HESI RN
Monroe College RN HESI Maternity Questions
Extract:
Question 1 of 5
The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum. Her uterus is firm, and she has a moderate flow of lochia. Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?
Correct Answer: A
Rationale: A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client's heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.
Question 2 of 5
The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has risen from 110/60 mmHg to 140/90 mmHg. Which nursing protocol is of the highest priority?
Correct Answer: B
Rationale: When preparing to administer magnesium sulfate to a laboring client with elevated blood pressure, ensuring that calcium gluconate is immediately available is of the highest priority. Calcium gluconate is the antidote for magnesium sulfate toxicity, and having it readily available is crucial in case of an overdose.
Question 3 of 5
After breastfeeding for 10 minutes on each breast, a new mother calls the nurse to the postpartum room to assist with changing the newborn's diaper.As the mother begins the diaper change, the newborn regurgitates the breast milk. What should be the nurse's first action?
Correct Answer: D
Rationale: Sit the newborn upright and burp by gently rubbing or patting the upper back is the most appropriate first action. This position helps bring up any air swallowed during feeding, reducing the likelihood of spitting up. Gently rubbing or patting the back encourages the burp reflex.
Question 4 of 5
A client at 10-weeks gestation calls the clinic reporting a low-grade fever, moderate cramping, and heavy bright-red bleeding. What advice should the nurse give the client?
Correct Answer: B
Rationale: The client's symptoms of low-grade fever, moderate cramping, and heavy bright-red bleeding could indicate a serious condition such as a miscarriage or an ectopic pregnancy.
Therefore, immediate medical evaluation is necessary.
Question 5 of 5
The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?
Correct Answer: B
Rationale: Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.