HESI RN
Hesi RN Maternal Newborn Questions
Extract:
Question 1 of 5
A client who delivered vaginally 18 hours ago develops a slight fever. The client's delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?
Correct Answer: A
Rationale: Prolonged SROM significantly increases the risk of postpartum endometritis due to extended exposure to pathogens.
Question 2 of 5
A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit troubled with a headache. The initial assessment findings include a blood pressure of 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?
Correct Answer: D
Rationale: Assessing deep tendon reflexes and clonus detects CNS irritability, critical for identifying severe preeclampsia and eclampsia risk.
Question 3 of 5
When is the best time to administer a rubella vaccine to a client?
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
Question 4 of 5
A client in active labor receives a prescription for oxytocin 6 milliunits/minute intravenously (IV). The IV bag contains oxytocin 10 units in lactated Ringer's 1,000 mL. How many mL/hour should the nurse program the infusion pump to deliver? (Enter numerical value only.)
Correct Answer: 36
Rationale: Calculated as: (6 milliunits/min ÷ 10,000 milliunits) × 1,000 mL = 0.6 mL/min; 0.6 mL/min × 60 min/hour = 36 mL/hour.
Question 5 of 5
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.