HESI COMPREHENSIVE REVIEW FOR NCLEX-RN
EXAMINATON 2024/2025 VERIFIED QUESTION AND
ANSWERS WITH RATIONALE( GRADED A+)
A primigravida, when returning for the results of her multiple marker screening (triple screen),
asks the nurse how problems with her baby can be detected by the test. What information will the
nurse give to the client to describe best how the test is interpreted?
A.
If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human
chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal
defect.
B.
If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible
chromosomal defect.
C.
If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of
all structural anomalies.
D.
If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal
findings.
Rationale:Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal
blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol
in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina
bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker
screening is that any defects covered by skin will not be evident in the blood sampling. After 15
weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.
,HESI COMPREHENSIVE REVIEW FOR NCLEX-RN 2024/2025
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
A.
Maternal blood pressure
B.
Maternal temperature
C.
Fetal heart rate (FHR)
D.
White blood cell count (WBC)
Rationale:The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of the cervix is favorable.
The fluid should be assessed for color, odor, and consistency. Option A should be assessed every
15 to 20 minutes during labor but is not specific for AROM. Option B is monitored hourly after
the membranes are ruptured to detect the development of amnionitis. Option D should be
determined for all clients in labor.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture
of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick
return to baseline, with and without contractions. Based on this fetal heart rate pattern, which
intervention is best for the nurse to implement?
A.
Turn the client to her side.
B.
Begin oxygen by nasal cannula at 2 L/min.
C.
Place the client in a slight Trendelenburg position.
,HESI COMPREHENSIVE REVIEW FOR NCLEX-RN 2024/2025
D.
Assess for cervical dilation.
Rationale:The goal is to relieve pressure on the umbilical cord, and placing the client in a slight
Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a
variable fetal heart rate deceleration, which is typically caused by cord compression and can
occur with or without contractions. Option A may be helpful but is not as likely to relieve the
pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D
is not the priority intervention at this time. After repositioning the client, a vaginal examination
is indicated to rule out cord prolapse and assess for cervical change.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed.
Which instruction should the nurse provide to this client?
A.
Breastfeed the infant, ensuring that both breasts are completely emptied.
B.
Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.
Breastfeed on the unaffected breast only until the mastitis subsides.
D.
Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating
the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate
complete emptying of the breast tissue. Option C will not relieve the engorgement on the
affected side. Option D will not decrease antibiotic effects on the infant.
, HESI COMPREHENSIVE REVIEW FOR NCLEX-RN 2024/2025
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?
A.
Observe the parents applying a Pavlik harness.
B.
Provide a referral for an orthopedic surgeon.
C.
Schedule a physical therapy follow-up home visit.
D.
Teach the parents to check for hip joint mobility.
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. Early treatment often negates
the need for surgery, and option B is not indicated until approximately 6 months of age. Option
C is not indicated for hip dysplasia. It is best for the pediatrician to monitor hip joint mobility,
and teaching the parents to perform this technique is likely to increase their anxiety.
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 has had nothing to eat, she is too
weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
A.
Altered nutrition, less than body requirements for lactation
B.
Alteration in comfort related to nausea and abdominal distention
C.
Impaired bowel motility related to pain medication and immobility
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