HESI RN
Maternity HESI 2023 Quizlet Questions
Question 1 of 5
The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm, and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?
Correct Answer: D
Rationale: In a postpartum client with a perineal hematoma, assessing heart rate and blood pressure is crucial as it can help determine the client's circulatory status. A perineal hematoma has the potential to cause significant blood loss leading to hypovolemia. Monitoring vital signs like heart rate and blood pressure can provide immediate information on the client's hemodynamic stability and guide further interventions if needed.
Question 2 of 5
A client who is 32 weeks' gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
Correct Answer: A
Rationale: Inspecting the client's face for edema is crucial to assess for preeclampsia, a serious condition characterized by high blood pressure during pregnancy. Edema, particularly facial edema, can be a significant indicator of preeclampsia, prompting the need for further evaluation and management to ensure the well-being of both the client and the unborn child.
Question 3 of 5
A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?
Correct Answer: B
Rationale: Removing restraints one at a time for range of motion exercises prevents muscle stiffness and allows assessment of the skin.
Question 4 of 5
When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?
Correct Answer: A
Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.
Question 5 of 5
After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil� Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac� Soy Isomil� Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?
Correct Answer: D
Rationale: The LPN/LVN should inform the mother that Similac� Soy Isomil� Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.
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