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2020 HESI OB/MATERNITY V 2 EXAM Graded A+
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2020 HESI OB/MATERNITY V 2 EXAM Graded A+
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2020 HESI OB/MATERNITY V 21. The nurse is caring for a client who had an emergency cesarean 4. A client is receiving an epidural infusion of a narcotic for pain relief
section, with her husband in attendance the day before. The baby’s after a cesarean section. The nurse would report to the anesthesiologist
Apgar was 9/9. The woman and her partner had attended childbirth if which of the following were assessed?
education classes and had anticipated having a water birth with family
a) Respiratory rate 8 rpm.
present. Which of the following comments by the nurse is appropriate?
b) Complaint of thirst.
a) ―Sometimes babies just don’t deliver the way we expect them c) Urinary output of 250 cc/hr.
to.‖ d) Numbness of feet and ankles.
b) ―With all of your preparations, it must have been disappointing
for you to have had a cesarean.‖
5. A client, 2 days postoperative from a cesarean section, complains to
c) ―I know you had to have surgery, but you are very lucky that
the nurse that she has yet to have a bowel movement since the surgery.
your baby was born healthy.‖
Which of the following responses by the nurse would be appropriate at
d) ―At least your husband was able to be with you when the baby
this time?
was born.‖
a) ―That is very concerning. I will request that your physician
2. A nurse has brought a 2-hour-old baby to a mother from the nursery.
order an enema for you.‖
The nurse is going to assist the mother with the first breastfeeding
experience. Which of the following actions should the nurse perform b) ―Two days is not that bad. Some patients go four days or longer
first? without a movement.‖
c) ―You have been taking antibiotics through your intravenous.
a) Compare mother’s and baby’s identification bracelets.
That is probably why you are constipated.‖
b) Help the mother into a comfortable position.
d) ―Fluids and exercise often help to combat constipation. Take a
c) Teach the mother about a proper breast latch.
d) Tickle the baby’s lips with the mother’s nipple. stroll around the unit and drink lots of fluid.‖
3. The obstetrician has ordered that a post-op cesarean section client’s 6. A post–cesarean section, breastfeeding client, whose subjective pain
patient-controlled analgesia (PCA) be discontinued. Which of the level is 2/5, requests her as needed (prn) narcotic analgesics every 3
following actions by the nurse is appropriate? hours. She states, ―I have decided to make sure that I feel as little pain
from this experience as possible.‖ Which of the following should the
a) Discard the remaining medication in the presence of another nurse conclude in relation to this woman’s behavior?
nurse.
b) Recommend waiting until her pain level is zero to discontinue a) The woman needs a stronger narcotic order.
the medicine. b) The woman is high risk for severe constipation.
c) Discontinue the medication only after the analgesia is c) The woman’s breast milk volume may drop while taking the
completely absorbed. medicine.
d) Return the unused portion of medication to the narcotics d) The woman’s newborn may become addicted to the
cabinet. medication.
,7. A nurse is assessing a 1-day postpartum woman who had her baby d) Irrigate incision twice daily with antibiotic solution.
by cesarean section. Which of the following should the nurse report to
11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal
the surgeon?
delivery with local anesthesia, states that she needs to urinate. Which
a) Fundus at the umbilicus. of the following actions by the nurse is appropriate at this time?
b) Nodular breasts.
a) Provide the woman with a bedpan.
c) Pulse rate 60 bpm.
b) Advise the woman that the feeling is likely related to the
d) Pad saturation every 30 minutes.
trauma of delivery.
8. The nurse is assessing the midline episiotomy on a postpartum c) Remind the woman that she still has a catheter in place from
client. Which of the following findings should the nurse expect to see? the delivery.
a) Moderate serosanguinous drainage. d) Assist the woman to the bathroom.
b) Well-approximated edges.
12. A nurse is assessing the fundus of a client during the immediate
c) Ecchymotic area distal to the episiotomy.
postpartum period. Which of the following actions indicates that the
d) An area of redness adjacent to the incision.
nurse is performing the skill correctly?
