HESI RN
Maternity HESI 2023 Quizlet Questions
Question 1 of 5
After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
Correct Answer: B
Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.
Question 2 of 5
A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child's plan of care?
Correct Answer: B
Rationale: In the case of slipped femoral capital epiphysis, surgical intervention is often required. Post-surgery care is crucial to prevent complications such as infection and ensure proper healing. This care includes monitoring and managing pin and incision sites for signs of infection, promoting wound healing, and preventing postoperative complications. The focus on pin and incision care is essential for the child's recovery and overall well-being.
Question 3 of 5
A client who is receiving oxytocin to augment early labor begins to experience tachysystolic tetanic contractions with variable fetal heart decelerations. Which action should the nurse implement?
Correct Answer: A
Rationale: When a client experiences tachysystolic tetanic contractions with variable fetal heart decelerations, indicating uterine hyperstimulation, the priority action is to turn off the oxytocin infusion. This step aims to reduce uterine activity, which can compromise fetal oxygenation and lead to adverse outcomes.
Question 4 of 5
The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?
Correct Answer: C
Rationale: For performing an amniotomy, the nurse should have a sterile glove to maintain asepsis and an amniotic hook to rupture the amniotic sac. Litmus paper is not required for this procedure, and a fetal scalp electrode is used for fetal monitoring, not for an amniotomy.
Question 5 of 5
When assessing a child with HIV, which system should the nurse assess first?
Correct Answer: A
Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.
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