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HESI_RN_Maternity_Nursing_Exam. Questions and Aswers. 100%

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1. A primigravida mother who is one day post delivery tells the nurse that she is not producing enough milk for her new baby, and she wants to begin breastfeeding at home when her milk comes in. What ... info should the nurse obtain before responding to the client? Awhen the lactation consultant is scheduled to visit the client in her home Bthe womans understanding of how her body produces breast milk. Cif the woman is feeling pressured by her family to breast feed her infant. Dwhy the woman thinks her infant is not receiving enough milk Sometimes new mothers do not understand that colostrums provided adequate nutrition the first three days following delivery. So the clients thinking regarding this issue should be assessed (D). Waiting for a visit from a lactation consultant (A) to address this issue is likely to inhibit lactation if the mother delays suckling the infant. Although assessing the mother’s understanding of milk production (B) may provide a teaching opportunity, it does not elicit information about the clients concern regarding the delay of breast feeding/ Assessing the mothers feelings about her family’s desire for her to breastfreed (C) doesn’t address the issue athand. 2. A client with endometritis is preparing for discharge on her third postpartum day, Which statement by he client indicates that the discharge teaching was effective? AI should limit my visitors until this infection clears BI will resume breastfeeding when the infection is gone CI should sit an upright position as much as possible DI will stop taking antibiotics when my fever disappears A client with endo metris should sit in an upright position© to facilitate drainage of lochia and prevent infected fluids from enetering the peritoneal cavity. (A,B and D) indicate a needs for additional instruction. Endometritis is an infection of the endometrial lining and is not contagious, so visitors do not need to be restricted or limited(A). there is no indication to stop or withholding breastfeeding (b) if a client develops endometritis. All antibiotics should be completed regardless of fever abatement. 3. A multipara postpartum client complains about intenst cramping while breastfeeding. What instructions should the nurse provide to this client? A TAKE A PRESCRIBED ANALGESIC AN HOUR PRIOR TO BREASTFEEDING B change then infants position during the next feeding C drink two glasses of Water 30 minutes prior to breastfeeding D void and completely empty bladder before each feeding The client is experiencing atterpains which typically affect multigravidas due to relaxation of the uterine muscles and release of oxytocin during breastfeeding. The client should take a prescribed analgesic one hour before breastfeeding (A) to relieve this discomfort. Infant positioning during B is effective in relieving sore nipples. C and D are not effectivemeasures for relieving uttering cramping. 4. A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collossion. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? A Suspect that the monitor is malfunctioning and recount the heart rate manually BExplain to the client that a rapid heart right is normal for a preterm fetus. CPerform a vaginal Examination to see if the accident initiated preterm labor DAdminister oxygen to the client and contact the healthcare provider immediately. D Administering oxygen and contacting the healthcare provider (D) are the priority interventions for fetal oxygen deprivation secondary to placental abruption, which is known complication of trauma to the mother. A wastes time and increased the chance of errors in the assessment. Bprovides the client with dales information. C increased the risk of hemorrhage, further compromising fetal oxygenation, and is not a recommended intervention at this time. Vaginal bleeding should be assessed without palpation. 5. The nurse is assessing a 24 hour postpartum client. Which finding would be most indicative of a postpartum infection. 6. in caring for a newborn infant who starts gagging and becomes cyanotic, what action should the nurse implement first? agive three back blows to clear the airway bcall for assistance and start CPR csuction mouth nose with bulb d. provide oxygen by resuscitation bag and mask Suctioning with a bulb syringe may be the first and only action needed to clear the airway_C. Although – A is appropriate for foreign body aspirations or choking, it is not indicated for this infant. B us the next priority if the infant is not breathing or continues to be cyanotic. Newborns who are breathing usually become less cyanotic after the airway s cleared oxygen is administered(D). 