Exam (elaborations)
NURS 407 HESI Maternity- Houston Community College
- Course
- NURS 407 (NURS407)
- Institution
- Houston Community College
NURS 407 HESI Maternity- Houston Community College/NURS 407 HESI Maternity- Houston Community College
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HESI MATERNITY1. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client’s teaching plan? ( hydratidiform mole)
A. Oral contraceptive use for at least one year.
2. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome?
C. Betamethasone (Celestone) 12 mg deep IM.
3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information
should the nurse provide the client about this fiding?
Clots may form inside a boggy uterus and need to be expelled
4. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit
of 25.1%. What foot should the nurse encourage this client to include in her diet? B. Chicken. 5.The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? 0.3
6.The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?
C. Blood pressure 149/90. Methergine check bp 7.A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time?
D. Contractions decrease with walking.
8.A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for
this finding?
C. The TSH is high because of the low production of T4 by the thyroid.
9.A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
D. Stimulate the infant to cry.
10.At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time
to administer a rubella vaccine to this client?
D. Early postpartum, within 72 hours of delivery . 11.A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
D. Contraction pattern.
12.One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first?
A. Check the differential, since the WBC is normal for this client.
13.A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client’s condition, what information is most important for the nurse to provide?
A. Maternal blood pressure.
14.A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is
the primary nursing consideration when supporting the parents of a child with this anomaly? C. Offer information about ultrasonography and genotyping to determine sex assignment. 15.During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client.
Lie on the left side or right side while sleeping or resting
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