HESI RN: Maternity - Test Bank Latest Update 2024/2025
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HESI RN: Maternity
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HESI RN: Maternity
HESI RN: Maternity - Test Bank Latest
Update 2024/2025HESI RN: Maternity - Test Bank Latest
Update 2024/2025HESI RN: Maternity - Test Bank Latest
Update 2024/2025HESI RN: Maternity - Test Bank Latest
Update 2024/2025HESI RN: Maternity - Test Bank Latest
Update 2024/2025HESI RN: Maternity ...
HESI RN: Maternity - Test Bank Latest
Update 2024/2025
26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height in
measured at 29cm. Based on these findings what actions the nurse implement.
a. Notify the healthcare provider of the finding
b. Document the finding in the medical record
c. Schedule the client for a biophysical profile
d. Request another nurse measure the fundus - ANSWER-b. Document the finding in the medical record
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back, and
abdomen. What action should the nurse implement? documented the findings in the infant's record -
ANSWER-Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonly referred to
as "flea bites," but is a normal finding that is documented in the infant's record.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is
transferred to the postpartum unit. The nurse knows that assessment for what complication has the
highest priority for this client?
a. postpartum psychosis
b. hard, painful uterine afterpains
c. placenta accreta
d. disseminated intravascular coagulation* - ANSWER-d. disseminated intravascular coagulation*
A 26-week gestation primigravida who is carrying twins is seen in the clinic today. Her final height is
measured at 29 cm. Based on these findings, what action should the nurse implement?
a. notify the HCP of the finding
b. schedule the client for a biophysical profile
c. document the finding in the medical record
d. request another nurse measure the fundus - ANSWER-c. document the finding in the medical record
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height in
measured at 29cm. Based on these findings what actions the nurse implement.
A) Notify the healthcare provider of the finding
B) Document the finding in the medical record
C) Schedule the client for a biophysical profile
D) Request another nurse measure the fundus - ANSWER-B) Document the finding in the medical record
,HESI RN: Maternity - Test Bank Latest
Update 2024/2025
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? - ANSWER-
Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic receptors in
the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug may cause
tachycardia, increased cardiac output, restlessness, headache, and a feeling of "nervousness".
A 28-year-old client in active labor complains of cramps in her leg. What intervention should the nurse
implement? - ANSWER-Extend the leg and dorsiflex the foot
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client is capable) and
putting the heel of the foot on the floor is the best means of relieving leg cramps
A 3-hour old male infant's hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a
respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best
for the nurse to implement?
A. Perform a heel- stick to monitor blood glucose level
B. Gradually warm the infant under a radiant heat source
C. Administer oxygen by mask at 2L/minute
D. Notify the pediatrician of the infant's unstable vital signs - ANSWER-B. Gradually warm the infant
under a radiant heat source
A 30- year-old primigravida delivers a 9-pound infant vaginally after a 30- hour labor. What is the priority
nursing action for this client?
A. Observe for signs of uterine hemorrhage
B. Encourage direct contact with the infant
C. Assess the blood pressure for hypertension
D. Gently massage fundus every four hours - ANSWER-A. Observe for signs of uterine hemorrhage
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks' gestation in preterm labor.
She is given a dose of terbutaline sulfate (Brethine) 0.25 mg subcutaneous. Which assessment is the
highest priority for the nurse to monitor during the administration of this drug? - ANSWER-Monitoring
maternal and fetal heart rates is most important when terbutaline is being administered.
,HESI RN: Maternity - Test Bank Latest
Update 2024/2025
Terbutaline acts as a sympathomimetic agent that stimulates both beta 1 receptors (causing
tachycardia, a side effect of the drug) and stimulation of beta 2 receptors (causing uterine relaxation, a
desired effect of the drug).
A 32- week primigravida who is in preterm labor receives a prescription for an infusion of D5W 500 ml
with magnesium sulfate 20 grams at 1 gram/hour. How many ml/hours should the nurse program the
infusion pump? - ANSWER-ANS: 25
A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action should the nurse take
first?
a. assess the urine for proteinuria
b. record the finding on a flowsheet
c. obtain blood pressure reading
d. notify the healthcare provider - ANSWER-d. notify the healthcare provider
A 33-year-old client at 9 weeks gestation tells the nurse that while she has "cut down," she still has at
least one alcoholic drink every evening before bedtime. What intervention should the nurse implement?
a) Notify child protective services of the client's illicit drug use and probable child endangerment
b) Praise the client for her actions and offer to discuss ways to decrease consumption even more
c) Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit -
ANSWER-c) Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit
A 33-year-old client at 9 weeks gestation tells the nurse that while she has "cut down," she still has at
least one alcoholic drink every evening before bedtime. What intervention should the nurse implement?
a. Notify child protective services of the client's illicit drug use and probable child endangerment
b. Praise the client for her actions and offer to discuss ways to decrease consumption even more
c. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit -
ANSWER-c. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing
magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
, HESI RN: Maternity - Test Bank Latest
Update 2024/2025
b. Blood pressure 140/90
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12
breaths/minute are cardinal signs of magnesium sulfate toxicity
A 38-week primigravida client who is positive for group A beta streptococcus receives a prescription for
cefazolin 2grams IV to be infused over 30mins. The medications available in 2 grams/100ml of normal
saline. The nurse should program the infusion pump to deliver how many ml/hours? - ANSWER-1.6ml/hr
A 38-week primigravida client who is positive for group A beta streptococcus receives a prescription for
cefazolin 2grams IV to be infused over 30mins. The medications available in 2 grams/100ml of normal
saline. The nurse should program the infusion pump to deliver how many ml/hours? - ANSWER-200
ml/hr.
A 38-week primigravida who works as a secretary and sits at a computer for 8 hours each day tells the
nurse that her feet have begun to swell. Which instruction would be most effective in preventing
pooling of blood in the lower extremities? - ANSWER-Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will straighten out the pelvic veins and increase venous return.
A 39-week gestational multigravida is admitted to labor and delivery spontaneous rupture of
membranes and contraction occurring 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated
6cm, 90% effaced and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has
ranged between 170 and 180 beats/minute. What action should the nurse implement?
a. Obtain a blood specimen for hemoglobin
b. Take an oral maternal temperature
c. Straight Catheterize client
d. Send amniotic fluid for analysis - ANSWER-b. Take an oral maternal temperature
A 39-week gestational multigravida is admitted to labor and delivery spontaneous rupture of
membranes and contraction occurring 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated
6cm, 90% effaced and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate has
ranged between 170 and 180 beats/minute. What action should the nurse implement?
A) Obtain a blood specimen for hemoglobin
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