7, the nurse is assessing a postpartum client who delivered an 11 pound infant veginally 2 hours ago. The client’s fundus is fingerbreadths above the umbilicus, deviated to the right side, and boogy. After the client voids 200 ml of urine using a bedpan, what action should the nurse implement? a palpate the suprapubic region for distention b.assist the client to the bathroom to void creevaluate the clinet in 15 minutes dadminister a prn prescription for ocytocin Neonatal maccrosoma increases the risk for iterine inertia, predisposing the client to uterine sinus bleeding, which cause the uterus to become boggy and displace, The client’s risk for postpartum bleeding is further increased by a full bladder, which should be assessed –A after the client voids 200 ml using the bedpan. Before ambulating the client to the bathroomB, thebladder should be assessed, Delaying assessment C doesn’t change the client’s uterine displacement, which is likely the result of a full bladder. Although oxytocin administrationD may ultimately be indicated, further assessment, attempts to empty the bladder, and uterine massage should be implemented first. 8. a client asks the nurse about the harmful effects of taking prescribed drugs during pregnancy. When do drugs taken by a mother have the most significant effect on a fetus? a. 24 hours before delivery b. the first trimester c. first stage of labor d. six weeks prior to becoming pregnant Drugs taken during the first trimester of pregnanacyB cause the most concern for fetal development. Although(A,C,D) should be considered, teratogenic effects of drugs on embryological formation during the first trimester of pregnancy are most significant. 9. the nurse observes a newborn with swelling of the scalp and suspects that is the result of birth trauma. Which intervention should the nurse implement to differentiate between caput succedaneum and cephalhematoma? a. transilluminate the skull b. palpate the anterior fontanel c. examine the suture lines d. measure the head circumference Cephalhematome is bound by suture lines while caput succedaneum crosses suture lines, so –C aids in differentiating between the two conditions. A is used to assess for the possibility of excess fluid or decreased brain tissue in the skill. B and D are not helpful in differentiaiting between the teo conditions 10.a woman who recently delivered a normal newborn calls the clinic crying and describes feeling overwhelmed and discouraged. Which information is most important for the nure to obtain? a. does she describe herself as described b. has she seen a mental health provider c. how long has she been feeling this way d. is there anyone with her at this time? “baby blues” are expected, usually resolve with the first week after delivery and rarely need additional treatment, but the nurse should further assess for postpartum depression. The most important information to obtain is the onset and duration of the client’s feelingsC to assess for postpartum depression (A). Additional information (A,B, and D) should also be obtained to determine the need for referrals and support persons. 11, a client is admitted to the hospital in active labor, and the nurse plans to assess her blood pressure q15 minutes between contractions. What is the main reason for determining the client’s blood pressure between contractions? 12. a client at 29 weeks gestation is receiving magnesium sulfate 3 grams pre term labor. After administering the loading dose, what asssessment finding should the nurse report to the healthcare provider immediately? a. a decrease in respirations from 20 to 17 breaths/min b. an increase in temperature from 98.9 to 99.9 can increase in blod pressure from 110/65 to 120/85 d. a decrease in deep tendon reflexes from 3+ to 1+ A decrease in the deep tendon reflexes occurs prior to respiratory depression which is a sign of magnesium sulfate toxicity –D and needs to be reported to the health care provider immediately. A needs to be monitored closely, but does not need to be reported immedietly. (B and C) are not related to the administration of magnesium sulfate 13. at a routine prenatal visit, a client at 34 weeks gestation complains of nasal stuffiness and occasional nose bleeds aestrogen bprogesterone crelaxin dhuman chorionic gonadotropion Increased estrogen secretion during pregnancy induces edema and vascular congestion of the nasal mucosa, which can lead to nasal stuffiness and epistaxis (A). (B, C and D) have no effect on nasal mucosa. 