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HESI (Maternal) QUESTIONS CORRECTLY ANSWERED FREQUENTLY TESTED AND A+ GRADED
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HESI (Maternal) QUESTIONS CORRECTLY ANSWERED FREQUENTLY TESTED AND A+ GRADED
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HESI (Maternal) QUESTIONS CORRECTLYANSWERED FREQUENTLY TESTED AND A+
GRADED.
A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. The head is really funny looking." Which response by the nurse
is best?
A. "This is not an unusually shaped head, especially for a first baby."
B. "It may look odd, but newborn babies are often born with heads like that."
C. "That is normal. The head will return to a round shape within 7 to 10 days."
D. "Your pelvis was too small, so the head had to adjust to the birth canal."
C. "That is normal. The head will return to a round shape within 7 to 10 days."
Option C reassures the mother that this is normal in the newborn and provides
correct information regarding the return to a normal shape. Although option A is
correct, it implies that the client should not worry. Any implied or spoken "don't
worry" is usually the wrong answer. Option B is condescending and dismissing; the
mother is seeking reassurance and information. Option D is a negative statement
and implies that molding is the mother's fault.
STUDY MODE: Maternity
Question 18 of 125
ID: 4_6
A client who delivered by cesarean section 24 hours ago is using a patient-
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice
chips only since surgery. She is now complaining of bloating. Which nursing
action takes the highest priority? (Select all that apply.)
A. Call the health care provider to obtain an order to increase her diet.
B. Administer the ordered magnesium hydroxide.
C. Encourage her to change position every 30 minutes.
,D. Turn out the lights and discourage visitors.
E. Encourage her to breast feed every two hours.
B, C
Impaired bowel motility caused by surgical anesthesia, pain medication, and
immobility is the priority nursing diagnosis and addresses the potential problem of a
paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D
is not as important as impaired motility.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. What is the next
nursing action?
A. Use thread to tie off the umbilical cord.
B. Provide privacy for the woman.
C. Reassure the husband and keep him calm.
D. Put the newborn to the breast immediately.
D. Put the newborn to the breast immediately.
Putting the newborn to the breast will help contract the uterus and prevent a
postpartum hemorrhage. This intervention has the highest priority. Option A is not
necessary; the infant can be transported attached to the placenta. Option B is an
important psychosocial need but does not have the priority of option D. Although the
husband is an important part of family-centered care, he is not the most important
concern at this time.
The clinic nurse is performing an assessment on a client who is 20 weeks
gestation, which was confirmed by ultrasound. When performing the fundal
height assessment, where will the nurse start palpating the abdomen?
A. Midway between the symphysis pubis and the umbilicus
B. At the umbilicus
C. Between the umbilicus and the xiphoid process.
D. Two cm below the xiphoid process.
,B. At the umbilicus
The uterus enlarges 1 cm per week after about 18 weeks of pregnancy, ± 2 cm. At 20
weeks the uterus should be around the umbilicus. By 38 weeks the uterus is at the
xiphoid process.
The nurse is preparing a newborn for discharge. There is an order for a hepatitis B
vaccination prior to discharge. When planning to administer the vaccination,
what information must the nurse obtain from the infants chart?
A. Temperature
B. Site of the vitamin K injection
C. Presence of bleeding at the gums
D. Hepatitis B immune status
B. Site of the vitamin K injection
Infants receive injections in their thigh muscle. The nurse must understand where the
vitamin K injection was delivered shortly after birth. The hep B injection is commonly
administered in the opposite thigh. While temperature regulation is important in the
newborn, it is not related to the administration of hep B. Infants do not have any
clotting capacity until vitamin K is developed in the GI system, after the presence of
food. Bleeding of the gums is not related to the administration of hep B. Immunity to
hep B is not passively transferred from mother to infant.
The nurse calls a client who is 4 days postpartum to follow up about her transition
with her newborn at home. The woman tells the nurse, "I don't know what is
wrong. I love my baby, but I feel so let down. I seem to cry for no reason!" Which
adjustment phase should the nurse determine the client is experiencing?
A. Taking-in phase
B. Postpartum blues
C. Attachment difficulty
D. Letting-go phase
B. Postpartum blues
, During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her own
psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
The nurse is providing care to an infant at 24 hours old. Upon assessment, the
nurse observes milia on the newborn's nose. What is the nurse's next action?
A. Document the findings in the newborn's chart.
B. Ask another nurse to confirm the findings.
C. Assess the mother for the presence of milia.
D. Contact the pediatric health care provider.
A. Document the findings in the newborn's chart.
Milia are common tiny white raised areas, generally located on an infant's nose or
face. They are self-resolving, requiring no immediate medical attention. Teach the
mother that the milia will generally resolve in a month. Only documentation is
required for this client.
The nurse is counseling a couple who has sought information about conceiving.
The couple asks the nurse to explain when ovulation usually occurs. Which
statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation
A. Two weeks before menstruation
Ovulation occurs 14 days before the first day of the menstrual period. Although
ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is
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