HESI RN
HESI RN Care of Women and Pediatric Nursing Questions
Extract:
Question 1 of 4
The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
Correct Answer: C
Rationale: Vigorous crying ' indicates effective lung function and oxygenation, key for extrauterine transition. Flexion ' and Babinski reflex ' are normal but less specific. Tachycardia (220 bpm,
D) suggests distress.
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 4
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 4
The nurse prepares to initiate magnesium sulfate therapy for the client. What is the priority nursing action?
Correct Answer: B
Rationale: Assessing deep tendon reflexes and respiratory rate ' before magnesium sulfate ensures safety, detecting toxicity risks. Increasing rate ', stopping for decelerations ', or giving antihypertensives ' are not initial priorities.
Question 4 of 4
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 5 of 4
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.