14, a client whose blood type is o negative delivers an infant who is o positive. Six hours after delivery the client has a negative indirect coombs. Which intervention should the nurse implement? aadminister one standard dose of Rhogam within 72 hours of delivery b teach the new mother about incompatibility of blood types and RhoGAM cassess the direct Coombs result of the infant to determine if RhoGAM is necessary d evaluate the father’s blood type and Rh to crossmatch the RhoHAM A Indirect Coombs measures whether or not maternal blood has been sensitixed to the Rh factor. Then this blood test is negative, it means that no sensitization has occurred and can be further prevented if the administration of RhoGAM occurs within72 hours of delivery –A. B is the impotant but not aas important as administering RhoGAM. C doesn’t determine eligibility for RhoGAM. D is not taken into consideration in the preparation of RhoGAM. 15. An Rhnegative client sufferes a miscarraige at 12 weeks gestation. Which plan for Rho(d) immune globulin (RhoGAM) administartion should the nurse implement? aadminister Rho immune globulin (RhoGAM) within 2 weeks following the miscarriage b. Rho(D) immune globulin (Rhogam) is not needed since the was not a full term infant cadminister Rho(D) immune globulin (RhoGAM) within 72 hrs after the misscarriage dadminister Rho(d) immune globulin (RhoGAM) only if the fetus is determines to be Rhpositive. c RhoGAM should be administered within 72 hours after a miscarriage © to be effective in preventing isoimmune hemolytic disease with the next pregnancy. (A) is too late. (B and D) are false. RhoGAM should be administered to all RH negative women following a miscarriage 16. Following vaginal delivery in a birthing suite, the nurse assesses a newborn male and finds that his respiration are 58 breaths per minute and his hands and feet are cyanotic. What action should the nurse take? aRecord the findings and continue to observe the infant badminister oxygen at 5l/minute cNotify the pediatrician immediately dtransfer the infant into the nursery to determine his oxygen saturation rate. Based on the date provided (A) is the best intervention. A newborn infants respirations should rage between 40 60 breaths/min. Acrocyanosis (bluing if the hands and feet) is a normal occurrence at birth and should not be confused with central cyanosis, which reflects impaired gas exchange and is exhibited by the neonate’s skin and mucous membrane turning blue. (B,C, AND D) should be implemented if central cyanosis is noted. 17., A low risk primigravida at 28 weeks gestation arrives for her regular antepartal clinic visit. Which assessment findings should the nurse consider within normal limits for this client? a. 2+ proteninuria b. pulse increase of 10 beats/min c.3+ glucosuria d. Fundal height of 36 centimeters B Blood volume increases 25 to 40% in pregnancy which increases cardiac output and increases heart rate by approximately 10 to 20 beats/minute (B). Proteinuria (A) is a sign f pregnancy induced hypertension (PIH). Although decreased renal threshold for glucose causes mild glucosuria (1+) in pregnancy, 3+ indicates gestational diabetes –C. At 28 weeks gestation, the fundal height should be at 28 cm, not 36 cm, this could indicate large for gestational age infant or a twin pregnancy (D). 18. The registered nurse is observing a newly hired LPN give a newborn a vitamin K (aquameohyton ) injection . The LPN uses a filter needle to draw 0.25 ml of aquamephyton in to the syringe, cleanses the thigh with alcohol in a circular motion, and prepares to inject the needle to 90 degree angle in left castus lateralis. What action should the RN take? apraise the pn for using the injection technique b tell the Pn to change the flter needle to a ½ inch needle c instruct the pn to give the injection at 45 degrees angle dsuggest injectiong the medication into the ventrogluteal muscle b A single intramuscular injection of 0.5 to 1 mg (0.25 ml to 0.5 ml) f vitamin K is administered after borth to prevent hemorrhagic disorders. The injection should be drawn form the ampoule with a filter but administered with a 2325 gauge, 3/8 1/2 inch needle, not a filter needle (B). (A, C and D) are not the technique for giving a Vitamin K injection to a newborn. 