Which finding for a client in labor at 41\u00adweeks gestation requires
additional assessment by the nurse?
Cervix dilated 2 cm and 50% effaced.
Score of 8 on the biophysical profile.
Fetal heart rate of 116 beats per minute.
One fetal movement noted in an hour.
A client at 28\u00adweeks gestation arrives at the labor and delivery unit with
a complaint of bright red, painless vaginal bleeding. For which
diagnostic procedure should the nurse prepare the client?
Contraction stress test.
Internal fetal monitoring.
Abdominal ultrasound.
Lecithin\u00adsphingomyelin ratio.
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon
fundal assessment, the nurse determines the uterus is boggy and is
displaced above and to the right of the umbilicus. Which action should
the nurse implement next?
Document the color of the lochia.
Observe maternal vital signs.
Assist the client to the bathroom.
Notify the healthcare provider.
A multiparous client is experiencing bleeding 2 hours after a vaginal
delivery. What action should the nurse implement next?
HESI MATERNAL NEWBORN GUIDE 2019
Correct Questions & Answers<\/p>\n\n\n\n
Determine the firmness of the fundus.
Give oxytocin (Pitocin) intravenously.
Inform the healthcare provider of the bleeding.
Assess the vital signs for indicators of shock.
The nurse notes a pattern of the fetal heart rate decreasing after each
contraction. What action should the nurse implement?
Give 10 liters of oxygen via face mask.
Prepare for an emergency cesarean section.
Continue to monitor the fetal heart rate pattern.
Obtain an oral maternal temperature.
A client at 28\u00adweeks gestation experiences blunt abdominal trauma.
Which parameter should the nurse assess first for signs of internal
hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate patterns.
Alteration in maternal blood pressure.
Which client should the nurse report to the healthcare provider as
needing a prescription for Rh Immune Globulin (RhoGAM)?
Woman whose blood group is AB Rh\u00adpositive.
Newborn with rising serum bilirubin level.
Newborn whose Coombs test is negative.
Primigravida mother who is Rh\u00adnegative.<\/p>\n\n\n\n
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https:\/\/www.coursehero.com\/file\/24089440\/2016-OB-HESI-Guidedocx\/
HESI MATERNAL NEWBORN PROCTORED EXAM
(STUDY GUIDE) 2021\/2022<\/p>\n\n\n\n
This study source was downloaded by 100000839976293 from CourseHero.com on 01-26-2022 06:57:35 GMT -06:00
https:\/\/www.coursehero.com\/file\/24089440\/2016-OB-HESI-Guidedocx\/<\/p>\n\n\n\n
HESI MATERNAL NEWBORN 2019 EXAM – REVISION GUIDE
190+ Correct Questions & Answers<\/p>\n\n\n\n
HESI MATERNAL NEWBORN
EXAM (STUDY GUIDE)
2020\/2021<\/p>\n\n\n\n
HESI MATERNAL NEWBORN PROCTORED EXAM STUDY GUIDE 2020\/2021<\/p>\n\n\n\n
c. Ambulate the client to strengthen the contraction pattern
d. Position the client in a lithotomy position to administer perineal care
Ans: B – the nurse should assess fetal heart tones. After an amniotomy is performed, the
umbilical cord may be washed down below the presenting part and cause umbilical cord
compression, which would be indicated by variable deceleration on the fetal heart tracing. An
explanation of the rationale for amniotomy would be given before d procedure. After assessing
the fetal response to the amniotomy, perineal care s provided. The nurse would ambulate
client only if the presenting part were engaged.<\/p>\n\n\n\n
a. Assess the client\u2019s vital signs immediately
b. Observe for prolapsed cord and monitor fetal heart rate
c. Administer oxygen through a face mask at 6-10 L per min
d. Position the client on her side
Ans: B \u2013 the nurse should immediately check for prolapsed cord and monitor FHR. When the
membranes rupture, the cord may become compressed between the fetus and maternal cervix
or pelvis, thus compromising fetoplacental perfusion. It isn\u2019t necessary to position the client on
her left side, monitor maternal vital signs, or administer oxygen when the client\u2019s membrane
rupture.<\/p>\n\n\n\n
b. \u201cYou will probably take this medication until you are discharged from the hospital.
