HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 of 5
A primigravida arrives at the maternity unit's observation area because she believes she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding would confirm to the nurse that the client is not in labor at this time?
Correct Answer: B
Rationale: Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.
Question 2 of 5
A pregnant woman is learning how to perform kick (fetal movement) counts. What should the nurse instruct her to do?
Correct Answer: D
Rationale: If 10 kicks are not felt within one hour, drinking orange juice and counting for another hour is a common recommendation. The sugar in the juice can sometimes stimulate the baby to move. However, if the mother still doesn't feel 10 movements within 2 hours, she should contact her healthcare provider.
Question 3 of 5
The nurse is caring for a client who delivered 6 hours ago. The client's uterus is boggy and is displaced above and to the right of the umbilicus. What action should the nurse take?
Correct Answer: D
Rationale: Encouraging the client to void is the correct action. A full bladder can displace the uterus, preventing it from contracting properly. By emptying the bladder, the uterus may be able to contract and return to its normal position.
Question 4 of 5
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival?
Correct Answer: A
Rationale: Heat loss is a significant concern for newborns immediately after birth. Newborns have a large surface area relative to their body weight, which makes them more susceptible to heat loss. Maintaining a warm environment is crucial to prevent hypothermia, which can lead to complications such as hypoglycemia and respiratory distress.
Question 5 of 5
An unlicensed assistive personnel (UAP) informs the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is experiencing a severe headache.The client's blood pressure is 110/70 mm Hg, respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98.6° F (37° C). The client's fundus is firm and one fingerbreadth above the umbilicus.What should the charge nurse do first?
Correct Answer: C
Rationale: Determining if the client received anesthesia during delivery is the correct first action. A severe headache in the postpartum period can be a sign of a post-dural puncture headache, which can occur as a complication of spinal or epidural anesthesia.