HESI_Maternity 2019 v1 52 questions with answers,100% CORRECT

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1. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in ... this client’s teaching plan? 2. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? 3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding? 4. Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl with a history of frequent urinary tract infections? 5. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet? 6. The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? 7. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? 8. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12- year-old sibling are the child bedside. Which instruction best supports this family? 9. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time? 10. Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest? 11. The nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child? 12. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding? 13. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? 14. At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? 15. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? 16. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? 17. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client’s condition, what information is most important for the nurse to provide? 18. While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement? 19. During a routine clinic visit, the nurse determines that a 5-year-old boy’s blood pressure is 112/70. When calculating the child’s blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next? 20. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? 21. A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child’s hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice? A. Rewash the child’s hair following a 24-hour isolation period. B. Wash the child’s bed linens and clothing in hot soapy water Maybe this C. Take the child to a hair salon for a shampoo and a shorter haircut. D. Dispose of the child’s brusches, combs, and others hair accessories. 22. During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client. 23. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? 24. The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? 25. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? 26. 27. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only) 13 28. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? 29. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take? . 30. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son’s acne cream, benzoyl peroxide, on the baby’s face. Which answer should the nurse to provide? 31. The nurse is providing preoperative teaching to a teenaged client with appendicitis information should the nurse include about postoperative activity? 32. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? 33. 33. 34. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? 35. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer’s Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only) 36. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby’s weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? 37. A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? 38. A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? 39. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority? 40. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration? 41. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child? 42. A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first? 43. A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant’s skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)? 44. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-weeks gestation. The baseline fetal heart rate (FHR) is 144 beats/minute. The client is instructed to mark the fetal monitor paper by pressing a button attached to the fetal monitor each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. Which outcome indicates a reactive NST? 45. A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform? 46. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse to review before reporting to the healthcare provider? 47. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea ( sudden aimless movements of the arms and legs). Which information should the nurse tell to the parents? 48. 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? 49. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to the body size. Which action is most important for the nurse to take next? 50. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis af eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan? 51. During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, “We don’t plan on having any more children, since the next child is likely to inherit this disorder.” How should the nurse respond? 52. The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority? 53. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes? 54. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? . 55. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance. Review for Maternity Hessi • The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. • Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 • Ampicillin 1 gram IV push q8h. • Betamethasone (Celestone) 12 mg deep IM • Butorphanol (Stadol) 1 mg IV push q2h PRN pain 2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? • Carrots • Chicken • Yogurt • Cheese 3. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? • Respiratory rate of 22 breaths/min • A large amount of lochia rubra • Blood pressure 149/90 • Positive Homan’s sign 4. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? • Begin a training program lifting weights and running • Splint affected joints during activity • Exercise in a swimming pool • Perform passive range of motion exercises twice daily 5. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? • Pain level • Blood pressure • Infusion site • Contraction pattern 6. One day after vaginal delivery of a full term baby, a postpartum client’s white blood cell count is 15.000/mm. What action should the nurse take first? • Check the differential, since the WBC is normal for this client • Assess the client’s temperature, pulse, and respirations q4h • Assess the client’s perineal area for signs of a perineal hematoma • Notify the healthcare provider, since this finding is indicative of infection 7. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? • Discuss the need for cortisol and aldosterone replacement therapy after discharge • Support the parents in their decision to assign sex of their child according to their preference • Offer information about ultrasonography and genotyping to determine sex assignment • Explain that corrective surgical procedures consistent with sex assignment can be delayed 8. The nurse assessing a 9-year old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? • Back pain for a few days • A history of hypertension • A sore throats last week • Diuresis during the nights 9. A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer? 13 10. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? • Alert the neonatal team and prepare for neonatal resuscitation • Notify the healthcare provider from the client’s bedside • Obtain written consent for an emergency cesarean section • Draw a blood sample for stat hemoglobin and hematocrit 11. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? • Turn the client to her left side • Contact the healthcare provider • Assess the fetal heart rate • Check the cervical dilation 12. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? A. Obtain a culture of any sputum or wound drainage. • Obtain a culture of any sputum or wound drainage • Initiate normal saline IV at 50 ml/hr • Administer a loading dose of penicillin IM • Administer the initial dose of folic acid PO 13. A child has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? • Respiratory alkalosis • Respiratory acidosis • Metabolic alkalosis • Metabolic acidosis 14. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? • Respiratory alkalosis • Respiratory acidosis • Metabolic acidosis • Metabolic alkalosis 15. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child? • Reduce cerebral edema and lower intracranial pressure • Avert hypotension and septic shock • Prevent cardiac arrhythmias and heart failure • Promote kidney perfusion and normal blood pressure. 16. A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2- station. What action should the nurse implement first? • Decrease the oxytocin infusion rate • Determine current cervical dilation • Request placement of the epidural • Give a bolus of intravenous fluids 17. A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider? • CO combining power • Calcium • Sodium • Chloride 18. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents? • Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged • The chorea or movements are temporary and will eventually disappear • Permanent life-style changes need to be made to promote safety in the home • Consistent discipline is needed to help the child control the movements 19. The nurse is measuring the frontal occipital circumference (FOC) of a 3- month-old infant, notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? • Measure the infant’s head to heel length • Observe the infant for sunset eyes • Palpate the anterior fontanel for tension and bulging • Plot the measurement on the infant’s growth chart 20. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan? • Keep airway equipment at the bedside. • Allow liberal family visitation • Monitor blood pressure, pulse, and respirations q4h • Assess temperature q1h 21. During a well-child visit for their child, one of the parent who has an autosomal dominant disorder tells the nurse, “We don’t plan on having any more children, since the next child is likely to inherit this disorder”. How should the nurse respond? • Explain that the risk of inhering the disorder decrease by 50% with each child the couple has • Acknowledge that the next that the next child will inherit the disorder since the first child did not • Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked • Confirm that there is a 50% chance of their future children inheriting the disorder 22. The nurse is caring for a one-year-old child following surgical correction of hypospadias. The nursing action has the highest priority? • Monitor urinary output • Auscultate bowel sounds • Observe appearance of stool • Record percent of diet eaten 23. Patient with Duchenne Disease. The nurse has to explain to the mother that: 24. Primipara patient. What is the pet to share time a, home that is not recommended? 25. An infant with letralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? • Administer morphine sulphate • Start IV fluids • Place the infant in a knee-chest position • Provide 100% oxygen by face mask 26. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12 year old sibling at the child’s bedside. Which instruction best supports family? • While waiting for the healthcare provider, only one visitor may stay with the child • All of you should leave while the healthcare provider sutures the child’s forehead • It is best if the sibling goes to the waiting room until the suturing is completed • Please decide who will stay when the healthcare provider begins suturing 27. The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask “how can our son have this disease? We are wondering if we should have any more children” What information should the nurse provide these parents? • This is an inherited X-linked recessive disorder, which primarly affects male children in the family • The male infant had a viral infection that went unnoticed and iuntreated, so muscle damage was incurred • The XXXX muscle groups of males can be impacted by a lack of the protein dystrophyn in the mother • Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles 28. A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? • Bilateral bronchial breath sounds • Diaphragmatic respiration • A resting respiratory rate of 35 breathe per minute • Flaring of the nares 29. A two year old child with a heart failure(HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? • Determine the pulse deficit • Administer the schedule dose • Calculate the safe dose range • Review the serum digoxin level 30. Which nursing intervention is most important to include in the plan of care for for a child with acute glomerulonephritis? • Encourage fluid intake • Promote complete bed rest • Weight the child daily • Administer vitamin supplements 31. A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain? • High blood cholesterol level on routine screening • Increased thirst and urination • A recent strep throat infection • A recent DPT immunization • A newborn yellow abdomen and chest • Child HIV • Glomerunephritis • Percentile 97 • To confirm RDS in a newborn • Cryptorchidism • Diaper • ADHD • Watery vaginal white in the first trimester • Propanol • Palirizumab (synagis) 43. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " altered nutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care? 44. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide? 45. A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? 46. A blind litter girld, 8 year sold was admitted to the hospital ..... 47. Apple 48. 9 redondiado 49. Preclancia 50. A woman with mastitis 51. Belling 52. A pregnant woman with hypermesis gravidarium, what is the best nurse intervention. [Show More]

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