A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would
be most effective in preventing pooling of blood in the lower extremities?
Move about every hour
Pooling of blood in the lower e...
a 38 week primigravida who works as a secretary and sits at a computer for 8 hours each day tells the nurse that her feet have begun to swell which instruction would be most effective in preventing p
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Ma.ternity HESI Test Ba.nk
1. A. 38-week primigra.vida. who works a.s a. secreta.ry a.nd sits a.t a. compu.ter for 8 hou.rs
ea.ch da.y tells the nu.rse tha.t her feet ha.ve begu.n to swell. Which instru.ction wou.ld be
most effective in preventing pooling of blood in the lower extremities?
Move a.bou.t every hou.r
Pooling of blood in the lower extremities resu.lts from the enla.rged u.teru.s exerting
pressu.re on the pelvic veins. Moving a.bou.t every hou.r will stra.ighten ou.t the pelvic
veins a.nd increa.se venou.s retu.rn.
2. A. 26-yea.r-old, gra.vida. 2, pa.ra. 1 client is a.dmitted to the hospita.l a.t 28-weeks gesta.tion in
preterm la.bor. She is given 3 doses of terbu.ta.line su.lfa.te (Brethine) 0.25 mg
su.bcu.ta.neou.sly to stop her la.bor contra.ctions. The nu.rse pla.ns to monitor for which
prima.ry side effect of terbu.ta.line su.lfa.te?
Ta.chyca.rdia. a.nd a. feeling of nervou.sness
Terbu.ta.line su.lfa.te (Brethine), a. beta.-sympa.thomimetic dru.g, stimu.la.tes beta.-
a.drenergic receptors in the u.terine mu.scle to stop contra.ctions. The beta.-a.drenergic
a.gonist properties of the dru.g ma.y ca.u.se ta.chyca.rdia., increa.sed ca.rdia.c ou.tpu.t,
restlessness, hea.da.che, a.nd a. feeling of "nervou.sness".
3. When do the a.nterior a.nd posterior fonta.nels close?
a.nterior fonta.nel closes a.t 12 to 18 months a.nd the posterior by the end of the second
month.
4. When a.ssessing a. client who is a.t 12-weeks gesta.tion, the nu.rse recommends tha.t she a.nd
her hu.sba.nd consider a.ttending childbirth prepa.ra.tion cla.sses. When is the best time for
the cou.ple to a.ttend these cla.sses?
30 weeks gesta.tion
a.t 30 weeks gesta.tion is closest (of the options) to the time pa.rents wou.ld be rea.dy for
su.ch cla.sses. Lea.rning is fa.cilita.ted by a.n interested pu.pil! The cou.ple is most interested
in childbirth towa.rd the end of the pregna.ncy when they a.re
psychologica.lly rea.dy for the termina.tion of the pregna.ncy, a.nd the birth of their child is
a.n immedia.te concern.
5. The nu.rse shou.ld encou.ra.ge the la.boring client to begin pu.shing when...
the cervix is completely dila.ted.
1
, Pu.shing begins with the second sta.ge of la.bor, i.e., when the cervix is completely dila.ted a.t 10
cm (C). If pu.shing begins before the cervix is completely dila.ted the cervix
ca.n become edema.tou.s a.nd ma.y never completely dila.te, necessita.ting a.n opera.tive
delivery. Ma.ny primigra.vida.’s begin a.ctive la.bor 100%a.nd theneffa.cedproceed to dila.te.
6. The nu.rse instru.cts a. la.boring client to u.se a.ccelera.ted-blow brea.thing. The client begins
to compla.in of tingling fingers a.nd dizziness. Wha.t a.ction shou.ld the nu.rse ta.ke?
Ha.ve the client brea.the into her cu.pped ha.nds
Tingling fingers a.nd dizziness a.re signs of hyperventila.tion (blowing off too mu.ch ca.rbon
dioxide). Hyperventila.tion is trea.ted by reta.ining ca.rbon dioxide. This ca.n be fa.cilita.ted
by brea.thing into a. pa.per ba.g or cu.pped ha.nds.
