HESI RN
HESI RN Care of Women and Pediatric Nursing Questions
Extract:
History and Physical
Nurses' Notes
Vital Signs
Diagnostic Results
Provider's Prescriptions
The client is gravida 4, term 3, preterm 0, abortions 0, living children 3 (GTPAL), at 37 weeks and 1 day gestation by 10-week ultrasound. She presents with contractions every 3 to 4 minutes for the past 2 hours. The vaginal examination reveals she is 4 cm dilated, 50% effaced, and at -3 station. Membranes are intact. Prenatal course is unremarkable, with normal laboratory results. The estimated fetal weight by Leopold's maneuver is 6 pounds (2.72 kg).
Question 1 of 5
Complete the diagram by selecting: The condition the client is most likely experiencing. Two actions the nurse should take to address the condition. Two parameters the nurse should monitor to assess the client's progress.
| Options | Normal | Abnormal |
|---|---|---|
| Preeclampsia with severe features. | ||
| Gestational hypertension. | ||
| Placental abruption. | ||
| Preterm labor. | ||
| Actions to Take Choices A. Administer magnesium sulfate as prescribed. B. Prepare for emergency cesarean section. C. Place the client in a supine position. D. Monitor for signs of magnesium toxicity. E. Restrict the client’s fluid intake to 500 mL per day. | ||
| Parameters to Monitor Choices A. Urine output of at least 30 mL/hour B. Fetal heart rate variability C. Oxygen saturation of at least 95% D. Serum magnesium levels above 8 mg/dL E. Deep tendon reflexes |
Correct Answer: A
Rationale: Condition: Preeclampsia with severe features ' due to high blood pressure (170/98 mmHg) and magnesium sulfate use. Actions: Administer magnesium sulfate ' to prevent seizures and monitor for toxicity '. Parameters: Monitor urine output (A, ≥30 mL/hour) for renal function and deep tendon reflexes ' for toxicity. Gestational hypertension ', placental abruption ', and preterm labor ' do not fit the clinical picture.
Question 2 of 5
The nurse evaluates the client's progress. Review the findings below and determine if each one is normal or abnormal.
Correct Answer: A
Rationale: Blood pressure (170/98 mmHg,
A) is abnormal, suggesting preeclampsia. Pain (5/10,
B), brief variable decelerations ', and magnesium sulfate infusion ' are normal in this context.
Extract:
Question 3 of 5
A client at 37 weeks gestation presents to labor and delivery with contractions every 2 minutes. The nurse observes several shallow, small vesicles on her pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition?
Correct Answer: D
Rationale: Herpes simplex virus (HSV) causes painful, shallow vesicles or ulcers in the genital area, which matches the client's symptoms. Genital warts ' present as flesh-colored or gray swellings, not vesicles. German measles ' causes a rash and fever, not genital vesicles. Syphilis ' typically presents with a chancre or rash, not vesicular lesions.
Question 4 of 5
The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4°F (38°C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
Correct Answer: A
Rationale: The vital signs are within normal postpartum ranges. A temperature of 100.4°F can be normal due to labor exertion, and a heart rate of 58 beats/minute is typical due to increased stroke volume. Documenting ' is appropriate. Assessing lochia ', administering acetaminophen ', or reporting the heart rate ' are not indicated without further concerns.
Question 5 of 5
During a prenatal visit, a client at 30 weeks gestation reports persistent heartburn during the past two weeks. The nurse notes the client has 3+ bilateral, pitting, pedal edema. Which action should the nurse implement?
Correct Answer: B
Rationale: Significant edema (3+) may indicate preeclampsia, especially at 30 weeks. Asking about blurred vision and headache ' is critical to assess for preeclampsia symptoms. Heartburn is common (A,
D), but edema takes priority. Checking urine for glucose/ketones ' is unrelated to edema or preeclampsia.