, it is not a common side effect of anti-rejection drugs. It is crucial for the nurse to provide accurate information to the client. Option C) Explain the benefits of waiting for a five-year post-transplant period is incorrect as there is no specific five-year waiting period recommended universally. The decision to conceive after an organ transplant should be individualized based on the woman's health status and the advice of her healthcare team. Option D) Determine if the client is considering options for adopting a child is incorrect as the client has expressed her desire to start a family biologically. While adoption is a valid option, it is essential for the nurse to address the client's immediate concerns regarding pregnancy post-transplant. Educationally, this question highlights the importance of understanding the unique considerations and risks associated with pregnancy after organ transplantation. Nurses need to provide accurate information, support, and guidance to help women make informed decisions about their reproductive health post-transplantation.
Question 3 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 4 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 5 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.