NEW GENERATION COMPREHENSIVE HESI EXAMS FOR PREGNANCY, LABOR, CHILDBIRTH, AND POSTPARTUM | REAL EXAMS WITH RATIONALE

NEW GENERATION COMPREHENSIVE HESI EXAMS FOR PREGNANCY, LABOR, CHILDBIRTH, AND POSTPARTUM | REAL EXAMS WITH RATIONALE Which action provides support for the fetal head as it is being delivered? Applying suprapubic pressure Placing a hand firmly against the perineum Distributing the fingers evenly around the head Maintaining pressure against the anterior fontanel Rationale Distribution of the fingers around the head will prevent a rapid change in intracranial pressure while the head is being born and keeps the head from 'popping out,' which could result in maternal perineal trauma. Applying suprapubic pressure will not aid in the birth of the head. Placing a hand firmly against the perineum may interfere with the birth and harm the neonate. Maintaining pressure against the anterior fontanel could injure the neonate. Between contractions that are 2 to 3 minutes apart and last about 45 seconds the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. Which is the priority nursing action? Notify the health care provider. Resume continuous fetal heart monitoring. Continue to monitor the maternal vital signs. Document the fetal heart rate as an expected response to contractions. Rationale The expected FHR is 110 to 160 beats/min between contractions. An FHR of 100 beats/min is bradycardia (baseline FHR slower than 110 beats/min) and indicates that the fetus may be compromised, requiring notifying the health care provider and medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. Although a fetal heart rate slower than 110 beats/minute should be documented, it is not an expected response. Test-Taking Tip: Work with a study group to create and take practice tests. Think of the kinds of questions you would ask if you were composing the test. Consider what would be a good question, what would be the right answer, and what other answers might appear right but would in fact be incorrect. Which physiological alteration does the nurse expect in a client's hematological system during the second trimester of pregnancy? An increase in hematocrit An increase in blood volume A decrease in sedimentation rate A decrease in white blood cells (WBCs) Rationale The blood volume increases by approximately 50% during pregnancy. Peak blood volume o