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Maternity HESI Exam Latest Update October 2024 After performing an Ortolani test, the nurse observes that a newborn has asymmetric gluteal and thigh skinfolds and uneven knee levels. What does the nurse infer from this assessment? The infant had: A low bi$7.99
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Maternity HESI Exam Latest Update October 2024 After performing an Ortolani test, the nurse observes that a newborn has asymmetric gluteal and thigh skinfolds and uneven knee levels. What does the nurse infer from this assessment? The infant had: A low bi
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Maternity HESI Exam Latest Update October 2024
After performing an Ortolani test, the nurse observes that a newborn has asymmetric gluteal and thigh skinfolds and uneven knee levels. What does the nurse infer from this assessment? The infant had:
A low birth weight.
A vertex presentation at birt...
After performing an Ortolani test, the nurse observes that a newborn has asymmetric gluteal and thigh
skinfolds and uneven knee levels. What does the nurse infer from this assessment? The infant had:
A low birth weight.
A vertex presentation at birth.
Amniotic prolapse before birth.
A breech presentation at birth. - Answer--A breech presentation at birth.
The newborn was found to have asymmetric gluteal and thigh skinfolds and uneven knee levels, which
indicate a positive Ortolani test. The test reveals that the infant has developmental dysplasia of the hips
(DDH). DDH occurs more often in female infants with breech presentation at birth. Therefore the
newborn had breech presentation before birth. Low birth weight may be due to gestational diabetes
and preterm deliveries; however, low a low birth weight is unrelated to developmental dysplasia of the
hips. Amniotic prolapse is not associated with uneven knee lengths and asymmetric gluteal and thigh
skinfolds. Vertex presentation of the newborn is an edematous area that is present at birth, extends
across suture lines of the skull, and usually disappears spontaneously within 3 to 4 days after birth.
p. 572
,If the mother's HBsAg status is unknown, then the infant's weight is considered to determine the time
for the administration of the HBIG vaccine. The infant weighs 1800 g, so the HBIG vaccine is given within
12 hours after the infant's birth. Therefore the HBIG vaccine should be administered 9 hours after birth,
not 13, 14, or 18 hours after. If the mother's HBsAg status is known and the baby weighs more than
2000 g, then the HBIG vaccine can be administered within a week of the newborn's birth. In such a
situation, the vaccine can be administered at 13, 14, or 18 hours after the birth of the infant.
During the assessment of a postpartum patient, the nurse finds the patient has endometritis. Which
medication should be administered in the treatment plan for this patient?
Endometritis is a common postpartum infection. It usually begins as a localized infection at the placental
site and spreads to the entire endometrium. Endometritis is usually managed by giving the patient a
broad-spectrum antibiotic drug, like Clindamycin (Cleocin). Therefore clindamycin (Cleocin) should be
involved in the treatment plan for management of endometritis. Misoprostol (Cytotec), ergonovine
(Ergotrate), and methylergonovine (Methergine) are uterotonic drugs used to manage postpartum
hemorrhage (PPH) caused by uterine atony.
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani
maneuver:
tells the parents that one leg may be longer than the other, but they will equal out by the time the
infant is walking.
,alerts the physician that the infant has a dislocated hip.
informs the parents and physician that molding has not taken place.
suggests that if the condition does not change, surgery to correct vision problems might be needed. -
Answer--alerts the physician that the infant has a dislocated hip.
Upon assessment, the nurse finds that the infant has a sunken abdomen, bowel sounds heard in the
chest, nasal flaring, and grunting. What clinical condition does the nurse suspect the infant has based on
these findings?
The nurse is taking care of a newborn. The nurse finds out that the infant weighs 1800 g and the
mother's HBsAg status is unknown. When should the nurse administer the hepatitis B immune globulin
(HGIB) vaccine to the infant?
9 hours after the infant is born
13 hours after the infant is born
, 14 hours after the infant is born
18 hours after the infant is born - Answer--9 hours after the infant is born
The nurse observes increased bilirubin levels in the laboratory reports of a newborn. Which
complication does the nurse expect in the newborn if this condition is poorly monitored?
Syndactyly
Kernicterus
Rectal fistula
Down syndrome - Answer--Kernicterus
Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the body
during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can cause
the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more
digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by
the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not
associated with increased bilirubin levels.
The nurse is assessing an infant with a body weight of 2500 g. Two days after delivery the blood report
of the infant's mother confirms the presence of hepatitis B. What medication does the primary health
care provider instruct the nurse to administer to the infant?
Intravenous (I.V.) hepatitis B vaccine
Intramuscular (IM) hepatitis B vaccine
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