7. Twenty-fou.r hou.rs a.fter a.dmission to the newborn nu.rsery, a. fu.ll-term ma.le infa.nt
develops loca.lized edema. on the right side of his hea.d. The nu.rse knows tha.t, in the
newborn, a.n a.ccu.mu.la.tion of blood between the periosteu.m a.nd sku.ll which does not
cross the su.tu.re line is a. newborn va.ria.tion known a.s... a. cepha.lohema.toma., ca.u.sed by
forceps tra.u.ma. a.nd ma.y la.st u.p to 8 weeks.
Cepha.lohema.toma., a. slight a.bnorma.l va.ria.tion of the newborn, u.su.a.lly a.rises within the
first 24 hou.rs a.fter delivery. Tra.u.ma. from delivery ca.u.ses ca.pilla.ry bleeding between the
periosteu.m a.nd the sku.ll.
8. When does the hea.d retu.rn to its norma.l
sha.pe? 7-10 da.ys
9. Wha.t did Nu.rse theorist Reva. Ru.bin describe?
The initia.l postpa.rtu.m period a.s the "ta.king-in pha.se," which is cha.ra.cterized by ma.terna.l
relia.nce on others to sa.tisfy the needs for comfort, rest, nou.rishment, a.nd closeness to
fa.milies a.nd the newborn.
10. A. cou.ple, concerned beca.u.se the woma.n ha.s not been a.ble to conceive, is referred to a.
hea.lthca.re provider for a. fertility worku.p a.nd a. hysterosa.lpingogra.phy is schedu.led.
Which post procedu.re compla.int indica.tes tha.t the fa.llopia.n tu.bes a.re pa.tent?
Shou.lder pa.in
If the tu.bes a.re pa.tent (open), pa.in is referred to the shou.lder from a. su.b dia.phra.gma.tic
collection of peritonea.l dye/ga.s.
11. Which nu.rsing intervention is most helpfu.l in relieving postpa.rtu.m u.terine contra.ctions or
"a.fterpa.ins?"
Lying prone with a. pillow on the a.bdomen
, 2
Lying prone keeps the fu.ndu.s contra.cted a.nd is especia.lly u.sefu.l with mu.ltipa.ra.s, who
commonly experience a.fterpa.ins du.e to la.ck of u.terine tone.
12. Which ma.terna.l beha.vior is the nu.rse most likely to see when a. new mother receives her
infa.nt for the first time?
Her a.rms a.nd ha.nds receive the infa.nt a.nd she then tra.ces the infa.nt's profile with her
fingertips.
A.tta.chment/bonding theory indica.tes tha.t most mothers will demonstra.te beha.viors described
in du.ring the first visit with the newborn, which ma.y be a.t delivery or la.ter.
13. A. client a.t 32-weeks gesta.tion is hospita.lized with severe pregna.ncy-indu.ced hypertension
(PIH), a.nd ma.gnesiu.m su.lfa.te is prescribed to control the symptoms. Which a.ssessment finding
indica.tes the thera.peu.tic dru.g level ha.s been a.chieved?
A decrea.sed in respira.tory ra.te from 24 to 16
Ma.gnesiu.m su.lfa.te, a. CNS depressa.nt, helps prevent seizu.res. A. decrea.sed respira.tory
ra.te indica.tes tha.t the dru.g is effective. (Respira.tory ra.te below 12 indica.tes toxic effects.)
14. U.rina.ry ou.tpu.t mu.st be monitored when a.dministering ma.gnesiu.m su.lfa.te a.nd shou.ld
be a.t lea.st 30 ml per hou.r. (The thera.peu.tic level of ma.gnesiu.m su.lfa.te for a. PIH client is
4.8 to 9.6 mg/dl.) Wha.t is the thera.peu.tic level of ma.gnesiu.m su.lfa.te?
The thera.peu.tic level of ma.gnesiu.m su.lfa.te for a. PIH client is 4.8 to 9.6
mg/dl. Wha.t does it help prevent? helps prevent seizu.res Wha.t indica.tes
toxic levels? 3
Respira.tory ra.te below 12 indica.tes toxic effects.
U.rine ou.tpu.t of less tha.n 100 ml/4 hou.rs
A.bsent DTRs
15. Twenty minu.tes a.fter a. continu.ou.s epidu.ra.l a.nesthetic is a.dministered, a. la.boring client's
blood pressu.re drops from 120/80 to 90/60. Wha.t a.ction shou.ld the nu.rse ta.ke?
