HESI Comprehensive NCLEX-RN Practice Maternity with

HESI Comprehensive NCLEX-RN Practice (Maternity) with complete solution

An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which recommendation should the nurse make to this expectant father?A.Suggest that his wife seek professional counseling to deal with her symptoms.B.Explain that his wife is exhibiting ambivalence about the pregnancy.

• Ask him to report similar abnormal behaviors at the next prenatal visit.

D.Reassure him that normal maternal-fetal bonding is occurring. - answerD) Reassure him that normal maternal-fetal bonding is occurring.Rationale: These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No intervention is needed.

The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is completed, it is most important for the nurse to obtain which information?A.Maternal blood pressure B.Maternal temperature C.Fetal heart rate (FHR) D.White blood cell count (WBC) - answerC) Fetal heart rate (FHR) Rationale: The FHR should be assessed before and after the procedure to detect changes that may indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for color, odor, and consistency.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding?A.Cyanosis of the hands and feet B.Skin color that is slightly jaundiced

C.Tiny white papules on the nose or chin D.Red patches on the cheeks and trunk - answerB) Skin color that is slightly jaundiced Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed.Which instruction should the nurse provide to this client?A.Breastfeed the infant, ensuring that both breasts are completely emptied.B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.C.Breastfeed on the unaffected breast only until the mastitis subsides.D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. - answerA) Breastfeed the infant, ensuring that both breasts are completely emptied.Rationale: Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue.

A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the lower extremities?A.Wear support stockings.B.Reduce salt in the diet.C.Move about every hour.D.Avoid constrictive clothing. - answerC) Move about every hour.Rationale: Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous return.

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of blood between the periosteum and skull that does not cross the suture line?A.Cephalhematoma, which is caused by forceps trauma

B.Subarachnoid hematoma, which requires immediate drainage C.Molding, which is caused by pressure during labor D.Subdural hematoma, which can result in lifelong damage - answerA) Cephalhematoma, which is caused by forceps trauma Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull.

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home?A.Wash the cord frequently with mild soap and water.B.Cover the cord with a sterile dressing.C.Allow the cord to air-dry as much as possible.D.Apply baby lotion after the baby's daily bath - answerC) Allow the cord to air-dry as much as possible.Rationale: Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process.

A mother expresses fear about changing the infant's diaper after circumcision. What information should the nurse include in the teaching plan?A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.B.Wash off the yellow exudate on the glans once every day to prevent infection.C.Place petroleum ointment around the glans with each diaper change and cleansing.D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. - answerC) Place petroleum ointment around the glans with each diaper change and cleansing.Rationale: With each diaper change, the glans penis should be washed with warm water to remove any urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing surface.

A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in

preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline sulfate?A.Drowsiness and paroxysmal bradycardia B.Depressed reflexes and increased respirations C.Tachycardia and a feeling of nervousness D.A flushed warm feeling and dry mouth - answerC) Tachycardia and a feeling of nervousness Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness.

A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective in preventing nipple soreness?A.Wear a cotton bra with nonbinding support.B.Increase nursing time gradually over several days.C.Ensure that the baby is positioned correctly for latching on.D.Manually express a small amount of milk before nursing. - answerC) Ensure that the baby is positioned correctly for latching on.Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast.

A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?" Which explanation is appropriate?A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat." B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day." C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry." D."If you're concerned, you might consider bottle feeding so that you can monitor intake." - answerB) "Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."