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
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 2 of 5
The nurse reviews the assessment findings along with the healthcare provider's prescriptions. Which immediate intervention(s) would the nurse initiate? Select all that apply.
Correct Answer: A,C,D,E,G
Rationale: Increasing IV fluids ', stopping magnesium ', administering oxygen ', obtaining magnesium levels ', and giving calcium gluconate ' address preeclampsia and magnesium toxicity risks. Blood pressure ' and cesarean prep ' are not immediate interventions.
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
A client at 40 weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which action(s) should the nurse plan to perform? Select all that apply.
Correct Answer: A,B,D
Rationale: Standard precautions ' prevent HIV transmission. Antiviral medication ' reduces vertical transmission risk. Bottle-feeding ' prevents postnatal transmission via breast milk. Droplet precautions ' and negative pressure rooms ' are unnecessary as HIV is not airborne.
Question 5 of 5
In preparing a gravid client for a triple screen analysis, which action should the nurse take?
Correct Answer: C
Rationale: Triple screen analysis requires a maternal blood sample to assess fetal abnormality risks. Preparing to draw blood ' is the correct action. Drinking water ', left lateral position ', and fetal monitoring ' are unrelated to this test.