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Year-2021
, HESI Maternity
Which finding for a client in labor at 41-weeks gestation requires
additional assessment by the nurse?
Cervix dilated 2 cm and 50% effaced.
Score of 8 on the biophysical profile.
Fetal heart rate of 116 beats per minute.
One fetal movement noted in an hour.
A client at 28-weeks gestation arrives at the labor and delivery unit with
a complaint of bright red, painless vaginal bleeding. For which
diagnostic procedure should the nurse prepare the client?
Contraction stress test.
Internal fetal monitoring.
Abdominal ultrasound.
Lecithin-sphingomyelin ratio.
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon
fundal assessment, the nurse determines the uterus is boggy and is
displaced above and to the right of the umbilicus. Which action should
the nurse implement next?
Document the color of the lochia.
Observe maternal vital signs.
Assist the client to the bathroom.
Notify the healthcare provider.
A multiparous client is experiencing bleeding 2 hours after a vaginal
delivery. What action should the nurse implement next?
, Determine the firmness of the fundus.
Give oxytocin (Pitocin) intravenously.
Inform the healthcare provider of the bleeding.
Assess the vital signs for indicators of shock.
The nurse notes a pattern of the fetal heart rate decreasing after each
contraction. What action should the nurse implement?
Give 10 liters of oxygen via face mask.
Prepare for an emergency cesarean section.
Continue to monitor the fetal heart rate pattern.
Obtain an oral maternal temperature.
A client at 28-weeks gestation experiences blunt abdominal trauma.
Which parameter should the nurse assess first for signs of internal
hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate patterns.
Alteration in maternal blood pressure.
Which client should the nurse report to the healthcare provider as
needing a prescription for Rh Immune Globulin (RhoGAM)?
Woman whose blood group is AB Rh-positive.
Newborn with rising serum bilirubin level.
Newborn whose Coombs test is negative.
Primigravida mother who is Rh-negative.
, The nurse is caring for a client whose labor is being augmented with
oxytocin (Pitocin). Which finding indicates that the nurse should
discontinue the oxytocin infusion?
The client needs to void.
Amniotic membranes rupture.
Uterine contractions occur every 8 to 10 minutes.
The fetal heart rate is 180 bpm without variability
A client in labor receives an epidural block. What intervention should the
nurse implement first?
Encourage oral fluids.
Assess contractions.
Monitor blood pressure.
Obtain a radial pulse.
A multiparous client is admitted to the postpartum unit after a rapid
labor and birth of an infant weighing 4,000 grams. The client's fundus is
boggy, lochia is heavy, and vital signs are unchanged. After having the
client void and massaging the uterus, the client's fundus remains
difficult to locate, and the rubra lochia remains heavy. What action
should the nurse implement next?
Recheck the client's vital signs.
Notify the healthcare provider.
Insert an indwelling urinary catheter.
Massage the fundus in 30 minutes.
The nurse is providing discharge teaching for a gravid client who is
being released from the hospital after placement of cerclage. Which
instruction is the most important for the client to understand?
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