58 Questions
What action should the nurse take first upon learning that the client drank coffee before a scheduled C-Section?
Inform the anesthesia care provider
Prior to the anesthesiologist's arrival, what should the nurse do when caring for a postpartum client exhibiting symptoms of a spinal headache?
Place procedure equipment at the bedside
Based on the newborn's physical findings, what condition should the nurse prioritize assessment for?
Hypoglycemia
What complication should the nurse suspect in a 35-week gestation infant with a respiratory rate of 72 breaths per minute, nasal flaring, grunting, and retractions?
Transient tachypnea of the newborn
In a 42-week gestation client who has progressed rapidly after initiating oxytocin infusion, what should the nurse do next?
Stop the oxytocin and initiate oxygen therapy
What is the purpose of testing the newborn's blood type?
To decide if RhoGAM 50 is necessary
What condition did the nurse observe about the infant's delivery?
The infant had molding on the head
Why is it important for the nurse to call these findings to the attention of the pediatrician?
To determine the need for further medical intervention
In what scenario would oxytocin drip be prescribed?
For a woman in her third trimester of pregnancy with hypotonic dystocia
What is the significance of a woman being Rh-negative in relation to her newborn?
It indicates the need for RhoGAM 50 administration
Which assessment finding is most crucial for monitoring during active labor with hypotonic dystocia?
Electronic fetal monitoring data
What condition is the client likely experiencing based on the symptoms described?
Herpes simplex virus
What advice should the nurse give to a client who is breastfeeding and using the same diaphragm as before pregnancy?
Use an alternative form of birth control until a new diaphragm can be obtained.
What is the priority nursing action for a primigravida who delivered a 9-pound infant vaginally after a 30-hour labor?
Massage the fundus every 4 hours
What is the most appropriate action if a client reports using the same diaphragm postpartum?
Recommend using spermicides with the diaphragm
What could be the consequence of a client continuing to use the same diaphragm postpartum?
Greater likelihood of vaginal infections
Why is it important for a breastfeeding mother to use an alternative form of birth control until obtaining a new diaphragm?
To reduce the risk of an unplanned pregnancy
How many factors related to contractions are mentioned in the text?
Three
What aspect of contractions is discussed regarding intensity?
Strength
Which factor refers to the duration of contractions?
Length
What is interval in the context of contractions?
The frequency between contractions
Which factor relates to how close or far apart contractions are?
Interval
What intervention should the nurse implement when contractions are occurring every 5 minutes with a 20-second duration?
Restart the oxytocin per oxytocin protocol
What makes the nurse realize a primigravida client is not in labor?
Contractions stop when the client is walking
What action should the nurse take after observing regular contractions with cervical changes post misoprostol administration?
Administer oxytocin 4 hours later
How many ml/hr should the nurse program the infusion pump to deliver when using Lactated Ringers 1,000 ml with Pitocin 20 units for a multigravida client?
20 ml/hr
After a fetus dies in utero at 32 weeks gestation, what is the most important action for the nurse to take?
Encourage the mother to hold and spend time with her baby
What should be done for a client at 36 weeks gestation following a minor vehicle collision?
Monitor fetal heart rate for 24 hours
What is the correct dosage of phytonadione (Vitamin K1) in ml should the nurse administer to a newborn based on the information provided?
0.4 ml
Why should the nurse withhold methylergonovine maleate (Methergine) from a postpartum client with a blood pressure of 149/90?
Hypertension
Which activity would be most beneficial for a 16-year-old with juvenile rheumatoid arthritis (JRA) to strengthen and mobilize joints?
Exercise in a swimming pool
What is the fetal heart rate and contraction pattern observed through the external fetal heart monitor in the presented case?
Fetal heart rate of 120 beats/minute with irregular contractions every 10 to 15 minutes
What instruction would be most appropriate for the nurse to give to the family of a child with a lacerated forehead before suturing?
"Both parents and one sibling can stay at the child's bedside"
In what scenario would a nurse encourage a client to include chicken in her diet?
Iron-deficiency anemia
The nurse is administering methylergonovine maleate (Methergine) to a postpartum client. What finding would indicate that the nurse should withhold the drug?
Positive Homan’s sign
Which medication is used as a tocolytic to decrease contractions in premature deliveries?
Betamethasone (Celestone)
What is the recommended physical therapy regimen to strengthen and mobilize joints and surrounding muscles in a 16-year-old with juvenile rheumatoid arthritis (JRA)?
Passive range of motion exercises
When should the nurse encourage a postpartum client to use Butorphanol (Stadol)?
