NU472 Week 7 EAQ Evolve Elsevier Optional Practice
For HESI Maternity Exam Questions And Answers
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Which is the most common complication for which the nurse must monitor preterm infants?
o Hemorrhage
o Brain damage
o Respiratory distress
o Aspiration of mucus
o Respiratory distress
· Immaturity of the respiratory tract in preterm infants is evidenced by a lack of functional alveoli, smaller lumina with
increased possibility of collapse of the respiratory passages, weakness of respiratory musculature, and insufficient
calcification of the bony thorax, leading to respiratory distress. Hemorrhage is not a common occurrence at the time of
birth unless trauma has occurred. Brain damage is not a primary concern unless severe hypoxia occurred during labor; it
is difficult to diagnose at this time. Aspiration of mucus may be a problem, but generally the air passageway is suctioned
as needed.
The electronic fetal monitor on a client receiving an infusion of oxytocin (Pitocin) displays contractions every 2 minutes
and lasting 95 seconds. Which is the appropriate nursing action?
o Stop the oxytocin (Pitocin) infusion.
o Administer oxygen at 8 to 10 L/min.
o Increase the main line fluid delivery rate to 150 mL/hr.
o Prepare the client for insertion of an intrauterine pressure catheter.
o Stop the oxytocin (Pitocin) infusion.
· The contraction pattern indicates hyperstimulation of the uterus. Stopping the oxytocin (Pitocin) infusion permits
relaxation of the uterus and perfusion of the placenta. Oxygen cannot reach the placenta until the uterus is relaxed, so
administering oxygen will not help. Increasing the rate of delivery of the main line fluid does not affect hyperstimulation
of the uterus. Insertion of an intrauterine pressure catheter will only provide measurement of the internal uterine
pressure and will not affect uterine contractions.
Which instruction would the nurse give to the pregnant client with anemia?
o Take an iron and calcium supplement together daily.
o Drink orange juice with an iron supplement.
, o Include fresh fruit at every meal.
o Include 4 servings of calcium-rich foods daily.
o Drink orange juice with an iron supplement.
· The vitamin C in orange juice aids in absorption of iron, which is used to treat anemia. Taking calcium at the same time
as iron will reduce absorption of the iron. Fresh fruits are recommended in pregnancy but are not a primary source of
iron. Including calcium-rich foods is also recommended, but this does not address anemia.
A neonate born at 35 weeks’ gestation has Apgar scores of 8 and 9. At 4 hours of age, the newborn begins to experience
respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. Which
condition is the nurse concerned about based on these findings?
o Hypoglycemia
o Bacterial sepsis
o Cocaine withdrawal
o Meconium aspiration
o Bacterial sepsis
· Preterm neonates react to infection with respiratory distress and subnormal temperatures. Although hypothermia is one
sign of hypoglycemia, the newborn is not exhibiting other signs, such as tremors and lethargy. Four hours of age is too
early for signs of cocaine withdrawal to occur. The data do not indicate that meconium was present at birth.
A client is scheduled to have breast augmentation surgery in the outpatient surgical unit. Which discharge instructions
would the nurse provide? Select all that apply. One, some, or all responses may be correct.
o "Avoid taking aspirin or other nonsteroidal anti-inflammatory drugs (such as ibuprofen) for pain relief."
o "Sleep with your head and torso elevated for at least 1 week."
o "Sleep on your back or sides but not on your stomach."
o "Begin slowly raising your arms over your head after the first week."
o "Take your temperature daily and notify the clinic if it goes above 99.6°F (37.6°C)."
o "Avoid taking aspirin or other nonsteroidal anti-inflammatory drugs (such as ibuprofen) for pain relief."
o "Sleep with your head and torso elevated for at least 1 week."
o "Take your temperature daily and notify the clinic if it goes above 99.6°F (37.6°C)."
· Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided because of their anticoagulant effects. Elevating the
head and torso will reduce edema at the surgical site. Checking the temperature will help identify the presence of
infection. The side-lying position may be traumatic to the surgical area; the client should sleep on her back. Raising the
arms above the head may cause movement of the pectoralis muscle and could result in trauma to the surgical area; the
arms should not be raised above the head for a minimum of 3 weeks.
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