HESI Version 5(2021), (A Grade), Questions and Answers, All Correct Study Guide, Download to Score A 1. One hour after delivery the nurse is unable to palpate the uterine funds of a client who had an epidural and notes a large amount of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current vital signs. Which intervention should thenurse implement next. a. Document number of pad changes in the last hour b. Provide bedpans to void if unable to ambulate c. Palpate the supra cubic area for bladder distention d. Increases the rate of the oxytocin infusion 2. The father of a 3-day old infant who is breast feeding calls the postpartum help line toreport that his wife is acting strangely. She is irritable, cannot cope with the baby, andfrequently cries for no appeared reason. What information is most important for the nurse to provide the father? a. Contact the clinic if the behaviors continue for more than two weeks or becomesworse b. Tell the father count the newborns number of soiled diapers over the next few days. c. A fluctuation in hormones in the early postpartum period can cause mood changes. d. Recommend giving supplemental bottle feedings to the baby between breastfeeding. 3. Which action should the nurse take if an infant, who was born yesterday weighing7.5lbs (3,317grams) weights 7 lbs. (3,175grams) today. 2 a. Monitor the stool and urine output of the neonate for the last 24 hours b. Inform and assure the mother that this is a normal weight loss c. Encourages the mother to increase frequency of breastfeeding. d. After verifying the accuracy of the weight, notify the healthcare provider. 4. A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the clients record indication that she was medicated 30minutes ago with butorphanol (Stadol) 2mg and promethazine (Phenergan) 25mg IVpush. Vaginal examination reveals that the client cervical dilation is 3cm, 70% effaced, and at a 0 station. What action should the nurse implement? • Discontinue the Pitocin infusion • Medicate the client with an additional 1mg of Stadol IV push • Notify the healthcare provider • Instruct the client to use deep breathing during contraction 5. A woman who delivered a 9-pound baby boy by cesarean section under spinal anesthesia is recovering in the post anesthesia care unit. Her fundus is firm at the umbilicus and a continues to trickle bright red blood with no clots from the vagina inobserved by the nurse. Which actions should the nurse implemented. • Massage the fundus • Assess her blood pressure • Apply ice pack to perineum • Let the infant breast feed