2024 HESI Maternity OB Exam Latest Version Actual Exam Questions

2024 HESI MATERNITY OB EXAM LATEST VERSION ACTUAL EXAM QUESTIONS WITH DETAILED VERIFIED ANSWERS/A+ GRADE ASSURED A multiparous client has been in labor for 8 hours when her membranes rupture. Which action should the nurse implement first? Prepare the client for imminent birth. Assess the fetal heart rate and pattern. Document the characteristics of the fluid. ✔- Assess the fetal heart rate and pattern. Notify the client's primary healthcare provider. A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. Which action should the nurse implement first? Administer 10 L of oxygen via face mask. Give the healthcare provider a status report. Place the client in the knee-chest position. Wrap the cord with gauze soaked in saline. ✔- Place the client in the knee-chest position. The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? Ask the mother why she won't look at the infant. Observe the mother for other bonding behaviors. Examine the newborn's eyes for the ability to focus. Recognize this as a common reaction in new mothers. behaviors. ✔- Observe the mother for other bonding A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? The client may have a bladder or kidney infection. Bladder capacity increases during pregnancy. During pregnancy, a woman is especially sensitive to body functions. The growing uterus is putting pressure on the bladder. the bladder. ✔- The growing uterus is putting pressure on Which nursing action should be implemented when intermittently gavage-feeding a preterm infant? Allow the formula to flow by gravity. Avoid letting the infant suck on the tube. Insert feeding tube through nares. Apply steady pressure to the syringe. ✔- Allow the formula to flow by gravity. A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client? During the second trimester beer can be consumed without harm to the fetus. Wine can be consumed several times a week after the first trimester. Only one drink with the evening meal is not harmful to the fetus. Abstinence is strongly recommended throughout the pregnancy. recommended throughout the pregnancy. ✔- Abstinence is strongly The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? Avoid alcohol because it is excreted in breast milk. Avoid spicy foods to prevent infant colic. Increase caloric intake by approximately 500 calories/day. Double prenatal milk intake to improve Vitamin D transfer to the excreted in breast milk. ✔- Avoid alcohol because it is A preterm infant with an apnea monitor experiences an episode of apnea. Which action should the nurse implement first? Ventilate with an Ambu bag. Perform nasal and airway suctioning. Administer supplemental oxygen. Gently rub the infant's feet or back to stimulate respirations and place in the radiant warmer. Gently rub the infant's feet or back to stimulate respirations and place in the radiant warmer. ✔- A client delivers twins, one is stillborn and the other is recovering in an intensive care nursery. As the nurse provides assistance to the bathroom, the client, softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to provide? "Don't be sad. You'll need to be strong to care for your healthy baby." "Do you want to go to the nursery and see your baby?" "I am sorry for your loss. Do you want to talk about it?" "It is always sad to lose a baby. Would you like me to call your minister?" loss. Do you want to talk about it?" ✔- "I am sorry for your A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client reports feeling light-headed and dizzy, and she states that her fingers are tingling. Which action should the nurse implement? Notify the healthcare provider. Help her breathe into a paper bag. Administer oxygen via nasal cannula. Tell the client to slow her breathing. ✔- Help her breathe into a paper bag. A client is receiving an oxytocin infusion for induction of labor. When the client begins active labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent return to baseline before each contraction ends. Which action should the nurse implement? Insert an internal monitor device. Change the client's position. Discontinue the oxytocin infusion. Document the finding in the client record. ✔- Document the finding in the client record. A gravid client develops maternal hypotension following regional anesthesia. Which intervention(s) should the nurse implement? (Select all that apply.) Administer oxygen. Increase IV fluids. Perform a vaginal examination. Assist the client to a sitting position. Place the client in a lateral position. Monitor fetal status. ✔- Administer oxygen. Increase IV fluids. Place the client in a lateral position. Monitor fetal status. During an assessment of a multiparous client who delivered an 8-pound 7-ounce infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. Which action should the nurse implement next? Perform fundal massage. Assess blood