HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 of 5
A nurse is evaluating a newborn who was delivered quickly at 38 weeks gestation. The newborn is shaky, has a fast heart rate, and high blood pressure. Which assessment action should the nurse prioritize?
Correct Answer: D
Rationale: Performing a drug screen for cocaine is the priority in this situation. The symptoms described - shakiness, a fast heart rate, and high blood pressure - can be signs of neonatal abstinence syndrome, which can occur if the mother used certain drugs, such as cocaine, during pregnancy.
Question 2 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 3 of 5
A multiparous client at 36-hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 cm above the umbilicus. What action should the nurse take first?
Correct Answer: B
Rationale: Encouraging the client to void can help if the bladder is full. A full bladder can displace the uterus and interfere with uterine contractions, leading to increased bleeding.
Question 4 of 5
A client at 35 weeks gestation complains of pain whenever the baby moves. The nurse notes the client's temperature to be 101.20 F (38.4° C), with severe abdominal or uterine tenderness on palpation. What condition do these findings suggest?
Correct Answer: B
Rationale: Chorioamnionitis is an infection of the membranes surrounding the fetus and is associated with prolonged labor. Symptoms include fever, abdominal pain, and fetal tachycardia. The client's symptoms of pain when the baby moves, a high temperature, and severe abdominal or uterine tenderness on palpation align with this condition.
Question 5 of 5
A client who is anovulatory and has hyperprolactinemia is undergoing infertility treatment with metformin, menotropins, and human chorionic gonadotropin. What side effect should the nurse instruct the client to report immediately?
Correct Answer: D
Rationale: A rapid increase in abdominal girth can be a sign of ovarian hyperstimulation syndrome, a rare but potentially serious side effect of fertility treatments. This condition can cause rapid weight gain, abdominal pain, and bloating, and should be reported immediately.