1) One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next?
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HESI RN OB 2023
1)One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should the nurse implement next?
A.Document number of pad changes in the last hour
B.Increase the rate of the oxytocin infusion
C.Palpate the suprapubic area for bladder distention
D.Provide bedpan to void if unable to ambulate
2)At 40-week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?
A.Place a pillow under the client’s head and knees.
B.Place a wedge under the client’s right hip.
C.Encourage the client to turn on her left side.
D.Explain to the client that her position is not safe.
3)After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborns diaper. As the mother begins the diaper change, the newborn spits up the breast milk.
What action should the nurse implement first?
A.Wipe away the spit-up and assist the mother with the diaper change
B.Turn the newborn to the side and bulb suction the mouth and nares
C.Sit the newborn up and burp by rubbing or patting the upper back
D.Place the newborn in a position with the head lower than the feet
4)A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
A.History of irritable bowel syndrome (IBS)
B.Pain scale rating of a “9” on a 0-10 scale.
C.Last menstrual period 7 weeks ago.
D.Reports white, curly vaginal discharg 5)The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple’s elongated tip in the back of the oral cavity. What instruction should the nurse provide the mother about feedings?
A.Alternate milk with water during the feedings.
B.Squeeze the nipple base to introduce milk into the mouth.
C.Position the baby in the left lateral position after feeding.
D.Hold the newborn in an upright position.
6)An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take?
A.Prepare the client for an echocardiogram.
B.Limit the client’s fluids.
C.Document in the client’s record.
D.Notify the healthcare provider.
7)A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the hcp of the clients condition, what information is most important for the nurse to provide?
A.Total amount of Pitocin infused
B.Maternal Blood pressure
C.Maternal Apical Pulse rate
D.Time Pitocin infusion completed
8)The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which assessment finding warrants immediate intervention by the nurse?
A.Sweating during feedings
B.Weak peripheral pulse
C.Bluish tinge to the tongue
D.Increased respiratory rate
9)A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which information is most important for the nurse to provide the client?
A.When there is no significant vaginal bleeding
B.When ambulating to void does not cause dizziness
C.After the vitamin K injection is given to the baby
D.After the baby no longer demonstrates acrocyanosis
10)A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions are noted on the external monitor. Which intervention should the nurse implement?
A.Weight perineal pads
B.Weight daily
C.Measure intake and output
D.Ambulate 15 minutes QID
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