HESI RN
Herzing University HESI Maternity Questions
Extract:
Question 1 of 5
An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7-pound (3,175 gram) infant 12 hours ago is reporting 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. Which action should the charge nurse implement first?
Correct Answer: C
Rationale: A severe headache post-delivery may indicate a post-dural puncture headache, especially if anesthesia was used, requiring immediate notification of the healthcare provider.
Question 2 of 5
During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
Correct Answer: C
Rationale: Increased white, thin, watery discharge (leukorrhea) is a normal physiological change in pregnancy due to hormonal shifts, requiring no immediate intervention.
Question 3 of 5
The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.
Question 4 of 5
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)
Correct Answer: 450
Rationale:
To deliver 6 grams over 20 minutes from a solution of 20 grams in 500 mL, the concentration is 25 mL/g. Thus, 6 grams requires 150 mL over 20 min, which is (150 mL / 20 min) x 60 = 450 mL/hour.
Question 5 of 5
A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
Correct Answer: C
Rationale: The time of membrane rupture is critical to assess the risk of infection, which increases with prolonged rupture, especially in active labor.