HESI RN
Herzing University HESI Maternity Questions
Extract:
Question 1 of 5
Assessment findings of a 4-hour-old newborn include: 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, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
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
What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?
Correct Answer: C
Rationale: Relaxation techniques like deep breathing can help manage nausea, especially if triggered by stress or anxiety, making it the most effective immediate intervention.
Question 4 of 5
The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer's Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number)
Correct Answer: 12
Rationale:
To deliver 2 milliunits/minute from a solution of 10 units (10,000 milliunits) in 1000 mL, the concentration is 10 milliunits/mL. Thus, 2 milliunits/minute requires 0.2 mL/minute, which is 0.2 x 60 = 12 mL/hour.
Question 5 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: B
Rationale: Bright red vaginal bleeding is a critical sign that may indicate placental issues or fetal distress. Assessing the fetal heart rate and contraction pattern is the highest priority to ensure the well-being of both mother and baby.