1. A client who is in the second trimester of pregnancy tells the nurse that she wants touse
herbal therapy. Which response is best for the nurse to provide?
It is important that you want to take part in your care.
The emphasis of alternative and complementary therapies, such as herbal therapy, isthat the
client is viewed as a whole being, capable of decision-making and an integralpart of the health
care team, so recognizes the client's request.
2. A primigravida client who is 5 cm dilated, 90% effaced, and at 0 station is requesting anepidural
for pain relief. Which assessment finding is most important for the nurse to report to the
healthcare provider?
A platelet count of 67,000/mm3.
Thrombocytopenia (low platelet count) should be reported to the healthcare providerbecause
it places the client at risk for bleeding when an epidural is administered.
3. A 24-hour-old newborn has a pink papular rash with vesicles superimposed on thethorax,
back, and abdomen. What action should the nurse implement? documented the findings in
the infant's record
Erythema toxicum (or erythema neonatorum) is a newborn rash that is commonlyreferred
to as "flea bites," but is a normal finding that is documented in the infant'srecord.
4. When explaining "postpartum blues" to a client who is 1 day postpartum, which
symptoms should the nurse include in the teaching plan? (Select all that apply.)
Mood swings
Tearfulness
"Postpartum blues" is a common emotional response related to the rapid decrease inplacental
hormones after delivery and include mood swings, tearfulness, feeling low,emotional, and
fatigued.
5. The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose?
Assess for maternal pre-eclampsia
Alpha-fetoprotein (AFP) is a screening test used in pregnancy. Elevated AFP may indicate an
increased risk of neural tube defects such as anencephaly and spinal bifida.
6. The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform?
Observe for an asymmetrical Moro (startle) reflex
The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle.
Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has
Version | Latest |
Category | HESI |
Release date | 2021-09-08 |
Pages | 32 |
Language | English |
Comments | 0 |
High resolution | Yes |
Sales | 0 |
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