pressure. Notify the healthcare provider. Encourage the client to void. ✔- Perform fundal massage. The nurse notes a pattern of the fetal heart rate decreasing after each contraction. Which action should the nurse implement? Give 10 liters of oxygen via face mask. Prepare for an emergency cesarean section. Continue to monitor the fetal heart rate pattern. Obtain an oral maternal temperature. ✔- Give 10 liters of oxygen via face mask. A multiparous client delivered a 7-pound, 10-ounce infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? Document the color of the lochia. Observe maternal vital signs. Assist the client to the bathroom. Notify the healthcare provider. ✔- Assist the client to the bathroom. A client at 35 weeks gestation visits the clinic for a prenatal check-up. Which disclosure by the client warrants further assessment by the nurse? Periodic abdominal pain. Ankle edema in the afternoon. Backache with prolonged standing. Shortness of breath when climbing stairs. ✔- Periodic abdominal pain. The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the vital signs monitor. Which action should the nurse implement? Obtain a serum glucose level. Give the infant medication for pain. Feed the newborn 1 ounce of formula. Request a genetic consultation. ✔- Give the infant medication for pain. A client with asthma who is 8 hours postdelivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer? Oxytocin. Ibuprofen. Fentanyl. Hemabate. ✔- Oxytocin. A client at 39 weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39 weeks, 34 weeks, and 35 weeks gestation. What is her gravida number? 3. 4. 2. 1. ✔- 4. Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor? Brighten the lighting so the mother can view the infant. Complete the newborn assessment as quickly as possible. Provide positive reinforcement for maternal care of the infant. Encourage early initiation of breast or formula feeding. formula feeding. ✔- Encourage early initiation of breast or A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin for epilepsy, has a history of irregular periods, is under stress at work, and has not been sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results? Having an irregular menstrual cycle. Using an anticonvulsant for epilepsy. Taking the pregnancy test too early. Being under too much stress at work. ✔- Using an anticonvulsant for epilepsy. A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? Bruising. Oral intake. Hemoglobin. Bilirubin. ✔- Bilirubin. The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. Which is the most important factor affecting this client's pregnancy outcome? Mother's age. Amount of insulin required prenatally. Degree of glycemic control during pregnancy. Number of years since diabetes was diagnosed. ✔- Degree of glycemic control during pregnancy. A client in active labor at 39 weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, which action should the nurse implement? Escort the client to the bathroom. Offer the client a bed pan. Perform a nitrazine test. Clean the perineal area. ✔- Perform a nitrazine test. While monitoring a client in active labor, the nurse observes a pattern of 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change? Fetal well-being with labor progression. Signs of uteroplacental insufficiency. Episodes of fetal head compression. Occurrences of cord compression. ✔- Fetal well-being with labor progression. A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client will remain after pregnancy? Pruritus. Chloasma. Vascular spiders. Striae gravidarum. ✔- Striae gravidarum. The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1,200 mg during pregnancy. The client responds, "I don't like milk." Which dietary adjustments should the nurse recommend? Increase organ meats in the diet. Eat more green, leafy vegetables. Add molasses and whole-grain bread to the diet. Choose more fresh citrus and other fruits daily. ✔- Eat more green, leafy vegetables. A primigravida at 12 weeks gestation tells the nurse that she does not like dairy products. Which food should the nurse recommend to increase the client's calcium intake? Canned clams. Fresh apricots. Canned sardines. Spaghetti with meat sauce. ✔- Canned sardines. The nurse on the postpartum unit receives reports for 4 clients during the change of shift. Which client should the nurse assess for risk of postpartum hemorrhage (PPH)? A primigravida who had a spontaneous birth of preterm twins. A multigravida who delivered an 8-pound 2-ounce infant after an 8 hour labor. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. A primiparous client who had an emergency cesarean birth due to fetal distress. client receiving magnesium sulfate during induction for severe preeclampsia. ✔- A multiparous The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature of 95.1°F (35.06° C), heart rate of 136 beats/minute, and a respiratory rate of 48 breaths/minute. Based on these findings, which action should the nurse take first? Check the infant's arterial blood gases. Notify the pediatrician of the infant's vital signs. Assess the infant's blood glucose level. Encourage the infant to take the breast or sugar water. ✔- Assess the infant's blood glucose level. The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. Which nursing action should the nurse implement? Institute contact precautions. Obtain a rectal temperature. Assess for abdominal distention. Decrease the amount of feeding. ✔- Assess for abdominal distention. The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37 weeks gestation. Which nursing action should be implemented first? Provide tactile stimulation. Administer flow with 100% oxygen. Asses the functionality of the monitoring device. Evaluate the newborn's color and respirations. ✔- Evaluate the newborn's color and respirations. Which cardiovascular findings should the nurse assess further in a client who is at 20-weeks gestation? Decrease in pulse rate. Decrease in blood pressure. Increase in heart sounds (S1, S2). Increase in red blood cell production. ✔- Decrease in pulse rate. While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding? Molding. Hemangioma. Cephalohematoma. Caput succedaneum. ✔- Caput succedaneum. A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. Which action should the nurse implement next? Determine the firmness of the fundus. Give oxytocin intravenously. Inform the healthcare provider of the bleeding. Assess the vital signs for indicators of shock ✔- Determine the firmness of the fundus. A nulliparous client telephones the labor and delivery unit to report that she is in labor. Which action should the nurse implement? Emphasize that food and fluid intake should stop. Tell the client to stay home until her membranes rupture. Ask the client to describe why she thinks she is in labor. Suggest the client come to the hospital for labor evaluation. thinks she is in labor. ✔- Ask the client to describe why she Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? Silver nitrate. Erythromycin. Ceftriaxone. Vitamin K. ✔- Vitamin K The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Rate of 58 breaths per minute. Grunting is heard with a stethoscope. ✔- Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Grunting heard with a stethoscope. Which finding indicates to the nurse that a 4-day-old infant is receiving adequate breast milk? Gains 1 to 2 ounces per week. Saturates 6 to 8 diapers per day. Rests for 6 hours between feedings. Defecates at least once per 24 hours. ✔- Saturates 6 to 8 diapers per day. When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? Quiet the infant before counting the heart rate. Listen at the apex of the heart. Count the heart rate for at least one full minute. Palpate the umbilical cord. ✔- Count the heart rate for at least one full minute. The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make? Inform the mother that the injection was prescribed by the healthcare provider. Explore the mother's concerns about the infant receiving an injection of vitamin K. Explain that vitamin K is required by state law and compliance is mandatory. Remind the mother that all babies receive this shot and it is relatively painless. mother's concern about the infant receiving an injection of vitamin K. ✔- Explore the A preeclamptic client has developed severe features which include pulmonary edema. While awaiting transport to the intensive care unit, what should the nurse assess? Assess fetal response. Note any complaint of sudden chest pain. Monitor for signs of impaired gas exchange. Observe for maternal blood pressure changes. ✔- Monitor for signs of impaired gas exchange. A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. Which action should the nurse implement at this time? -Ask to meet with the client and infant without family members present. -Do a brief assessment for only the infant while family members are present. -Observe interactions of family members with the newborn and each other. -Reschedule the visit so that the mother and infant can be assessed privately. interactions of family members with the newborn and each other. ✔- Observe A client at 25 weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? This is a demonstration of the fetus's acoustical reflex. The fetus can respond to sound by 24 weeks gestation. It is a coincidence the fetus responded at the same time. Report the fetus's behavior to the healthcare provider. weeks gestation. ✔- The fetus can respond to sound by 24- The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? Plan for a possible cesarean birth. Arrange for home uterine monitoring. Make arrangements for care at home. Report uterine cramping or low backache. ✔- Report uterine cramping or low backache. A client at 28 weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? It is