Focus on Maternity Exam

1. 1.79639408

The home care nurse is instructing a client with hyperemesis gravidarum about measures to ease

the nausea and vomiting. What does the nurse tell the client to do?

A. Eat foods high in calories and fat

B. Lie down for at least 20 minutes after meals

C. Eat carbohydrates such as cereals, rice, and pasta Correct

D. Consume primarily soups and liquids at mealtimes

Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice,

and pasta provide important nutrients and help prevent a low blood glucose level, which can

cause nausea. Soups and other liquids should be taken between meals to avoid distending the

stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally,

food portions should be small and foods with strong odors should be eliminated from the diet,

because food smells often incite nausea.

Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and

the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may

be difficult to digest will assist you in eliminating this option. Next eliminate the option that

involves consuming primarily soups and fluids at meals, recalling that liquids will cause

distention of the stomach. To select from the remaining options, recall that lying down after

meals can cause gastric reflux; this will direct you to the correct option.

Review: preventing nausea and vomiting

Level of Cognitive Ability: Applying

Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching and Learning

Content Area: Maternity/Antepartum

Giddens Concepts: Fluid and Electrolytes, Nutrition

HESI Concepts: Fluids and Electrolytes, Nutrition

Awarded 100.0 points out of 100.0 possible points.

2. 2.I79639405

The nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate

infusion to prevent eclampsia. Which finding indicates to the nurse that the medication

is effective?

A. Clonus is present.

B. Magnesium level is 10 mg/dL (4.11 mmol/L).

C. Deep tendon reflexes are absent.

D. The client experiences diuresis within 24 to 48 hours. Correct

Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs

within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal

perfusion is increased and the client is free of visual disturbances, headache, epigastric pain,

clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is

supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates

cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 

mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent.

Test-Taking Strategy: Focus on the subject, client with preeclampsia. Use the process of

elimination and focus on the strategic word“effective”. This indicates that the action of the

medication is appropriate. Recalling the actions of this medication and expected assessment

findings after a client receives magnesium sulfate will direct you to this option.

Review: magnesium sulfate infusion

Level of Cognitive Ability: Evaluating

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Evaluation

Content Area: Pharmacology

Giddens Concepts: Evidence, Perfusion

HESI Concepts: Evidence-Based Practice/Evidence, Perfusion/Clotting

Awarded 100.0 points out of 100.0 possible points.

3. 3.9639402

A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion

exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration

of:

A. Vitamin K

B. Protamine sulfate

C. Calcium gluconate Correct

D. Naloxone hydrochloride

Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the

effects of magnesium at the neuromuscular junction. It should be readily available whenever

magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the

administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is

the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone

hydrochloride is administered to treat opioid-induced respiratory depression.

Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium

toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in

directing you to the correct option.

Review: common antidotes if you had difficulty with this question.

Level of Cognitive Ability: Understanding

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Planning

Content Area: Pharmacology

Giddens Concepts: Clinical Judgment, Safety

HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety

Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 773).

St. Louis: Mosby.

Awarded 100.0 points out of 100.0 possible points.

4. 4.79639299

The maternity nurse is caring for a pregnant client with no history of preeclampsia who is

receiving a magnesium sulfate infusion. Why is this client receiving this infusion?

A. To contract the uterus Correct

B. To treat hypotension

C. To reverse extreme muscle weakness

D. To halt preterm labor contractions

Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth

muscle, including the uterus. It is used to halt preterm labor contractions and also for

preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed

respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased

urine output, pulmonary edema, and elevated serum magnesium levels

Test-Taking Strategy: Focus on the subject, pregnant client receiving magnesium sulfate

infusion. Know that magnesium sulfate is used to relax smooth muscle, not contract the muscle.

Note the options that are comparable or alike in that they are related to treating hypotension

and reverse extreme muscle weakness because these conditions are adverse effects of this

medication.

Review: Magnesium sulfate infusion

Level of Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Planning

Content Area: Pharmacology

Giddens Concepts: Clinical Judgment, Safety

HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety

Awarded 100.0 points out of 100.0 possible points.

5.

The nurse instructs a pregnant client about foods that are high in folic acid. Which item does the

nurse tell the client is the best source of folic acid?

A. Milk

B. Steak

C. Chicken

D. Lima beans Correct

Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and

fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts,

refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.

Test-Taking Strategy: Use the process of elimination and focus on the subject, source of folic

acid. Note the strategic word “best”. This indicates the most appropriate source of folic

acid. Eliminate the options that are comparable or alike in that they are high in protein. Next

eliminate milk, recalling that milk is high in calcium.

Review: foods high in folic acid

Level of Cognitive Ability: Applying

Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching and Learning

Content Area: Nutrition

Giddens Concepts: Nutrition, Reproduction

HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction

Awarded 100.0 points out of 100.0 possible points.

6.

The nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle

cap) about treatment of the condition. What does the nurse tell the mother to do?

A. Avoid the use of shampoo on the infant’s scalp

B. Apply oil to the affected area on the infant’s scalp Correct

C. Wash the infant’s scalp daily, using only tepid water

D. Shampoo the infant’s scalp, avoiding the anterior fontanel area

Rationale: Treatment includes the application of oil (e.g., mineral oil) to the area to help soften

the lesions followed by gentle removal of the scaly lesions with a comb before the head is

shampooed. Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the

skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not

wash over the anterior fontanel carefully for fear that they will hurt the infant. The nurse should

teach the mother how to shampoo the scalp and explain that she will not damage the fontanel

with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which

could cause irritation.

Test-Taking Strategy: Focus on the subject, infant with seborrheic dermatitis. Use the process

of elimination. Eliminate the option containing theclosed-ended word “only.” To select from

the remaining options, recall that this condition is characterized by the presence of scaly lesions;

this will direct you to the correct option.

Review: seborrheic dermatitis (cradle cap)

Level of Cognitive Ability: Applying

Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching and Learning

Content Area: Newborn

Giddens Concepts: Client Education, Tissue Integrity

HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity

Awarded 100.0 points out of 100.0 possible points.