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Maternity HESI Test bank (combined red hesi and other sources) An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually repri$12.49
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Maternity HESI Test bank (combined red hesi and other sources) An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually repri
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Maternity HESI Test bank (combined red hesi and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which rec...
maternity hesi test bank combined red hesi and other sources an expectant father tells the nurse he fears that his wife is losing her mind he states that she is constantly rubbing her abdo
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Maternity HESI Test bank (combined red
hesi and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He
states that she is constantly rubbing her abdomen and talking to the baby and
that she actually reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring.
D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the
procedure is completed, it is most important for the nurse to obtain which
information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC)
C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that
may indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the
cervix is favorable. The fluid should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is not specific for
AROM. Option B is monitored hourly after the membranes are ruptured to detect the
development of amnionitis. Option D should be determined for all clients in labor.
,A nurse receives a shift change report for a newborn who is 12 hours post-
vaginal delivery. In developing a plan of care, the nurse should give the highest
priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk
B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color
of the hands and feet) is a common finding in newborns; it occurs because the capillary
system is immature. Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks. Small red patches
on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in
newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic
therapy is prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the
infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on
the infant.
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue. Option B is less painful but does
not facilitate complete emptying of the breast tissue. Option C will not relieve the
engorgement on the affected side. Option D will not decrease antibiotic effects on the
infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction will
aid in the prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
,B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing.
C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic
veins and increase venous return. Option A would increase venous return from varicose
veins in the lower extremities but would be of little help with swelling. Option B might be
helpful with generalized edema but is not specific for edematous lower extremities.
Option D does not address venous return, and there is no indication in the question that
constrictive clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. In a newborn, what is
the most likely cause of this accumulation of blood between the periosteum and
skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage
A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding
between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common variation
of the newborn. Options B and D both involve intracranial bleeding and could not be
detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding
the newborn's umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath
, C.Allow the cord to air-dry as much as possible.
Rationale:Recent studies have indicated that air drying or plain water application may
be equal to or more effective than alcohol in the cord healing process. Options A, B, and
D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision.
What information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and
cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if
bleeding occurs.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove
any urine or feces, and petroleum ointment should be applied to prevent the diaper from
sticking to the healing surface. Prepackaged wipes often contain other products that
may irritate the site. The yellow exudate, which covers the glans penis as the area heals
and epithelializes, is not an infective process and should not be removed. If bleeding
occurs at home, the client should be instructed to apply gentle pressure to the site of the
bleeding with sterile gauze squares and call the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of
gestation in preterm labor. She is given three doses of terbutaline sulfate
(Brethine), 0.25 mg subcutaneously, to stop her labor contractions. What are the
primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth
C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates
beta-adrenergic receptors in the uterine muscle to stop contractions. The beta-
adrenergic agonist properties of the drug may cause tachycardia, increased cardiac
output, restlessness, headache, and a feeling of nervousness. Option A is not a side
effect. Options B and D are side effects of magnesium sulfate.
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