Every patient usually needs to take this medication.\u201d
c. \u201cIf your blood pressure is low, you won\u2019t be able to take this medication; I will establish a
new IV line so I can start Pitocin again.\u201d
d. \u201cMost people don\u2019t experience additional pain or cramping from taking this medication.\u201d
Ans: A \u2013 Methylergonovine, an ergot alkaloid, is commonly given to stimulate sustained
uterine contraction. It allows the uterus to remain contracted and firm, thus decreasing
postpartum bleeding. Abdominal cramping, which may become painful, is a common adverse
effect.
Methergine is discontinued when the lochia flow has decreased or the client complains of severe
cramping. Clients may need only a few doses of Methergine to keep the uterus contracted.
Taking Methergine is contraindicated in clients with hypertension.<\/p>\n\n\n\n
lOMoARcPSD|3920845
HESI MATERNAL NEWBORN PROCTORED RETAKE GUIDE
The nurse observes a new mother avoiding eye contact with her newborn. Which action should
the nurse take?
Observe the mother for other attachment behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose?
Screen for neural tube defects.
What action should the nurse implement to decrease the client’s risk for hemorrhage after a
cesarean section?
Check the firmness of the uterus every 15 minutes
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous
abortion at 8-weeks\u2019 gestation. What type of emotional response should the nurse anticipate?
Grief related to her perceptions about the loss of this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider?
Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple to
attend these classes?
At 30-weeks gestation is closest to the time parents would be ready for such classes. Learning is
facilitated by an interested pupil! The couple is most interested in childbirth toward the end of
the pregnancy when they are psychologically ready for the termination of the pregnancy, and the
birth of their child is an immediate concern.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion?
Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign
of an impending convulsion (eclampsia) and requires immediate attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important
for the nurse to report to the healthcare provider immediately?
Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal
therapy. Which response is best for the nurse to provide?
It is important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare
provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure
complaint indicates that the fallopian tubes are patent?<\/p>\n\n\n\n
lOMoARcPSD|3920845
If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic
collection of peritoneal dye\/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her
buttock. The nurse notes that both perineal pads are completely saturated and the client is lying
in a 6-inch diameter pool of blood. Which action should the nurse implement next?
Palpate the firmness of the fundus.
One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small
to large and her fundus is boggy despite massage. The client’s pulse is 84 beats\/minute and blood
pressure is 156\/96. The healthcare provider prescribes Methergine 0.2 mg IM \u00d7 1. What action
should the nurse take immediately?
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should
contact the healthcare provider and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client?
Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may
develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the
increased blood volume that occurs during pregnancy, so obtaining information about this
client’s health history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin?
Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the
client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture,
and fetal distress or demise.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity?
Urine output 90 ml\/4 hours. Urine outputs of less than 100 ml\/4 hours (D), absent DTRs, and a
respiratory rate of less than 12 breaths\/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which information should the
nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with
healthy lifestyles in the family (D) which is an intervention in preconception care that targets an
overall goal for a client preparing for pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a nonstress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test
should the nurse prepare the client for additional information about fetal status?<\/p>\n\n\n\n
lOMoARcPSD|3920845
Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining
5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and
heart rate.
A client with no prenatal care arrives at the labor unit screaming, “The baby is coming!” The
nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75%
effaced. What additional information is most important for the nurse to obtain?
Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes
priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider
may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the
fetus.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she is
not experiencing any uterine contractions or abdominal pain. What instruction should the nurse
provide?
Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a
placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous.
Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is
confirmed by transabdominal ultrasound (A).
A new mother is afraid to touch her baby’s head for fear of hurting the “large soft spot.” Which
explanation should the nurse give to this anxious client?
There’s a strong, tough membrane there to protect the baby so you need not be afraid to wash or
comb his\/her hair.
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In
which sequence should the nurse implement these nursing actions? (Arrange in order.)
Reposition the client.
Provide oxygen via face mask.
Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest priority?
Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and
prevent a postpartum hemorrhage–this intervention has the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary
infusion and complains of pain in her lower back. Which intervention should the nurse
implement?
Apply firm pressure to sacral area. The discomfort of back labor can be minimized by the
application of firm pressure to the sacral area<\/p>\n\n\n\n
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of
water has broken. The nurse identifies the presence of meconium fluid on the perineum and
determines the fetal heart rate is between 140 to 150 beats\/minute. What action should the nurse
implement next?