not necessary to keep such a close watch on weight gain. Try to exercise more because too much weight has been gained. Increase the calories in your diet to gain more weight per week. The weight gain is acceptable for the number of weeks pregnant. for the number of weeks pregnant. ✔- The weight gain is acceptable The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? The kidneys and renal function are not fully developed. Warmth promotes sleep so the infant will grow quickly. A large body surface area favors heat loss to the environment. The thick layer of subcutaneous fat is inadequate for insulation. heat loss to the environment. ✔- A large body surface area favors Which procedure evaluates the effect of fetal movement on fetal heart activity? Sonography. Contraction test. Biophysical profile. Non-stress test (NST). ✔- Non-stress test When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. Which action should the nurse implement next? Notify the healthcare provider immediately. Move the newborn to an isolation nursery. Document the finding as erythema toxicum. Obtain a culture from one of the vesicles. ✔- Document the finding as erythema toxicum A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? Blood pressure of 100/60 mm Hg. Fetal heart rate of 120 to 125 beats/minute. Contractions occur every 30 minutes. Respiratory rate of 11 breaths/minute. ✔- Respiratory rate of 11 breaths/minute. The father of a newborn tells the nurse, "My son just died." How should the nurse respond? "I am sorry for your loss." "There is an angel in heaven." "I understand how you feel." "You can have other children." ✔- "I am sorry for your loss." Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy? "Protein helps the fetus grow while I am pregnant." "Gestational diabetes is prevented by eating protein." "Anemia is averted by consuming enough protein." "My baby will develop strong teeth after he is born." pregnant." ✔- "Protein helps the fetus grow while I am An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. Which is the priority nursing intervention? Evaluate the blood pH. Begin humidified oxygen via hood. Stimulate infant crying. Place the infant under a radiant warmer. ✔- Begin humidified oxygen via hood. When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of home birth? Only the woman and her midwife should be present during the delivery. The woman should live no more than 15 minutes from the hospital. The woman's extended family should be allowed to attend the home birth. Medical backup should be available quickly in case of complications. available quickly in case of complications. ✔- Medical back up should be The nurse is caring for a client whose labor is being augmented with oxytocin. Which finding indicates that the nurse should discontinue the oxytocin infusion? The client needs to void. Amniotic membranes rupture. Uterine contractions occur every 8 to 10 minutes. The fetal heart rate is 180 bpm without variability. variability. ✔- The fetal heart rate is 180 bpm without Which gastrointestinal findings should the nurse be concerned about in a client at 28 weeks gestation? Pica. Pyrosis. Ptyalism. Decreased peristalsis. ✔- Pica. A female client who wants to deliver at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? Birth in the home setting is the preference for using a midwife for delivery. The pregnancy should progress normally and be considered low-risk. Natural child birth without analgesia is used to manage pain during labor. An obstetrician should also follow the client during pregnancy. normally and be considered low risk. ✔- The pregnancy should progress A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mmHg at the peak of a contraction and the resting tone is 6 to 10 mmHg. Based on this information, which action should the nurse implement? Notify the client's healthcare provider. Bring the delivery table to the room. Prepare to administer an oxytocic. Document the findings in the client record. ✔- Document the findings in the client record. A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? Contraction stress test. Internal fetal monitoring. Abdominal ultrasound. Lecithin-sphingomyelin ratio. ✔- Abdominal ultrasound. What information should the nurse include about perineal self-care for a client who is 24 hours postdelivery? Use cool water to decrease swelling of the perineum. Perineal care should be done at least twice per day. Reapply ice packs to the perineum after each voiding. Spray warm water from front to back using a squeeze bottle. back using a squeeze bottle. ✔- Spray warm water from front to A client who is at 24 weeks gestation presents to the emergency department holding her arm and reporting pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation? The woman and her partner are having a loud and hostile argument. The woman avoids eye contact and hesitates while answering questions. Other parts