Every 20 minutes
For which assessment finding should the nurse prioritize care in a postpartum client receiving Betamethasone (Celestone)?
Fetal movement felt by the client
What joint strengthening method should be avoided in a 16-year-old with juvenile rheumatoid arthritis (JRA)?
High-impact weight training
Why would a breastfeeding infant, screened for congenital hypothyroidism, have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH)?
The TSH is high because of the low production of T4 by the thyroid.
What should the nurse do first when a full-term infant in the nursery regurgitates and turns cyanotic?
Stimulate the infant to cry.
When is the best time to administer a rubella vaccine to a client who is non-immune at 6-weeks’ gestation?
Early postpartum, within 72 hours of delivery.
What is the most important assessment for a client receiving oxytocin to augment early labor each time the infusion rate is increased?
Contraction pattern evaluation.
Which lunch choice made by a mother for her child taking digitalis and a diuretic for heart failure indicates understanding of the best diet?
Peanut butter and banana sandwich with orange juice.
Which finding confirms to the nurse that a client is not in labor at a particular time?
Contractions decrease with walking.
In a child admitted with diabetic ketoacidosis demonstrating Kussmaul respiration, what acid-base alteration is the increased respiratory rate compensating for?
Metabolic acidosis
What action should the nurse prioritize if a 3-month-old infant's head circumference has increased significantly since birth?
Palpate the anterior fontanel for tension and bulging
For a 5-year-old child with Reye's syndrome, what is the primary goal of treatment?
Reduce cerebral edema and lower intracranial pressure
In a client whose labor is being augmented with oxytocin and requests an epidural for pain control, what should the nurse do first?
Determine current cervical dilation
What is the most crucial assessment for a 16-year-old client admitted with eclampsia but not currently convulsing?
Keep airway equipment at the bedside
What acid-base alteration is a client with Kussmaul respiration likely experiencing?
Metabolic acidosis
What should be a priority intervention discussed with parents who have an autosomal dominant disorder and are concerned about future children inheriting the disorder?
Discuss genetic counseling options
In a client with vomiting leading to the risk of metabolic alkalosis, what should be monitored closely?
Potassium levels
If a child is exhibiting chorea or temporary movements, what is the most important advice regarding discipline?
Use gentle discipline to support the child
What action may be necessary if a pregnant mother exhibits signs of metabolic alkalosis due to vomiting?
Provide potassium supplements
What lifestyle change is recommended to promote safety in the home for a child experiencing decreased muscle tension?
Reduce clutter and ensure clear pathways
Why are fine motor skill projects encouraged in children with decreased muscle tension?
To improve hand-eye coordination
Study Notes
Maternity and Pediatric Nursing
Herpes Simplex Virus
- Recognize symptoms of herpes simplex virus: shallow small vesicles on pubis, labia, and perineum
Birth Control
- Use alternative form of birth control until new diaphragm can be obtained
Respiratory and Metabolic Acidosis
- Kussmaul respiration is a compensatory mechanism for metabolic acidosis
- Vomiting can lead to metabolic alkalosis related to loss of hydrochloric acid
Pediatric Nursing
- Goal of treatment for Reye's syndrome: reduce cerebral edema and lower intracranial pressure
- Promote kidney perfusion and normal blood pressure in Reye's syndrome
Labor and Delivery
- Action to take when client is not in labor: contractions stop when client is walking
- Action to take when client is in labor: administer oxytocin (Pitocin) 4 hours later
- Priority nursing action after delivering a 9-pound infant vaginally: massage the fundus Q 4 hours
Postpartum Care
- Importance of holding and spending time with the baby after fetus died in utero
- Response to Rh-negative client: test newborn's blood type to determine need for RhoGAM
Pediatric Assessment
- Abnormal head/chest ratio: call findings to the attention of the pediatrician
- Action to take with hypotonic dystocia: monitor intensity, interval, and length of contractions
Newborn Care
- Importance of Vitamin K1 administration: 0.5 mg IM to newborns upon admission
- Action to take with transient tachypnea of the newborn: recognize respiratory rate of 72 breaths/minute, nasal flaring, grunting, and retractions
Medication Administration
- When to withhold methylergonovine maleate (Methergine): blood pressure of 149/90
- Importance of phytonadione (Vitamin K1) administration: 0.5 mg IM to newborns upon admission
Prepare for the HESI OB Maternity Version 1 exam with this set of brand new questions and answers, including screenshots. The material comes from a test taken on March 7th, 2022, and is designed to help you achieve a high score.
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