Complete a sterile vaginal exam. A vaginal exam (A) should be performed after the rupture of
membranes to determine the presence of a prolapsed cord.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The
nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is
144 bpm, and no FHR accelerations are occurring. What action should the nurse take?
Ask the client if she has felt any fetal movement.
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child,
but I would like to try with this baby.” Which intervention is best for the nurse to implement
first?
Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming
to the unit with suspected abruptio placentae. What findings should the charge nurse expect the
client to demonstrate? (Select all that apply.)
Dark, red vaginal bleeding.
Increased uterine
irritability. A rigid abdomen.
The nurse is teaching care of the newborn to a group of prospective parents and describes the
need for administering antibiotic ointment into the eyes of the newborn. Which infectious
organism will this treatment prevent from harming the infant?
Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2
hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and
inclusion conjunctivitis, an infection caused by chlamydia (C).
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index,
the nurse determines the infant has synchronized chest and abdominal movement, just visible
lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and
an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse
assign to this infant? (Enter numeral value only.)
A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges
from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th
finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total
score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates
maximum respiratory distress.<\/p>\n\n\n\n
OB-Maternal Newborn Exit HESI
Client with gestational diabetes; 39 wks gestation; second stage of labor After delivery of fetal head nurse
recognizes shoulder dystocia is occurring.
Assist the client to sharply flex her thighs up against the abdomen
During initial newborn assess, nurse finds HR irregular.
Document finding in infant record
Within 4 wks of birth client is admitted for disorganized speech, bizarre behavior and strange thoughts
about infant being possessed by demons. \u201caltered thought process, secondary to\u201d
Postpartum psychosis
Infant is treated for intussusceptions with hydrostatic reduction. What instructions in parents teaching
plan
Signs and symptoms of recurrence
Nurse teaching primagravida, describes herself as lacto-vegetarian, about nutrition during pregnancy.
Which foods
Cheese, green salad, fruit
Four clients present to L & D unit at the same time. Nurse should assess what complaint first?
Abdominal pain and bright red bleeding
Labor 12 hours suddenly has strong urge to have a BM. Action
Perform a sterile vaginal exam
Client went into labor at 3:15 am. When did the first stage of labor end
full dilation and effacement at 11:45 am
Pregnant with magnesium level 5.0
watch BP
Magnesium antidote
Calcium gluconate
Newborn baby with flea-like rash
normal and will disappear
How to tell if patient is in labor
Fern test
Baby acting jittery
check glucose level
Which will NOT increase breast milk supply
supplemental formula feedings
4 patients with conditions of concern-priority
Make sure patient has units of blood available<\/p>\n\n\n\n
When should someone be concerned about decels
To prevent neural tube disorders
Folic acid during PG
Indicators of IICP in infants
Bulging fontanels, high pitched cry, increased head circumference, wide suture lines, lethargy
Avoid in patients with IICP
Suctioning, coughing, straining and bending
Ovulation occurs on day 14 of menses
Menses cycle is 28 days total
Bluish coloration of the vagina
Chadwick\u2019s sign
Hegar\u2019s sign
Softening of isthmus of cervix at 8 weeks of pregnancy
Total weight gain during pregnancy should be
25-30 lbs (11-14kg)
During pregnancy how many calories should the mother intake
Increase of 300\/day from pre-pregnancy amount
TORCH
Toxoplasmosis
Having <300 ml of amniotic fluid and leading to fetal kidney problems
Oligohydramnios
The umbilical cord is composed of
2 arteries and 1 vein
Preterm is considered
20-37 weeks gestation
Term is considered
38-42 weeks gestation
Post-term is considered
Any time after 42 weeks
Know Nagal\u2019s rule-you will be given a woman\u2019s last period and you will have to figure her date of
conception (add 7 days to first day of last period, subtract 3 months, add 12 months)
Hyperhydration during pregnancy can lead to
Lower Hgb and Hct<\/p>\n","protected":false},"excerpt":{"rendered":"
Which finding for a client in labor at 41\u00adweeks gestation requiresadditional assessment by the nurse?Cervix dilated 2 cm and 50% effaced.Score of 8 on the biophysical profile.Fetal heart rate of 116 beats per minute.One fetal movement noted in an hour.A client at 28\u00adweeks gestation arrives at the labor and delivery unit witha complaint of bright […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-117529","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/117529","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=117529"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/117529\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=117529"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=117529"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=117529"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}