HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 of 5
A neonate, who is one day old, develops a cephalhematoma. Which common complication should the nurse assess this neonate for?
Correct Answer: B
Rationale: Cephalhematomas are caused by the rupture of blood vessels between the skull and periosteum, resulting in a blood collection. The breakdown of red blood cells in this trapped blood can lead to the release of bilirubin, increasing an infant's risk for hyperbilirubinemia and jaundice.
Question 2 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 3 of 5
The nurse observes on the fetal monitor that a laboring client has a variable deceleration. What action should the nurse implement first?
Correct Answer: B
Rationale: Changing the client's position is the recommended first action for variable decelerations. Repositioning the mother, such as moving her to a lateral or knee-chest position, can relieve potential cord compression and improve fetal oxygenation.
Question 4 of 5
A patient in early labor is receiving oxytocin and begins to experience tachysystolic or tetanic contractions with variable fetal heart decelerations. What should the nurse do next?
Correct Answer: B
Rationale: Discontinuing the oxytocin infusion is the correct action. Oxytocin is a hormone that stimulates uterine contractions during labor. If a patient begins to experience tachysystolic or tetanic contractions, which are excessively frequent or prolonged contractions, it could lead to fetal distress. Discontinuing the oxytocin can help reduce the frequency and intensity of the contractions.
Question 5 of 5
A client informs the nurse that she believes she is pregnant.Which sign or symptom is the best indicator that the client is pregnant?
Correct Answer: C
Rationale: Amenorrhea, or the absence of menstruation, is often the first and most reliable sign of pregnancy. If a woman is in her childbearing years and a week or more has passed without the start of an expected menstrual cycle, she might be pregnant.