HESI RN Maternity Exam 7n

Extract:

Question 1 of 5

A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for which complication is the highest priority for this client?

Correct Answer: A

Rationale: Severe postpartum hemorrhage increases the risk of DIC, a life-threatening clotting disorder. Psychosis, afterpains, and placenta accreta are less immediate concerns in this context.

Question 2 of 5

On the first postpartum day, the nurse examines a new mother's breasts. What condition is the nurse most likely to find?

A. Soft, with no change from before delivery. B. Filling and secreting colostrum. C. Slightly firm with an immediate let-down response. D. Firm, larger, and very tender to touch.

Correct Answer: B

Rationale: On the first postpartum day, breasts typically fill and secrete colostrum due to hormonal changes initiating lactation. Soft breasts, immediate let-down, or significant tenderness are less common at this stage.

Question 3 of 5

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child's back. Which parental statement indicates understanding of the procedure?

A. The skin incision should be kept moist by periodically wetting the dressing. B. When changing the dressing, the tape should be removed rapidly from the edges. C. The incision should be protected from fecal contamination by an intact dressing. D. To ensure easy removal of the sutures, the dressing should be kept dry.

Correct Answer: C

Rationale: An intact dressing prevents fecal contamination, reducing infection risk. Keeping the incision moist or removing tape rapidly can disrupt healing, and while a dry dressing aids suture removal, preventing contamination is the priority.

Question 4 of 5

A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

A. Praise the client for her actions and offer to discuss ways to decrease consumption even more. B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit. C. Notify child protective services of the client's illicit drug use and probable child endangerment. D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Correct Answer: D

Rationale: Alcohol consumption during pregnancy poses risks to the fetus. Referring the client to an outpatient program for disulfiram therapy addresses potential dependency effectively. Praising reduced intake may not suffice, insisting on blood tests is invasive, and notifying child protective services is inappropriate without evidence of drug use.

Question 5 of 5

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

A. Assess for bladder distention. B. Listen for bowel sounds. C. Document the observation. D. Check the scrotum for testicular descent.

Correct Answer: C

Rationale: Voiding from the ventral penis suggests hypospadias, a congenital condition. Documenting this finding ensures it is reported and addressed appropriately.