HESI RN
Maternity HESI Quizlet Questions
Question 1 of 5
The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?
Correct Answer: A
Rationale: The correct answer is A) The congenital absence of parasympathetic ganglion cells to the large intestine produces no peristalsis. Hirschsprung's disease is a congenital condition characterized by the absence of ganglion cells in the distal colon, leading to a lack of peristalsis in that segment of the bowel. This results in functional obstruction and failure to pass meconium, leading to abdominal distention in neonates. Option B) Pyloric obstruction causing reflux and projectile hematemesis is not consistent with Hirschsprung's disease. Pyloric obstruction occurs in the stomach, not the large intestine. Option C) Partial imperforated anal opening limiting passage of stools is indicative of an anorectal malformation, not Hirschsprung's disease. Option D) Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel is not characteristic of Hirschsprung's disease, which is marked by a lack of peristalsis in the affected segment of the colon. In an educational context, understanding the pathophysiological processes underlying different neonatal conditions is crucial for nurses caring for newborns. Recognizing the signs and symptoms of Hirschsprung's disease, such as failure to pass meconium and abdominal distention, can prompt early diagnosis and intervention to prevent complications. This knowledge is essential for providing safe and effective care to neonates with gastrointestinal issues.
Question 2 of 5
The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?
Correct Answer: D
Rationale: In this scenario, the correct action for the nurse to take is to obtain human chorionic gonadotropin (hCG) levels (Option D). At 10 weeks' gestation, the fundus should be at the umbilicus, not 3 fingerbreadths above the pubic symphysis, which could indicate a possible ectopic pregnancy. The presence of nausea, vomiting, and scant dark brown vaginal discharge further raises concern for ectopic pregnancy or other complications. Option A (Collect a urine sample for urinalysis) is not the priority in this situation as hCG levels would provide more specific information related to the pregnancy status. Option B (Measure vital signs) is important but does not address the specific concerns of fundal height and vaginal discharge. Option C (Recommend bed rest) is not the appropriate action without further assessment and diagnostic information. In an educational context, understanding the significance of fundal height, associated symptoms, and appropriate diagnostic tests is crucial for nurses caring for pregnant clients. This scenario highlights the importance of clinical assessment skills, knowledge of normal pregnancy findings, and the ability to recognize and respond to potential complications promptly to ensure optimal maternal and fetal outcomes.
Question 3 of 5
After two miscarriages, a client is instructed to increase her daily intake of foods that include folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
Correct Answer: C
Rationale: Collard greens are a good source of folic acid, which is important for preventing neural tube defects, especially in clients with a history of miscarriages. Since the client does not like green leafy vegetables, collard greens could be suggested as an alternative source of folic acid. Yogurt and whole milk do not contain significant amounts of folic acid, and while strawberries are a healthy choice, they are not a high source of folic acid compared to collard greens.
Question 4 of 5
The client delivered hours ago and has a boggy uterus displaced above and to the right of the umbilicus. What action should the nurse take?
Correct Answer: B
Rationale: In this scenario, the correct action is to encourage voiding (option B). After delivery, a boggy uterus displaced above and to the right of the umbilicus indicates uterine atony, which can lead to postpartum hemorrhage. Encouraging voiding helps the uterus contract by promoting the expulsion of clots and promoting uterine tone. Inspecting the perineal pad (option A) is important to assess for the amount and type of postpartum bleeding, but it does not directly address the issue of uterine atony. Monitoring vital signs (option C) is crucial in postpartum care, but addressing the boggy uterus should take precedence in this situation to prevent complications. Notifying the healthcare provider (option D) is important if interventions like encouraging voiding do not improve the uterine tone. However, this should not be the first action taken. Educationally, understanding the signs of uterine atony and knowing the appropriate interventions is crucial for nurses providing postpartum care to prevent complications like postpartum hemorrhage. Encouraging voiding promotes uterine contractions, aiding in the prevention of excessive bleeding and promoting maternal well-being.
Question 5 of 5
What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?
Correct Answer: D
Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.