of her body have injuries that are in different stages of healing. Examination reveals a fracture to the right humerus and multiple bruises. body have injuries in different stages of healing ✔- Other parts of her Which action should the nurse implement to prevent conductive heat loss in a newborn? Place the infant under a radiant warming system. Put a blanket on the scale when weighing the infant. Dry the newborn with a warmed blanket. Position the crib away from the windows. ✔- Put a blanket on the scale when weighing the infant. The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring at the peak of each contraction. Which action should the nurse implement? Notify the healthcare provider of fetal status. Give oxygen at 10 L per nasal cannula. Place the client in a side-lying position. Increase the flow rate of intravenous fluids. ✔- Place the client in a side-lying position. A client in labor receives an epidural block. Which intervention should the nurse implement first? Encourage oral fluids. Assess contractions. Monitor blood pressure. Obtain a radial pulse. ✔- Monitor blood pressure. A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (10 pounds, 2.5 ounces), which is the priority nursing action? Assess newborn reflexes for signs of neurological impairment. Leave the infant in the room with the mother to foster attachment. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. Perform a gestational age assessment to determine if the infant is large-for-gestational-age. Obtain serum glucose levels frequently while observing closely for signsof hypoglycemia. ✔- A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement? Avoid pumping her breasts. Continue breastfeeding every 2 hours. Skip a feeding to rest the breasts. Decrease fluid intake for at least 24 hours. ✔- Continue to breast feed every two hours Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? Tactile stimulation. Commercial warm packs. Skin-to-skin contact with the parent. Oral sucrose and nonnutritive sucking. ✔- Oral sucrose and nonnutritive sucking. The nurse is teaching a primigravida at 10-weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care? The risk for neonatal cerebral palsy increases with folic acid deficiencies during pregnancy. Folic acid can significantly reduce the incidence of intellectual disability. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects. The incidence of congenital heart defects is related to folic acid intake deficiencies. folic acid during embryogenesis reduces the incidence of neural tube defects ✔- Adequate The nurse assesses a high-risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. Which nursing action should be implemented? Place socks on the infant. Elevate the feet 15 degrees. Wrap feet loosely in a prewarmed blanket. Report findings to the healthcare provider. ✔- Report findings to the healthcare provider. Which action should the nurse implement with the family when an infant is born with anencephaly? Ensure that measures to facilitate the attachment process are offered. Prepare the family to explore ways to cope with the imminent death of the infant. Inform the family about multiple corrective surgical procedures that will be needed. Provide emotional support to facilitate the consideration of fetal organ donation. family to explore ways to cope with the imminent death of the infant. ✔- Prepare the A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client will remain after pregnancy? Pruritus. Chloasma. Vascular spiders. Striae gravidarum. ✔- Striae gravidarum. Which finding in the medical history of a postpartum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate? Pregnancy-induced hypertension. Placenta previa. Gestational diabetes. Postpartum hemorrhage. ✔- Pregnancy induced hypertension. Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? Request help with ambulation and perineal care. Exhibit interest in learning more about infant care. Sleep most of the time when the baby is not present. Be very excited and talkative about the birth experience. infant care. ✔- Exhibit interest in learning more about An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a nuchal cord after a 30minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide the parents about this finding? Further assessment is indicated. Petechiae occurs with forceps delivery. An increased blood volume causes broken blood vessels. The pinpoint spots are benign and disappear within 48 hours. disappear within 48 hours. ✔- The pinpoint spots are benign and The nurse administers meperidine 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. Which medication should the nurse anticipate administering to the infant? Naloxone. Nalbuphine. Fentanyl. Promethazine. ✔- Naloxone The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address that provides the best advantage of gravity during