19. the last vaginal examination for a primigravida in active labor revealed a cervical dilation at 8 cm and fetal position at a 0 station. The client has been contracting regularly every 2 to 3 minutes with moderate identation, and now begins to have increased bloody show, and become nauseated. The nurse should plan this client’s care based on which phase of labor? a. early active b. prodromal c. transition d. latent active C The 1st stage of labor, dilation, is divided into a latent phase, an active phase, and the transition phase ©, which is characterixed by an increase in bloody show, cervical dilarion of 8 to 10 cm, contraction every 2 mins, nausea and an urge to push. A is not a phase f labor. B is also not a phase of labor but is characterized by prolonged uterine contractions over several days. D is characterized by mild, irregular contractions, with light bloody show, if any. 20. The nurse performs a vaginal examinationa nd determines that a laboring client is 6 cm dilated, 85% effaced, and at stattion 1. When the membranes rupture, the nurse notices the amniotic fluid is clear but contains bits of vernix, and the fetal heart rate remains withing normal limits. Which action should the nurse implement. a. document the color and characteristics of the amniotic fluid b. collect a sample of the amniotic fluid for analysis c. place the client in lithomy position and adjust the stirrups. D. position the delivery table at foot of the bed A Amniotic fluid should be clear and may include bits of vernic, so the nurse should document the coloe and characteristics of the amniotic fluidA. B is indicated when the fluid is yellowish tinge(meconium stained) or foul smelling(indication of infection). The woman is not ready to deliver(cervical dilation is only 6 cm), so (C and D) are not necessary at this time. 21. the nurse is preparing a 5 day old infant with a serum bilirubin level of 19mg/dl for discharge from the hospital. When teaching the parents about a prescription for home phototherapy, what instructions should the nurse include in the discharge teaching plan? a. Change the position every two hours b. perform diaper changes under the light c. feed the infant every 4 hours d. dress with a white cotton shirt .=a An infant, who is receiving phototherapy for hyperbilirubinemia, should be repositioned every two hours (A). The position changes ensure that the phototherapy lights reach all of the body surface areas. Bathing, feedings, and diaper changes (B) are ways for the parents to bond with the infant, and can occur away from the treatment. Feedings need to occur more frequently than every 4 hours (C) to prevent dehydration. The infant should wear only a diaper (D) so that the skin is exposed to the phototherapy. 22. when assessing a client at 32 weeks gestation, the nurse determines that her deep tendon reflexes (DTRs) are 4+. What action should the nurse take first? adetermines the client’s blood pressure bno action is required since this is a normal finding cassess the client’s for pitting edema dnotify the healthcare provider A The nurse should first determine the client’s blood pressure(A). A blood pressure of 140/90 or above or a 30/15 rise over baseline readings, indicates preeclampsia. B is in. 4+ DTRs are abnormal and are a sign of preeclampsia. Edema should be assessed in hands and face. C is a sign of increasing generalized edema, occurs in the lower legs, and is more common with fluid retention. The health care provider should be notified after a completer assessment of the client for signs and symptoms of PIH has been completed (D). 23. an HIV positive mother delivers a 6 pound boy. Which intervention should the nurse initiate to prevent transfer of the HIV disease to this child? aask the mother to come the nursery to feed and care for the baby bencourage rooming in but prevent breastfeeding c clean the skin with alcohol prior to administering vitamin k injection dteach the mother to come to the nursery to feed and care for the baby B Rooming in should not be allowed but transmission of the mother’s body fluids (breast milk) should be prevented (B). Universal precautions should be instituted (prevention of blood and body fluid transmission). A is not indicated. (C and D are not indicated since there is no possibility of maternal body fluid transmission to the newborn during normal handling or during diaper changes. 