Exam (elaborations)
Maternity HESI
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Exam of 103 pages for the course Maternity HESI at Maternity HESI (Maternity HESI)
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MMATERNITY HESI QUESTIONS WITHCOMPLETE SOLUTION
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: - Continue to monitor
(normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further
evaluation? - Too much weight gain, gestational weight gain should only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"? - Active
movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say... - If your baby's
urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate - Inspect
perineal and rectal area.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx? - Fluid
volume excess.
RATIONALE: 3rd spacing.
Cesarean - hemorrhage risk assessment? - Check for fundal firmness Q15 min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min
checks stimulate fundus to contract and prevents bleeding.
Water broke, umbilical cord is on perineum, what does nurse do? - Place pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the
presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s? - To evaluate fetal growth and to
determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority? - Examine Q8 hrs for
jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What
would be a therapeutic response to the injection? - Increased HR and decrease in oral secretions.
Newborn assessment that indicates a cardiac problem? - RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
,Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give? - Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding. - Assess infants position while feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery. - Rhogam prevents maternal antibody formation for future Rh
positive babies.
24 hours after birth, cephalohematoma, what intervention? - Examine jaundice Q8 hours.
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
. Patient had twins born to multigravida, 12 hours ago. Nursing Dx? - Assess fundal tone and lochia flow.
. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex presentation,
greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last 4 contraction
peaks. What to do FIRST? - 02 via facemask.
Terbutaline (Brethine) injections for preterm labor. When do you hold and call the MD? - Bilateral
crackles in lungs on auscultation (critical complication).
RATIONALE: Could indicate pulmonary edema.
APGAR 3. Intervention? - Continue resuscitation efforts.
In PACU, the most important assessment for first 8 hours after cesarean: - Uterine atony.
RATIONALE: Uterine atony can lead to hemorrhage.
Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse response? - Increased risk
for spontaneous miscarriage.
RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in miscarriage.
Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station. - Apply counter
pressure to sacral area.
RATIONALE: Caused by malposition of the fetus.
Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine be given? - Give
early postpartum within 72 hours.
HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing congenital heart disease,
congenital cataracts, or both. All women should have their titers checked during pregnancy. If a woman's
titers are low, she should receive the vaccine after delivery and be instructed not to get pregnant within
3 months. Breast-feeding mothers may take the vaccine" (p. 288).
Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and nausea. Nurse Dx? - Pain
r/t transitional phase of labor.
Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse do? - Tell mother it is
normal.
,RATIONALE: Newborns can lose 10% of their wt and regain it later.
Receiving report on laboring pt from ER. Water broke and didn't know it. First thing the nurse does? -
Take temperature.
RATIONALE: Length of time membranes ruptured is important to monitor for infection.
Postpartum temporary bed-rest should be placed if? - Positive Homan's sign.
. Fundus hand placement: 1 massages the fundus the other is for... - The other hand anchors the lower
uterine section.
DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do? - Contact MD for BPP
(BioPhysical Profile).
Symptoms of hemorrhage/bleeding out: - LR 200 mL/hr using 18 gauge needle.
Most accurate way to determine fetal position at 29 weeks gestation. - Ultrasound.
RATIONALE: Provides direct view of the fetus.
To measure contractions... - From beginning of a contraction, to the beginning of the next contractions.
. Newborn assessment for respiratory distress. - Flaring of the nares.
RATIONALE: Forced inspiration, grunting, tachy (respirations >60), cyanosis, and retractions over chest
wall).
40 weeks pregnant, laboring, patient states supine is position of comfort, the nurse should? - Place
pillow wedge under right hip.
RATIONALE: Hypotension from pressure on vena cava is risk, the wedge relieves the pressure on the vena
cava.
MVA, 36 weeks, BP 80/50, HR 130, what does the nurse do? - Tilt the backboard to displace uterus.
. Patient concerned about yellow nipple discharge. - Tell the patient it is normal.
Nutrition teaching for pregnant teens. - Iron-deficient anemia.
38 weeks, laboring, which finding (condition) warrants a cesarean? - Active herpes lesions on perineum.
. Second stage of labor, what does nurse do first? - Let pt know that birth is imminent.
RATIONALE: Second stage pt is fully dilated and fetus is crowning.
Baby born breech, in the NICU they assess? - Ortolani's test.
RATIONALE: (from Saunders, couldn't find it in HESI). It is a test of hip laxity, used to diagnose hip
dysplasia.
IV LR 1000 mL with oxytocin (Pitocin) 40 units to deliver 15mL/hr. How many milli-units/minute is the
client receiving? - 10 mu/min.
, 38 week (IDM) infant of diabetic mother admitted to NICU @ 8.2 lbs. What is the priority Nursing Dx? -
Hypoglycemia.
FHR decreases after each contraction. What should the nurse do? - Give 10 lpm 02 via mask.
. Post partum teaching to prevent pregnancy. - Use condom and spermicidal gel.
1st trimester, Hgb 8.6, Hct 25.1, what food should the nurse encourage? - Chicken.
Oxytocin (Pitocin) 20 units in 1000 LR after delivery is for? - To stimulate uterine contractions to prevent
hemorrhage.
RATIONALE: Admin after placenta delivery. Prior to placental delivery would cause uterus to contract and
retain placenta.
. Full term infant, vaginal birth, placed in radiant warmer, is apneic. What to do FIRST? - Flick soles of
feet.
RATIONALE: Infant needs additional stimulation to initiate breathing.
One hand above pubic symphysis while massaging fundus of a patient who has a boggy uterine tone 15
min after delivery (7 lb baby). What does the nurse tell the patient? - Tell the patient that clots can form
in a boggy uterus.
Patient with preeclampsia is receiving IV Mag 6 grams administered over 20 min. The nurse attaches a
volume control device between the infusion pump and the bag of solution labeled "Magnesium Sulfate
20 grams/500 mL of D5W". How many mL should nurse place in volume controlled device? - 150 mL
Eye ointment QS is for? - Prevent eye infection.
Heelstick blood specimen on neonate for T4 and TSH prior to D/C home on 2 day old. Parents ask why,
the nurse states? - Required by law to screen for metabolic def.
Patient is 5 weeks pregnant, educate on nutrition... - Eat a well balanced diet, adjust PRN for proper
weight gain.
Assessing a 39 week pregnant patient admitted to L&D, which do you call MD for? - Temperature of
101.2
Patient asks if she can use the same diaphragm for birth control after her pregnancy, the nurse answers
... - Use alternative form of birth control until new diaphragm can be obtained.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his
lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which
intervention should the nurse implement first? - Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The
nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant.
Option B should be done based on the temperature, but first the glucose level should be obtained.
Option C helps raise the blood sugar, but first the nurse should determine the glucose level.
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