HESI RN
HESI RN Care of Women and Pediatric Nursing Questions
Extract:
Question 1 of 5
The nurse determines the need to perform further assessment based on the client's situation. Select the 2 actions that the nurse should perform immediately.
Correct Answer: A,B
Rationale: Vaginal exam ' assesses labor progress, and vital signs ' evaluate maternal status, both critical for immediate decision-making. Bladder palpation ', amniotic fluid exam ', and urine dipstick ' are secondary without specific indications.
Question 2 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.
Question 3 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.
Question 4 of 5
The nurse is caring for a term infant immediately following delivery. Which action should the nurse implement to reduce the risk of cold stress?
Correct Answer: D
Rationale: Drying and skin-to-skin contact ' prevent cold stress by maintaining warmth and promoting bonding. Bathing ', radiant warmer ', and room temperature ' are less effective or inappropriate immediately.
Question 5 of 5
A client at 37-weeks, 1-day gestation by a 10-week ultrasound, presents to labor and delivery with contractions every 3 to 4 minutes for the last 2 hours. The vaginal exam shows the client is 4 cm dilated, 50% effaced, -3 station. The membranes are intact. Contractions occur every 3 to 4 minutes per monitor, lasting 60 seconds, moderate by palpation. Fetal heart rate is 136 beats/minute with accelerations noted; no decelerations are noted. The estimated fetal weight by Leopold's is 6 pounds (2.72 kg). The prenatal course is unremarkable, with normal labs. The client's blood type is A-. An Rh' immune globulin injection was received at 28-weeks.
Correct Answer: A
Rationale: 37-weeks, 1-day gestation ' is term, reducing preterm risks but carrying early-term concerns like respiratory issues. Pain rating ', vaginal exam ', contractions ', and managed Rh-negative status ' are normal and not primary risk factors.