24. assessment findings of a 4 hour old newborn include: axillary temp 97.9 F, heart rate 150 beat/s min with a soft murmur, and irregular resp rate at 46 breaths//min. based on these finding what action should the nurse take? a. obtain a heel stick blood glucose level b. swaddle the infant in a warm blanket c. document the findings in the record d. place a pulse oximeter on the heel Since the vital signs are within normal range, the findings, should be documented (C). Based on these assessments findings (A,B,and D) are not warranted at this time. 25. The nurse finds a client at 32 weeks gestation in cardiac arrest. What adaptation of CPR should the nurse implement? Aopen the airway by placing the client’s head in the sniff position Bdisplace the uterus laterally using wedge under one hip CIncrease the ventilation to compression ration to 3:20 d. place one had over sternum for compressions 26. when assessing a client the first postpartum day, the nurse finds moderate amount of lochia rubra, with the uterus firm, dextroverted, and three fingerbbreadths above the umbilicus. What action should the nurse take first? a. massage the uterus to decrease atony b. assess the bladder for distention c. provide a stool softner for constipation d. check the hemoglobin to determine uterine hemorrhage b A fundus that is dectroverted (up to the right) and elevated above the umbilicus is indicative of bladder distention/urine retention (B). The nurse should always have the client empty her baldder the postpartum exam. This client’s uterus is firm, so (A) is in. A soft, boogy uterus indicates uterine atony. C doesn’t change uterine involution or placement. D should not be the nurse first suspicion when the uterus is firm and the lochia is moderate. 27. Following the vaginal delivery of a 9 pound infantm the nurse assess a new mother’s vaginal bleeding and finds that she has saturated three pads in the past hous, and has a boogy uterus. What action should the nurse take first. a. determine the client’s blood pressure B. Massage the fundus c. have the client empty her bladder d. assess the client’s pulse b All four actions should be taken by the nurse but (B) should be done first. Saturating more than one pad per hour following delivery is considered excessive bleedining. After stimulating the uterus with fundal massage, the nurse can then carry out (A,C and D). if the client’s uterus is dextroverted (shifted up and toward the right) the bleeding is likely due to a full bladder. Prior to having the client empty her bladder(c), the nurse should take action to decrease the bleeding by massaging the fundus 28. a primigravida at 39 weeks gestation is admitted to labor and delivery with spontatneous rupture of membranes (SROM) and contractions occuring every 2 to 3 minutes. A vaginal exam indicated that the cervic is dilated 6 cm, 90% effected, and the fetus is at +2 station. During the last 30 minutes the fetal heart rate has ranged between 170 and 180 beats/min. what action should the nurse implement first? Aobtain the maternal temperature b draw blood for a complete blood count c send amniotic fluid for analysis dprovide 4 liters of oxygen/face mask a Perisistent fetal tachycardia (fetal heart rate greater than 160 beats/min for more than 10 minutes) without decelerations, is commonly associated with prolonged labor following rupture of the membranes, so obtaining the maternal temperature (A) to assess for infection or amnionitis is the highes priority. ( B and C0 are actions that further assess for maternal infection, but first the maternal temperature should be obtained. Oxygen (D) should be administered if fetal heart rate deceleration are present. 29.a client who is bleeding after a vaginal delivery recieves a presciption for methyleergonovine (Methergine) 0.2 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg.ml. What is the maximum dosage in mg that the nurse should administer to this client? 0.2 mg/dose= Xmg/5 doses X=1 mg 30. The nurse should support and coach a client in the letent phaseof the first stage of laboe by encouraging the use of which breathing techniwue? adeep abdominal breathing bslowpaced breathing cpatterned paced breathing dmodified paced breathing During the latent phase of the first stage of labor, which can be long, slow paced breathing (B) is usually effective in calming the client and encouraging concentration and rest between contractions. (A,C, and D) are encouraged in the active phases of labor because these breathing techniques require more concentration and can increase the client’s fatigue. 