HESI RN
HESI RN Care of Women and Pediatric Nursing Questions
Extract:
Question 1 of 5
Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mmHg and her heart rate is 130 beats/minute. Which action should the nurse implement first?
Correct Answer: C
Rationale: Hypotension (80/50 mmHg) and tachycardia (130 bpm) suggest uterine compression of the vena cava. Tilting the backboard ' relieves this, improving blood flow. Saline infusion ', blood sampling ', and palpation ' are secondary.
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 2 of 5
The nurse reviews the findings for the client. Which findings are concerning and require intervention? Select all that apply.
Correct Answer: A,C,E
Rationale: High blood pressure ' suggests preeclampsia, variable decelerations ' indicate possible cord compression, and absent reflexes ' suggest magnesium toxicity, all requiring intervention. Pain ', normal fetal heart rate ', and temperature ' are not concerning.
Question 3 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.
Extract:
Question 4 of 5
The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
Correct Answer: C
Rationale: Nasal flaring ' indicates increased breathing effort, a sign of respiratory distress. Normal respiratory rate ', shallow respirations ', and abdominal breathing ' are typical in newborns.
Question 5 of 5
A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
Correct Answer: D
Rationale: Hypotonic dystocia involves weak contractions. Monitoring intensity, interval, and length of contractions ' is critical to assess oxytocin effectiveness. Blood pressure ', cesarean prep ', and perineal bulging ' are secondary.