Maternity HESI Quizlet

Questions 46

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Maternity HESI Quizlet Questions

Question 1 of 5

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care?

Correct Answer: A

Rationale: The correct answer is A: 'Patellar reflex 4+'. Hyperreflexia is a sign of severe preeclampsia and increases the risk of seizures, indicating the need for immediate intervention. Monitoring and addressing this finding are crucial in managing the client's condition and preventing complications.

Question 2 of 5

A multiparous client is involuntarily pushing while being wheeled into the labor triage area. The nurse observes the fetal head presenting at the perineum. Which action should the nurse take?

Correct Answer: A

Rationale: When the fetal head is visible at the perineum, the priority is to support the infant's birth to prevent injury. Providing support as the infant emerges helps ensure a safe delivery process and reduces the risk of complications associated with rapid or uncontrolled birth.

Question 3 of 5

A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother, who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which intervention is most important to implement?

Correct Answer: B

Rationale: Infusing normal saline intravenously is crucial to treat dehydration caused by fever and diarrhea. In this scenario, the infant's weak cry with no tears indicates severe dehydration, necessitating rapid fluid replacement via intravenous normal saline to restore fluid balance and prevent complications.

Question 4 of 5

What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?

Correct Answer: D

Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.

Question 5 of 5

During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct Answer: C

Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.

Similar Questions

During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
A child with glomerulonephritis is asking for strawberries. What should the nurse do?
The healthcare provider is reviewing the serum laboratory findings for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory result should be reported to the healthcare provider immediately?
The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing history, the client indicates that she has delivered premature twins, one full-term baby, and has had no abortions. Which GTPAL should the LPN/LVN document in this client's record?

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