31. a 28 year old gravida 2, para 1 client at 30 weeks gestation presents with contractions occuring 3 minutes apart with moderate intensity. A vaginal examination reveals that her cervix is dilated to 3 cm and is 100% effaced. Which nursing intervention has the highest priority for this client? a. assess blood pressure q15 minutrs b. send urine to the lab for urinalysis c. Administer betamethasne (Celestone) per prescription. d. obtain the client’s fingerprints for the birth record. c Respiratory Distress syndrome(RDS) is common in preterm infants who have immature lings. The incidence and severity of RDS has been found to be reduced if glucorticoids (eg betamethasone) are administered 24 to 48 hrs before birth to a woman who is less than 34 weeks gestation (C). (A,B and D) are all appropriate and necessary nursing interventions when assessing any laboring client, but none have the priority of © for the client experiencing preterm labor. 32. The nurse is preparing for the delivery of an infant whose primiparous mother is 35 years old and a low birth weight(LBW) infant is expected. Which intervention is most important for the nurse to implement? asend the placenta to pathology for analysis bencourage breast feeding after delivery cPreheat the radiant warmer. d obtain the infant’s birth weight The nurse should preheat the radiant warmer (C) to provide external warmth after birth and prevent heat loss by conduction and convection bc LBW infants have less insulating subcutaneous fat, and the goal after delivery is to provide an environment that will maintain the infant body temperature stability and minimizes oxygen consumption. Although (A) may provide information about the etiology of the neonates low birth weight, it is not the priority action. (B and D) are common nursing actions after delivery of an infant, but warmth and prevention of cold stress is the most important. 33. the nurse is presenting information about fetal development to a group of parents who are attending a Lamaze birthing class. When discussing cephalocaudal fetal development, which informaton should the nurse provide? afetal development occurs in a set order b the baby develops normally in one direction c the fetus develops from head to rump d brain development determines organ formation C Fetal system are developed in a predetermined order, best described by in the direction of head to rump (C ). While (A) may be true, cephalocaudal describes the specific order of fetal system development. (B) provides unclear information. (D) is inaccurate. 34. The nurse is preparing a client with Type 1 diabetes who is at 35 weeks gestation for amniocentesis. After obtaining maternal vital signs and a baseline fetal heart rate, which nursing interventin has the highest priority? a. obtain a baseline CBC b. provide family support c. ask the woman to void D. inititate a heparin lock The client should be instructed to void (C) prior to the procedure because reducing the size of the bladder helps to ensure that the needle is inserted into the uterus, and not the bladder, (A and D) are not required for this procedure. While (B) is important, it doesn’t have the priority of (C). 35. a 38 week primipara is admitted with spontaneous rupture of membranes (SROM) and irregular contractions occuring ever 10 min. the fetal heart rate is 178 beats/ min, and maternal vital signs include the temp 100.6 F, pulse 88 beats/ min, respirations 22 breaths/min, and blood pressure 120/79. What information is mot important for the nurse to obtain? A. color and amount of amniotic fluid b.last oral intake c. anesthesia choice d time membranes ruptures D Maternal fever and detal tachycardia are commonly associated with prolonged SROM and the nurse should determine the time the membranes rupture (D). (A) may provide information about fetal status, but the duration of ruptured membranes. Is more indicative of risk infection. (B and C) are important variables that help the nurse anticipate labor progress, but the duration of ruptured membranes is the priority in the situation. 36. The nurse has explained safety precautions and infant care to a primagravida mother and observes the mother as she gives care to her newborn during the first 2 days of rooming in. What action indicated the mother understands the instructions. aUses a bulb syringe in the newborn nare’s bPlaces the infant in a supine position to sleep. cwakes the infant up to breastfeed every 2 hours dbather the newborn in water using an infant sized tub B The mother’s understanding is indicated by placing the newborn in supine or back lying position to sleep (B), which is recommended to prevent the risk of sudden infant death syndrome (SIDS). The use of a bulb syringe in the nares can tramatixe the nasal mucuso and cause congestion which impedes suction, not nasal (b), is preferred to remove