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?- Skildor

Question 1 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?

A. Observe the urethral opening on the surface of the penis when the newborn voids. B. Perform transillumination of the scrotal sac to visualize shadows of the testes. C. Use a fingertip to palpate the inguinal canal for a retractile or undescended testis. D. Measure the size of the scrotal sac for length and width.

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.

Question 2 of 5

A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?

A. Encourage the mother to provide total care for her infant. B. Provide privacy so the mother can develop a relationship with the infant. C. Encourage the father to provide most of the infant's care during hospitalization. D. Meet the mother's physical needs and demonstrate warmth toward the infant.

Correct Answer: D

Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.

Question 3 of 5

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 1. What action should the healthcare provider take immediately?

A. Give the medication as prescribed and monitor for efficacy. B. Encourage the client to breastfeed rather than bottle-feed. C. Have the client empty her bladder and massage the fundus. D. Call the healthcare provider to question the prescription.

Correct Answer: D

Rationale: The correct action for the healthcare provider to take immediately is to call the healthcare provider to question the prescription. Methergine is contraindicated in clients with hypertension due to its potential to elevate blood pressure further. In this scenario, the client's blood pressure is already elevated at 156/96, making it unsafe to administer Methergine. The LPN/LVN should advocate for the client's safety by questioning the prescription to prevent potential harm.

Question 4 of 5

In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the

A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week. B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week. C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month. D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.

Correct Answer: D

Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.

Question 5 of 5

A woman at 36-weeks' gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest, and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. The nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

A. Perform a sterile vaginal examination to determine dilatation. B. Determine fetal position by performing Leopold maneuvers. C. Assess the fetal heart rate and client's contraction pattern. D. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.

Correct Answer: C

Rationale: The highest priority nursing intervention in this scenario is to assess the fetal heart rate and the client's contraction pattern. The presence of a large amount of bright red vaginal bleeding in a woman at 36-weeks' gestation who is Rh negative raises concerns about the well-being of the fetus. Monitoring the fetal heart rate and contraction pattern will provide crucial information about fetal status and help determine the appropriate course of action to ensure the safety and health of both the mother and the baby.

Maternity HESI Quizlet

Skildor

HESI RN

HESI RN

Maternity HESI Quizlet Questions

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