delivery? Walking. Squatting. Kneeling. Lithotomy. ✔- Squatting. A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tachycardia, and a cutaneous rash. Which nursing intervention should be implemented first? Inform the healthcare provider. Stop the transfusion. Administer calcium gluconate. Monitor vital signs electronically. ✔- Stop the transfusion Which action should the nurse implement when caring for a newborn immediately after birth? Keep the newborn's airway clear. Foster parent-newborn attachment. Administer eye prophylaxis and vitamin K. Dry the newborn and wrap it in a blanket. ✔- Keep the newborn's airway clear Which nursing intervention is priority during the fourth stage of labor? Promote bonding. Assess for hemorrhage. Provide comfort measures. Monitor uterine contractions. ✔- Assess for hemorrhage. A multigravida client at 40+ weeks gestation is induced using oxytocin. An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action? Labor has progressed at 1 cm/hr dilation. The intensity of contractions is 130 mmHg. Contractions are lasting 60 to 80 seconds. Oxytocin is infusing at a rate of 30 mUnit/min. ✔- The intensity of the contractions are 130 mm Hg. A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? Excretes prolactin and insulin. Produces nutrients for fetal nutrition. Secretes both estrogen and progesterone. Forms a protective, impenetrable barrier. ✔- Secretes both estrogen and progesterone. A multigravida client at 35 weeks gestation is diagnosed with gestational hypertension. Which symptom should the nurse instruct the client to report immediately? Backache. Constipation. Blurred vision. Increased urine output. ✔- Blurred vision A client is experiencing "back labor" and reports intense pain in the lower lumbar-sacral area. Which action should the nurse implement? Perform effleurage on the abdomen. Encourage pant-blow breathing techniques. Apply counterpressure against the sacrum. Assist the client in guided imagery. ✔- Apply counter pressure against sacrum Which action should the nurse implement when caring for a newborn receiving phototherapy? Reposition every 6 hours. Place an eyeshield over the eyes. Limit the intake of formula. Apply an oil-based lotion to the skin. ✔- Place an eyeshield over the eyes. During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide? Discontinue all forms of contraception. Make sure to include adequate folic acid in the diet. Lose weight so more weight is gained during pregnancy. Continue to take any medications that are taken regularly. ✔- Make sure to include adequate folic acid in the diet. A client comes into the clinic for her six-week postpartum checkup and complains that her left breast is erythematous and painful. The client asks, "Can I still breastfeed my baby?" Which is the best response for the nurse to provide? Advise to stop breastfeeding until the infection clears. Inform the client to continue breastfeeding. Begin all feedings with the infected breast. Tell the client to pump then discard the milk from the affected breast. continue breastfeeding. ✔- Inform the client to The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Heart rate of 158 beats per minute. Grunting is heard with a stethoscope. ✔- Chest breathing with nasal flaring Diaphragmatic breathing with chest retraction Grunting are signs of respiratory distress in the infant Which nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal? Play soft music and talk to soothe the infant. Administer chloral hydrate for sedation. Feed every 4 to 6 hours to allow extra rest. Swaddle the infant snugly and hold tightly. ✔- Swaddle the infant snuggly and hold tightly. The nurse is assessing a 12-hour-old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)? An extra digit on the left hand. Corneal clouding. Flat nasal bridge. Asymmetrical bulging fontanels. ✔- Flat nasal bridge. While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? Molding. Cephalohematoma. Caput succedaneum. Bulging fontanel. ✔- Cephalohematoma. A multiparous client is admitted to the postpartum unit after rapid labor and the birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. Which action should the nurse implement next? Recheck the client's vital signs. Notify the healthcare provider. Insert an indwelling urinary catheter. Massage the fundus in 30 minutes. ✔- Notify the healthcare provider. A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give? Apply ice to the breasts. Wear a loose-fitting bra. Run warm water on the breasts during a shower. Express small amounts of milk from the breasts. ✔- Apply ice to the breasts. Which assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? Maternal bradycardia. Hard, board-like abdomen. Decrease in fundal height. Decrease in abdominal pain. ✔- Hard Board like abdomen A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.) Tetanus. Rubella. Diphtheria. Chickenpox. Hepatitis B. ✔- Tetanus Diphtheria Hep B A client at 28 weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? Vaginal bleeding. Complaints of abdominal pain. Changes in fetal heart rate patterns. Alteration in maternal blood pressure. ✔- Changes in fetal heart rate patterns. Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin? A woman whose blood group is AB Rh-positive. A newborn with rising serum bilirubin level. A newborn whose Coombs test is negative. A primigravida mother who is Rh-negative. ✔- Primigravida mother who is Rh-negative. Which action is most important for the nurse to implement for a client at 36 weeks gestation who is admitted with vaginal bleeding? Monitor uterine contractions. Apply disposable pads under the client. Determine fetal heart rate and maternal vital signs. Obtain blood samples for hemoglobin hematocrit levels. ✔- Determine FHR and maternal vital signs A newborn infant who is 24 hours old is on a 4-hour feeding schedule of formula. To meet daily caloric needs, how many ounces are recommended at each feeding? 2 ounces. 4 ounces. 1.5 ounces. 3.5 ounces. ✔- 3.5 ounces Which client finding should the nurse document as a positive sign of pregnancy? Last menstrual cycle occurred 2 months ago. A urine sample with a positive pregnancy test. Presence of Braxton Hicks contractions. Fetal heart tones (FHT) heard with a doppler. ✔- fetal heart tones heard with doppler A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement? Obtain a precipitous delivery tray. Visualize the perineum for bulging. Call the healthcare provider for a STAT delivery. Instruct the client's partner to stay for the delivery. ✔- visualize perineum for bulging A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide to the client? Amniocentesis. Ultrasonography. Chorionic villus sampling. Maternal serum alpha-fetoprotein. ✔- Ultrasonography An infant born at 37 weeks gestation, weighing 4.1 kg (9.04 pounds) is 2 hours old and appears large for gestational age, flushed, and tremulous. Which procedure should the nurse follow to implement a glucose screening? (Arrange the examination process from first on top to last on the bottom.) 1.Collect a spring-loaded automatic puncture device. 2.Cleanse the puncture site on the lateral aspect of the heel. 3.Restrain the newborn's foot with your free hand. 4.Wrap the infant's foot with a heel warmer for 5 minutes. warmer for 5 minutes. ✔- Wrap the infant's foot with a heel Collect a spring-loaded automatic puncture device. Restrain the newborn's foot with your free hand. Cleanse the puncture site on the lateral aspect of the heel. A client at 8 months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? Many women imagine what their baby is like by interpreting fetal movements. The fetus in utero is capable of hearing and does respond to the mother's voice. The healthcare provider should address her concerns about her baby's hearing function. The interaction between the mother's voice and the fetus's response ensures bonding. in utero is capable of hearing and does respond to the mother's voice. ✔- The fetus A client at 8 weeks gestation asks the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a congenital heart defect (CHD) may occur? It depends on what the causative factors are for a CHD. We don't really know what or when CHDs occur. They usually occur in the first trimester of pregnancy. The heart develops in the third to fifth weeks after conception. fifth weeks after conception. ✔- The heart develops in the third to Which finding for a client in labor at 41 weeks gestation requires additional assessment by the nurse? Cervix dilated 2 cm and 50% effaced. A score of 8 on the biophysical profile. Fetal heart rate of 116 beats per minute. One fetal movement noted in an hour. ✔- One fetal movement noted in an hour. The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should the nurse document this finding? Acrocyanosis. Mongolian spots. Erythema toxicum. Harlequin sign. ✔- Mongolian spots. An infant with hyperbilirubinemia is receiving phototherapy. Which intervention should the nurse implement? Maintain NPO status. Monitor temperature. Apply skin lotion as prescribed. Change the T-shirt every 3 hours. ✔- Monitor temperature At 10 weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. Which assessment finding requires immediate intervention? Uterine cramping. Abdominal tenderness. Systolic blood pressure less than 100 mmHg. Intermittent nausea. ✔- Uterine cramping The nurse is giving discharge instructions for a client following a suction curettage for a hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? Oral contraceptives prevent a reoccurrence of a molar pregnancy. Pregnancy within 1 year decreases the chances of a future successful pregnancy. Diagnostic testing for human chorionic gonadotropin (hCG) levels is elevated by pregnancy. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation. Diagnostic testing for hCG levels are elevated by pregnancy ✔-