secretions. Awaking an infant every two hours to breastfeed is not necessary (C). The umbilical cord should be kept dry to prevent infection, so immersing the newborn in a tub of water (D) should be avoided until the umbilical cord falls off. 37. A multiparous client who delivered her infant three hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perineal pain after her last deliver. Which response would be best fot the nurse to provide this client? a explain the use of an analgesic spray to the perineal area to reduce pain b tell the client that warm sitz baths are used after the first 24 hours. cEncourage use of an ice pack for the first 24 hours. dteach the client to sit and stand with her buttocks tightened C Application of cold is preferred in the first 24 hours postpartum to promote comfort, reduce edema, and prevent hematoma dormation (C ). While A and D do increase comfort, they do not reduce edema or prevent hematoma, and both can increase “normal” discomfort even more. After 24 hours, (B) is used to increase circulation, increasing healing and promoting comfort. 38. When reviewing the records of a gravid client, the nurse notes that her deep tendion reflexes(DTRs) are 2+ Based on this information, which evaluation of the client’s condition is ? a She is in the early stages of eclampsia b she has severe preeclampsia cHer reflexes are within normal limits dHer neurological functoning is depressed c DTR of 2+ are within normal limits © for the bicep and patellar reflexes; 1+ would be a dull or sluggsigh response;3+ is a brisk response;4+ is more brisk DTRs of 4+ with sustained clonus are oftern associated with eclampsia (A). The client described in (B) would have DTRs of 3+ to 4+. The client described in (D) would have DTR of 1+. 39. a client at 8 weeks gestation is told her hemoglobin is 9.5 mg/dl. Which nursing intervention has the highest priority? aprovide the client with a list of goods high in iron binstruct the client to eat a well balance diet cexplain that this is a normal finding dobtain a prescription for an iron supplement When the hemoglobin level is below 10 mg/dl, iron deficiency anemia is suspected and the woman is prescribed iron supplementation (D). While implementing (A and B) would be beneficial to both mother and fetus, they would not supply enough iron to reverse the anemia. Although physiologic anemia (which occurs as the plasma volume increases more rapidly than red blood cell production) is normal in pregnancy ©, a hemoglobin of 9.3 is below normal for pregnancy (>11 mg/dl) 40. calculated by Nagele’s rul, a client is at 26 weeks gestation. She is moderately obese and carrying twins. The nurse measures her fundal height at 29 cm. Based on these findings, what conclusion is accurate? arecognizes this as a resasonable fundal height measurement for this client. bbefore taking further action, this finding needs to be confirmed by another nurse c this fundal height measurement many indicate intrauterine growth retardation since this is a mutiple bath. dthe healthcare provider needs to be notified immideately since this fundal height measurement is greater than expected A A fundamental height measurement of 29 cm is reasonable for this client (A). After 22 weeks the fundal heaight measurement in cm should be approximately the same as the gestation week. However, since the client is carrying twins the uterus can be expected to be larger. Also, because of her obesity, excess adipose tissue on her abdomen would increase the fundal increase the fundal height measurement. Because this a normal finding for this client (B,C and D) are not appropriate conclusions. 41. The healthcare provider prescribes 500 mg.hour of magnesium sulfate for a client with pregnancy induced hypertension (PIH). The pharmacy delivers a 500 ml IV that contains 4 grams of the drug. The nurse should set the IV infusion pump to deliver how many ml per hour. 63 First, convert the grams to milligrams: 4 gm/1gm X 100 mg equals 4000 mg. Next, determine the concentration of the solution: 4000 mg/500 ml = 8 mg/ml. To find the hourly flow rate, divide the prescribed dose (500 mg/hour) by the available solution concentration (8 mg/ml)= 62.5=63 ml/hour 42. The parents of a normal male newborn have signes an informed consent for circumsion. The healthcare provider has prescribed EMLA(eutectic mixture of local anesthetics) cream 1 gram to penis per occlusive dressing 60 minutes prior to procedure.What priority intervention should the nurse implement? a offer a pacifier dipped in glucose water bgive a PRN dose of liquid acetaminophen cApply petrolateum gauze dressings to the site. d position the swaddled newborn laterally Prevention and monitoring the excessive bleeding are priority interventions. A gauze dressing with petroleum ointment should be applied © to prevent the diaper from adhering to the penis and causing clot dislodgement and bleeding when the diaper is removesd. Comfort measures such as holding sucklining (A) or swaddling (D) should be provided for the infant’s pain, but do not have the same priority as prevent bleeding. Since pain is difficult to assess in a newborn, a PRN dose of acetaminophen (B) should be given, but is not the highest priority action. 