HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 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.
Question 2 of 5
A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time.I didn't realize having a baby would be this challenging.â€. What should the nurse's response be?
Correct Answer: A
Rationale: A client who is 3 weeks postpartum and feeling tired all the time is a common scenario. Adjusting to a new baby can be challenging and it's normal for new mothers to feel overwhelmed and fatigued. The nurse's response should be empathetic and supportive, encouraging the client to share more about her situation. This could help the nurse understand the client's support system and provide appropriate advice or resources.
Question 3 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 4 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 5 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.