HESI RN
Hesi RN Maternal Newborn Questions
Extract:
Question 1 of 5
A diabetic client delivers a full-term large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?
Correct Answer: A
Rationale: Obtaining a blood glucose level confirms hypoglycemia as the cause of jitteriness, common in LGA infants of diabetic mothers, guiding treatment.
Question 2 of 5
The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
Correct Answer: C
Rationale: These vital signs are normal postpartum; documenting them ensures accurate tracking without unnecessary interventions.
Question 3 of 5
A client receiving a solution of magnesium sulfate suddenly develops right upper quadrant pain. After reviewing abnormal laboratory results, what action should the nurse implement? (Select all that apply)
Correct Answer: A,B,C,D
Rationale: Monitoring fetal heart rate, repeating hepatic panel, checking for seizures, and assessing urinary output address potential HELLP syndrome and renal function in preeclampsia.
Question 4 of 5
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
Question 5 of 5
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation. Based on the client's symptoms, the nurse determines additional assessments are needed. Select the 4 assessments the nurse should perform.
| Fingerstick hemoglobin. |
| Urine for protein. |
| Perineal assessment. |
| Vision test. |
| Skin turgor. |
| Deep tendon reflexes. |
| Lung sounds. |
Correct Answer: B,D,F,G
Rationale: Urine protein, vision test, deep tendon reflexes, and lung sounds assess preeclampsia indicators like proteinuria, visual disturbances, CNS irritability, and pulmonary edema.