Hesi RN Maternal Newborn

Extract:

Question 1 of 5

A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

Correct Answer: C

Rationale: Bright red vaginal bleeding suggests possible placental issues; assessing fetal heart rate and contraction pattern is critical to detect fetal distress and guide urgent interventions.

Question 2 of 5

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

A. Improve insufficient dietary intake. B. Stimulate the immune system. C. Prevent hemorrhagic disorders. D. Help an immature liver.

Correct Answer: C

Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.

Question 3 of 5

A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)

A. A couple who express concern about birth defects after using an internet DNA testing site. B. A woman and her significant other who are excited about the prospect of having children. C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure. D. A man who states that his father was recently diagnosed with Huntington's disease. E. A couple who plan to use in-vitro fertilization with donated sperm.

Correct Answer: A,C,D,E

Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.

Question 4 of 5

Which action should the nurse take?

A. Document the normal finding. B. Notify the healthcare provider. C. Schedule an ultrasound. D. Obtain hematocrit level.

Correct Answer: B

Rationale: Notifying the healthcare provider about abnormal FHR patterns ensures timely intervention to address potential fetal distress.

Question 5 of 5

A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

A. Document the finding in the medical record. B. Schedule the client for a biophysical profile. C. Request another nurse measure the fundus. D. Notify the healthcare provider of the finding.

Correct Answer: B

Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.