HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 of 5
A newborn, who is 4 hours old, presents with the following symptoms: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonicity, and a weak cry. What should the nurse do based on these findings?
Correct Answer: D
Rationale: Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.
Question 2 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 3 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.
Question 4 of 5
While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby's forehead, sternum, and abdomen. What should be the nurse's next course of action?
Correct Answer: C
Rationale: Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.
Question 5 of 5
The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg. Which nursing protocol is of the highest priority?
Correct Answer: B
Rationale: When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.