HESI RN Maternity Exam 7n

Extract:

Question 1 of 5

A laboring client has a variable deceleration on the fetal monitor. What is the first action that the nurse should take?

Correct Answer: C

Rationale: Variable decelerations suggest cord compression. Changing the client's position is the first action to relieve it, improving fetal oxygenation. Oxygen, stopping oxytocin, or assessing dilation are secondary.

Question 2 of 5

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse expect?

A. Blood pressure variance across extremities. B. Hypotension. C. Tachycardia. D. Pulse oximetry reading within defined limits.

Correct Answer: C

Rationale: Tachycardia is common in toddlers with ventricular septal defects and heart failure as the heart compensates for increased workload. Blood pressure variance, hypotension, and normal pulse oximetry are not typical findings.

Question 3 of 5

A client at 28-weeks gestation whose hemoglobin level is 10.7 g/dL (107 g/L) and hematocrit is 32.3% (0.323 volume fraction), tells the nurse that she eats plenty of green vegetables. When the client asks the nurse how the pregnancy might affect the laboratory findings, which information should the nurse provide?

A. Increasing intake of protein might improve these values. B. Plasma volume increases, making the blood count appear low. C. Almost all women at 28-weeks gestation have anemia. D. It might be necessary to take an iron supplement twice daily.

Correct Answer: B

Rationale: Pregnancy increases plasma volume, diluting red blood cells and causing physiological anemia, explaining the low hemoglobin and hematocrit.

Question 4 of 5

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8Â° F (35.8Â° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

A. Place a pulse oximeter on the heel B. Swaddle the infant in a warm blanket C. Document the findings in the record D. Obtain a heel stick blood glucose level

Correct Answer: D

Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia. A heel stick glucose test is urgent to confirm and treat this condition.

Question 5 of 5

The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella. How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?

A. Low risk: Routine monitoring. B. Moderate to high risk: Initiate VTE prophylaxis per policy. C. Moderate risk or blood loss greater than 500 mL spontaneous vaginal delivery (SVD) or greater than 1,000 mL cesarean. D. High risk: Greater than 500 mL blood loss SVD or greater than 1,000 mL cesarean, vital sign changes.

Correct Answer: B

Rationale: MMR vaccination does not directly increase VTE or PPH risk. Evaluating based on overall health and pregnancy factors, with prophylaxis for moderate to high risk, is appropriate per policy.