HESI 1 MATERNITY EXAM
UPDATE 2024
Twenty minutes after a continuous epidural anesthetic is administered, alaboring client's blood
pressure drops from 120/80 to 90/60. What actionshould the nurse take?
Ans: Place woman in a lateral position
The nurse should immediately turn the woman to a la...
HESI 1 MATERNITY EXAM
UPDATE 2024
Twenty minutes after a continuous epidural anesthetic is administered, alaboring client's blood
pressure drops from 120/80 to 90/60. What actionshould the nurse take?
Ans: Place woman in a lateral position
The nurse should immediately turn the woman to a lateral position, place a pillow or wedge
under the right hip to deflect the uterus, increase the rate ofthe main line IV infusion, and
administer oxygen by face mask at 10-12 L/min. If the blood pressure remains low, especially if it
further decreases, the anesthesiologist/healthcare provider should be notified immediately.
Question 2.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28- weeks gestation in
preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously
to stop her labor contractions.The nurse plans to monitor for which primary side effect of
terbutaline sulfate?
Ans: Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates
,beta-adrenergic receptors in the uterine muscle to stop contractions. Thebeta-adrenergic
agonist properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
Question 3.
When do the anterior and posterior fontanels close?
Ans: anterior fontanel closes at 12 to 18 months and the posterior by theend of the second
month.
Question 4.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple
to attend theseclasses?
Ans: 30 weeks gestation
at 30 weeks gestation is closest (of the options) to the time parents would be ready for such
classes. Learning is facilitated by an interested pupil! Thecouple is most interested in childbirth
toward the end of the pregnancy when they are psychologically ready for the termination of the
pregnancy, and the birth of their child is an immediate concern
2
,Question 5.
The nurse should encourage the laboring client to begin pushingwhen... Ans: the
cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely dilated at 10 cm (C).
If pushing begins before the cervix is completely dilated the cervix can become edematous and may
never completely dilate, necessitating an operative delivery. Many primigravida’sbegin active labor
100% effaced and then proceed to dilate.
Question 6.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to
complain of tingling fingers and dizziness. What actionshould the nurse take?
Ans: Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbondioxide. This can be facilitated by
breathing into a paper bag or cupped hands.
Question 7.
Twenty-four hours after admission to the newborn nursery, a full-term maleinfant develops
localized edema on the right side of his head. The nurse knows that, in the newborn, an
accumulation of blood between the periosteum and skull which does not cross the suture line is
a newborn
3
, variation known as...
Ans: a cephalohematoma, caused by forceps trauma and may last up to 8weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usuallyarises within the first 24
hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and
the skull.
Question 8.
When does the head return to its normalshape?
Ans: 7-10 days
Question 9.
What did Nurse theorist Reva Rubin describe?
Ans: The initial postpartum period as the "taking-in phase," which is characterized by maternal
reliance on others to satisfy the needs for comfort, rest, nourishment, and closeness to families
and the newborn.
Question 10.
4
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