43. The mother of a 3 dayold male infant notices that his skin has yellowish tint. She asks the nurse about it. What is the most likely reason for jaundice in his infant. Lowered serum bilirrubin level die to red blood cells breakdown and immature renal function 44. What nursing intervention is of greatest benefit in preventing postpartum thrombophlebitis? aencourage use of supportive stockings bapply moist heat to varicose veins cencourage early prenatal care dpromote early postpartum ambulation Early ambulation (D) increases venous retuen and prevents thrombophlebitis. Clotting factors are normally elevated in the postpartum period to heal the placental site, thereby predisposing clients to thrombus formation. (A and B) are treatment measures for thrombophlebitis. © helps identify the client at risk for thrombophlebitis. 45. While assessing a client at 22 weeks gestation, the nurse suspects that the placenta soufflé rate was counted, rather than fetal heart rate. To confirm that the placenta soufflé rate was obtained, what action should be nurse taken. acompare the clients radial pulse rate with the ausculcalted rate. bApply a fetal monitor to assess for uterine contractions. cperform leopolld’ maneuvers to determine the position of fetus. dcollect a voided specimen to check for protein in the urine The nurse should palpate the client’s radial pulse rate (A). A soft blowing sound (placenta soufflé) ausculatated over the uterus (a) is caused by blood circulating through the placenta and corresponds to the maternal pulse rate. (B,C, and D) do not confirm that the rate auscultated is the placental soufflé. 46. after a client experiences spontaneous rupture of the membranes during labor, the nurse notes a visible prolapsed of the umbilical cord. What intervention should the nurse implement immediately. aadminsiter oxygen by face mask at 6l/min bprepare the client for a cesarean delivery cpush the presenting part off the cord dturn the client to a supine position =c The nurse should immediately push the presenting part off the cord (C) because when the cord prolapses, the presenting part will apply pressure to the cord, especially during the each contraction, and reduce perfusion to the infant. (A) can be delayed until pressure is removed from the cord. B is important but does not have the priority of C. D could place additional pressure on the cord. 47. A mother who is bottle feeding her baby develops breast engorgement. What is the best recommendation for the nurse to provide this client? aWear a tight bra and avoid breast stimulation. bExpress some milk from the breast by hand cExpose the breast to air dApply warm packs to the breast =A Compressing the milk sinuses by wearing a tightfitting bra and preventing breast stimulation (A) decreases prolactin secretion and milk production. (B) will increase milk production, although it will provide temporary relief. C is an intervention used for sore nipples, not engorgement. D will increase vasodilation and the engorgement. 48. The nurse is performing an admission physical assessment of a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider? a heel stick glucose of 65 mg/dl bhead circumference of 35 cm (14 inches) cWidened, tense, bulging fontanel d. highpitched shrill cry c C is indicative of increased intracranial pressure (ICP) that is expanding suture lines and fontanel tension. Normal capillary glucose for a neonate ranges between 4080 mg/dl (A). (B) is the upper limits of an average gestational age neonate, and the frontal occipital circumference should be compared with other measurements for the SGA neonate when reporting the finding. (D) is condsistent with increased ICO and may also be seen in congenital or chromosomal defects that alter vocal cord structure, and should be reported but (C) is the most critical finding to report. [Show More]

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