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Maternity HESI|66 Questions And Answers|100% Accurate
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Maternity HESI|66 Questions AndAnswers|100% Accurate
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH),
is being prepared for discharge. Which nursing intervention should be
included in this infant's discharge teaching plan? - -Observe the parents
applying a Pavlik harness.
Rationale: It is important that the hips of infants with hip dysplasia are
maintained in an abducted position, which can be accomplished by using the
Pavlik harness ; this keeps the hips and knees flexed, the hips abducted, and
the femoral head in the acetabulum.
-The nurse instructs a laboring client to use accelerated blow breathing. The
client begins to complain of tingling fingers and dizziness. Which action
should the nurse take? - -Have the client breathe into her cupped hands.
Rationale: Tingling fingers and dizziness are signs of hyperventilation
(blowing off too much carbon dioxide). Hyperventilation is treated by
retaining carbon dioxide. This can be facilitated by breathing into a paper
bag or cupped hands
-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 nausea and bloating,
and states that because she had nothing to eat, she is too weak to
breastfeed her infant. Which nursing diagnosis has the highest priority? - -
Impaired bowel motility related to pain medication and immobility.
Rationale: 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.
-Twenty-four hours after admission to the newborn nursery, a full-term male
infant develops localized swelling on the right side of his head. In a newborn,
what is the most likely cause of this accumulation of blood between the
periosteum and skull that does not cross the suture line? - -
Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn,
usually arises within the first 24 hours after delivery. Trauma from delivery
causes capillary bleeding between the periosteum and skull.
-A client who delivered a healthy infant 5 days ago calls the clinic nurse and
reports that her lochia is getting lighter in color and asks when the flow will
stop. How should the nurse respond? - -When the placental site has healed
Rationale: The placental site in the uterus usually heals in 3 to 6 weeks, and
the lochial flow should cease at that time.
, -The nurse is using the Silverman-Anderson index to assess an infant with
respiratory distress and determines that the infant is demonstrating marked
nasal flaring, an audible expiratory grunt, and just visible intercostal and
xiphoid retractions. Using this scale, which score should the nurse assign? - -
5
Rationale: The Silverman-Anderson index is an assessment scale that scores
a newborn's respiratory status as grade 0, 1, or 2 for each component; it
includes synchrony of the chest and abdomen, retractions, nasal flaring, and
expiratory grunt. No respiratory distress is graded 0 and a total of 10
indicates maximum respiratory distress. This infant is demonstrating
respiratory distress with maximal effort, so a grade 2 is assigned for marked
nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just
visible retractions, which is a total score of 5
-On admission to the prenatal clinic, a client tells the nurse that her last
menstrual period began on February 15 and that previously her periods were
regular (28-day cycle). Her pregnancy test is positive. What is this client's
expected date of birth (EDB)? - -November 22
Rationale: Subtract 3 months, add 7 days.
-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. Which
intervention has the highest priority? - -Put baby to breast immediately.
Rationale: The stimulation of breast milk with help clamp down the uterus to
prevent postpartum hemorrhage.
-A 38-week primigravida who works as a secretary and sits at a computer 8
hours each day tells the nurse that her feet have begun to swell. Which
instruction will aid in the prevention of pooling of blood in the lower
extremities? - -Move about ever hour.
Rationale: Pooling of blood in the lower extremities results from the enlarged
uterus exerting pressure on the pelvic veins. Moving about every hour will
relieve pressure on the pelvic veins and increase venous return.
-Which statement made by the client indicates that the mother understands
the limitations of breastfeeding her newborn? - -"Breastfeeding my infant
consistently every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the
day will cause a release of prolactin, which will suppress ovulation and
menses, but is not completely effective as a birth control method
-A new mother is having trouble breastfeeding her newborn. The child is
making frantic rooting motions and will not grasp the nipple. Which
intervention should the nurse implement? - -Encourage the mother to stop
feeding for a few minutes and comfort the infant.
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