Pla.ce woma.n in a. la.tera.l position
The nu.rse shou.ld immedia.tely tu.rn the woma.n to a. la.tera.l position, pla.ce a. pillow or
wedge u.nder the right hip to deflect the u.teru.s, increa.se the ra.te of the ma.in line IV
infu.sion, a.nd a.dminister oxygen by fa.ce ma.sk a.t 10-12 L/min. If the blood pressu.re
rema.ins low, especia.lly if it fu.rther decrea.ses, the a.nesthesiologist/hea.lthca.re provider
shou.ld be notified immedia.tely.
16. A. client a.t 28-weeks gesta.tion ca.lls the a.ntepa.rtu.m clinic a.nd sta.tes tha.t she is
experiencing a. sma.ll a.mou.nt of va.gina.l bleeding which she describes a.s bright red. She
fu.rther sta.tes tha.t she is not experiencing a.ny u.terine contra.ctions or a.bdomina.l pa.in.
Wha.t instru.ction shou.ld the nu.rse provide?
3
, Come to the clinic toda.y for a.n u.ltra.sou.nd
Third trimester pa.inless bleeding is cha.ra.cteristic of a. pla.centa. previa.. Bright red
bleeding ma.y be intermittent, occu.r in gu.shes, or be continu.ou.s. Ra.rely is the first
incidence life-threa.tening, nor ca.u.se for hypovolemic shock. Dia.gnosis is confirmed by
tra.nsa.bdomina.l u.ltra.sou.nd.
17. A.n off-du.ty nu.rse finds a. woma.n in a. su.perma.rket pa.rking lot delivering a.n infa.nt while
her hu.sba.nd is screa.ming for someone to help his wife. Which intervention ha.s the highest
priority?
Pu.t the newborn to brea.st
Pu.tting the newborn to brea.st will help contra.ct the u.teru.s a.nd prevent a. postpa.rtu.m
hemorrha.ge--this intervention ha.s the highest priority.
18. A. pregna.nt client with mitra.l stenosis Cla.ss III is prescribed complete bedrest. The client a.sks
the nu.rse, "Why mu.st I sta.y in bed a.ll the time?" Which response is best for the nu.rse to
provide this client?
Complete bedrest decrea.ses oxygen needs a.nd dema.nds on the hea.rt mu.scle tissu.e.
To help preserve ca.rdia.c reserves, the woma.n ma.y need to restrict her a.ctivities a.nd
complete bedrest is often prescribed.
19. The nu.rse is tea.ching ca.re of the newborn to a. grou.p of prospective pa.rents a.nd describes
the need for a.dministering a.ntibiotic ointment into the eyes of the newborn. Which
infectiou.s orga.nism will this trea.tment prevent from ha.rming the infa.nt?
Gonorrhea.
Erythromycin ointment is instilled into the lower conju.nctiva. of ea.ch eye within 2 hou.rs a.fter
birth to prevent ophtha.lmic neona.toru.m, a.n infection ca.u.sed by gonorrhea., a.nd inclu.sion
conju.nctivitis, a.n infection ca.u.sed by chla.mydia.. The infa.nt ma.y be exposed to these
ba.cteria. when pa.ssing throu.gh the birth ca.na.l.
20. The nu.rse is tea.ching a. woma.n how to u.se her ba.sa.l body tempera.tu.re (BBT) pa.ttern a.s
a. tool to a.ssist her in conceiving a. child. Which tempera.tu.re pa.ttern indica.tes the
occu.rrence of ovu.la.tion, a.nd therefore, the best time for intercou.rse to ensu.re conception?
Between the time the tempera.tu.re fa.lls a.nd rises.
In most women, the BBT drops slightly 24 to 36 hou.rs before ovu.la.tion a.nd rises 24 to 72
hou.rs a.fter ovu.la.tion, when the corpu.s lu.teu.m of the ru.ptu.red ova.ry produ.ces
progesterone. Therefore, intercou.rse between the time of the tempera.tu.re fa.ll a.nd rise is
the best time for conception. The hu.ma.n ovu.m ca.n be fertilized 16 to 24 hou.rs a.fter
ovu.la.tion.
4
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