HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 of 5
A client at 40-weeks gestation arrives at the obstetrical floor and reports that her amniotic membranes ruptured spontaneously at home. She is in active labor and feels the need to bear down and push. What is the most important information for the nurse to obtain?
Correct Answer: C
Rationale: The time the membranes ruptured is the most important information to obtain. This is because the risk of infection increases the longer the time between membrane rupture and delivery. Knowing the time of rupture helps guide decisions about inducing labor and administering antibiotics to prevent infection.
Question 2 of 5
An 18-week pregnant client was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks about the next steps. What should the nurse advise?
Correct Answer: D
Rationale: Explaining that a sonogram should be scheduled for definitive results is the most appropriate advice. An ultrasound can provide a more detailed view of the fetus and help identify any potential issues that might have led to the elevated AFP level. This would be the most informative next step and would guide further actions based on the findings.
Question 3 of 5
The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum. Her uterus is firm, and she has a moderate flow of lochia. Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?
Correct Answer: A
Rationale: A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client's heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.
Question 4 of 5
A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus. What action should the nurse take first?
Correct Answer: B
Rationale: Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Question 5 of 5
One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm (15 x 109/L). What action should the nurse take first?
Correct Answer: D
Rationale: A normal WBC in a postpartum client ranges from (12,000- 20, 000/mm. Checking the white blood cell differential helps determine the specific types of WBCs present and gives more information as to whether the elevation is the body's normal response to childbirth or a sign of infection.