HESI RN
Maternity HESI Quizlet Questions
Question 1 of 5
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
Correct Answer: C
Rationale: A pulse rate of 56 bpm is a normal finding for a primigravida client who is 12 hours postpartum. Bradycardia (pulse rate 50-70 bpm) can be a normal postpartum occurrence due to increased stroke volume and decreased cardiac output after delivery. Unilateral lower leg pain and saturating two perineal pads per hour are not normal findings and require further assessment. A soft, spongy fundus could indicate uterine atony, which is abnormal postpartum.
Question 2 of 5
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks what is the purpose of the ointment. The nurse would be correct in stating that the purpose of the ointment is:
Correct Answer: A
Rationale: The correct answer is A) Prevent eye infection. The eye ointment placed in the newborn's eyes is typically erythromycin ointment, which helps prevent neonatal conjunctivitis caused by bacteria such as Chlamydia or Gonorrhea that the infant may have been exposed to during delivery. This practice is a standard procedure to protect the infant's eyes from potential infections that could lead to serious complications if left untreated. Option B) Dilate the pupil so the red reflex can be visualized is incorrect because the purpose of the eye ointment is not related to visualizing the red reflex but rather to prevent infection. Option C) Clear the infant's vision is incorrect as the eye ointment is not used to clear the vision of the infant but to protect their eyes from infection. Option D) Prevent herpes infection is incorrect because while the eye ointment does prevent bacterial infections, it is not specifically for preventing herpes infection. Educationally, it is crucial for healthcare providers to understand the purpose of routine procedures performed on newborns to provide safe and evidence-based care. By recognizing the rationale behind practices such as applying eye ointment, nurses can effectively educate parents and caregivers about the importance of these interventions in safeguarding the health of newborns.
Question 3 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 4 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 5 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.