When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

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Maternity HESI 2023 Quizlet Questions

Question 1 of 5

When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?

Correct Answer: A

Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.

Question 2 of 5

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

Correct Answer: D

Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.

Question 3 of 5

During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?

Correct Answer: C

Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.

Question 4 of 5

The healthcare provider notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the healthcare provider implement first?

Correct Answer: B

Rationale: Changing the client's position is the priority intervention for variable decelerations as it can relieve pressure on the umbilical cord, potentially resolving the deceleration and improving fetal oxygenation. Assessing cervical dilation, administering oxygen via facemask, and turning off the oxytocin infusion are important interventions but addressing the fetal distress caused by variable decelerations takes precedence.

Question 5 of 5

A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

Correct Answer: A

Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.

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