9. A client, G1P1, who had an epidural, has just delivered a daughter,
a) The nurse measures the fundal height using a paper centimeter
Apgar 9/9, over a mediolateral episiotomy. The physician used low
tape.
forceps. While recovering, the client states, ―I’m a failure. I couldn’t
b) The nurse stabilizes the base of the uterus with his or her
stand the pain and couldn’t even push my baby out by myself!‖ Which
dependent hand.
of the following is the best response for the nurse to make?
c) The nurse palpates the fundus with the tips of his or her
a) ―You’ll feel better later after you have had a chance to rest and fingers.
to eat.‖ d) The nurse precedes the assessment with a sterile vaginal exam.
b) ―Don’t say that. There are many women who would be ecstatic
to have that baby.‖
c) ―I am sure that you will have another baby. I bet that it will be 13. A 1-day postpartum woman states, ―I think I have a urinary tract
a natural delivery.‖ infection. I have to go to the bathroom all the time.‖ Which of the
d) ―To have things work out differently than you had planned is following actions should the nurse take?
disappointing.‖
a) Assure the woman that frequent urination is normal after
10. The nurse is developing a standard care plan for postpartum clients delivery.
who have had midline episiotomies. Which of the following b) Obtain an order for a urine culture.
interventions should be included in the plan? c) Assess the urine for cloudiness.
d) Ask the woman if she is prone to urinary tract infections.
a) Assist with stitch removal on third postpartum day.
b) Administer analgesics every four hours per doctor orders.
c) Teach client to contract her buttocks before sitting.
, 14. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning.
Which of the following results should the nurse report to the primary health care provider?
a. White blood cells—12,500 cells/mm3.
b. Red blood cells—4,500,000 cells/mm3.
c. Hematocrit—26%.
d. Hemoglobin—11 g/dL
15. A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal 17. The nurse is examining a 2-day postpartum client whose fundus is
delivery, calls the obstetric office to state that she has saturated 2 pads 2 cm below the umbilicus and whose bright red lochia saturates about
in the past 1 hour. Which of the following responses by the nurse is 4 inches of a pad in 1 hour. What should the nurse document in the
appropriate? nursing record?
a) ―You must be doing too much. Lie down for a few hours and a) Abnormal involution, lochia rubra heavy.
call back if the bleeding has not subsided.‖ b) Abnormal involution, lochia serosa scant.
b) ―You are probably getting your period back. You will bleed like c) Normal involution, lochia rubra moderate.
that for a day or two and then it will lighten up.‖ d) Normal involution, lochia serosa heavy.
c) ―It is not unusual to bleed heavily every once in a while, after a
18. The nurse palpates a distended bladder on a woman who delivered
baby is born. It should subside shortly.‖
vaginally 2 hours earlier. The woman refuses to go to the bathroom, ―I
d) ―It is important for you to be examined by the doctor today. Let
really don’t need to go.‖ Which of the following responses by the
me check to see when you can come in.‖
nurse is appropriate?
16. A client, 2 days postpartum from a spontaneous vaginal delivery,
a) ―Okay. I must be palpating your uterus.‖
asks the nurse about postpartum exercises. Which of the following
b) ―I understand but I still would like you to try to urinate.‖
responses by the nurse is appropriate?
c) ―You still must be numb from the local anesthesia.‖
a) ―You must wait to begin to perform exercises until after your d) ―That is a problem. I will have to catheterize you.‖
six-week postpartum checkup.‖
19. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes
b) ―You may begin Kegel exercises today, but do not do any other
that the client’s lochia rubra is moderate and her fundus is boggy 2 cm
exercises until the doctor tells you that it is safe.‖
above the umbilicus and deviated to the right. Which of the following
c) ―By next week you will be able to return to the exercise
actions should the nurse take first?
schedule you had during your prepregnancy.‖
d) ―You can do some Kegel exercises today and then slowly a) Notify the woman’s primary health care provider.
increase your toning exercises over the next few weeks.‖ b) Massage the woman’s fundus.
c) Escort the woman to the bathroom to urinate.
d) Check the quantity of lochia on the peripad.
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