Monroe College RN HESI Maternity | Nurselytic

Questions 55

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Monroe College RN HESI Maternity Questions

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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

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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Similar Questions

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?
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?
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?
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?
A 25-year-old client experienced a severe postpartum hemorrhage following the vaginal birth of twins and is now transferred to the postpartum unit. What complication should the nurse prioritize during the client's assessment?

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