Maternity Practice HESI 7 year old diabetes I 6 month old introducing solid foods – should be introduced one at a time, every 4 to 7 days to determine food allergies Digoxin 3 month old with GHD, miss a dose – if missed in less than 4 hours, gibe dose, if elapsed more than 4 hours, hold and give dose at next scheduled time 36 weeks pregnant, Rh-, bright red vaginal bleeding, nursing intervention rubella vaccine – instruction about use of a reliable method of birth control for 28 days after the rubella vaccine is given 6 years old, rheumatic fever, chorea 1 month old vomiting forcefully after each meal, is afebrile, dehydrated, and pyloric stenosis – olive shaped mass in the abdominal area that is evident at diaper change 18 weeks gestation, high AFP level – need for follow up evaluation with a sonogram to provide visual evidence of fetal age and presence of neural tube defects left breast mastitis, instruction to do at home magnesium sulfate, toxicity signs continuous fetal monitoring, V shaped appearance child with suspected bacterial meningitis, would have a recent history of unrelated bacterial upper respiratory, sinus, or ear infection - ear ache HIV+, receiving AZT during labor diaphragm size – after each birth the diaphragm should be evaluated for correct sizing and use an alternative form of contraception until verified Type I, 35 weeks gestation, amniocentesis Dilantin, newly diagnosed tonic – clonic epilepsy, seizure management – child should have routine serum levels monitored, as well as liver function infant with barking cough, fever, runny nose – croup, mother should the baby in the bathroom steamed up with hot water from tub or shower osteomyelitis foods to eat, 6 years old – high protein/high calories, milk shake is best choice 4 year old DMD symptoms – teach parents about these changes so they can prepare and help protect child from injuries pelvic inflammatory disease (PID) - IV antibiotics tonsillectomy, bleeding action – assess for bleeding with illumination to visualize oropharynx Ceftriaxone, + gonorrhea APGAR, 1/10, color is acrocyanotic young girl, UTI 9 year old, celiac disease, appendectomy, food to not eat – crackers = have gluten history of preeclampsia, high blood pressure what to use when changing newborn’s diaper – plain water 18 year old daughter, serum test results 38cm fundal height, 30 weeks gestation – after 20 weeks, the fundal height in cm should approximate # of weeks gestation 5 year old, bowel movement, yellow, sticky, smells like sour milk – typical for breastfed newborns, continue to breastfeed absence of testes on newborn admission assessment 3 month old does not sleep through the night 14 month old, hospitalized – febrile seizures 3 year old girl, blind since birth, hospitalized, compound fracture of the femur and is now in traction, intervention fundal massage technique – anchor the lower uterine segment with one hand, while massaging the fundus with the other hand, to prevent uterine prolapse and uterine inversion Maternity HESI 4. The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client’s teaching plan? A) Insulin production is decreased during pregnancy B) increase daily caloric intake is needed ? C) injection requirements remain the same D) Blood sugars need less monitoring in the first trimester 5. A 38-week primigravida client who is positive for Group A Beta Streptococcus receives a prescription for cefazolin 2 grams IV to be infused over 30 minutes. The medications available in 2 grams/100 ml of normal saline. The nurse should program the infusion pump to deliver how many ml/hour? 1.6ml/hr 7. When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take? A) Measure bilirubin levels using transcutaneous bilirubinometry B) Review maternal medical records for blood type and Rh factor C) Prepare the newborn for phototherapy ? D) Evaluate cord blood Coomb’s test results 8. A new mother asks the nurse about an area of swelling on her baby’s head near the posterior fontanel that lies across the suture line. How should the nurse respond? A) “That is called caput succedaneum. It will absorb and cause no problems.” B) “That is called a cephalhematoma. It will cause no problems.” ? C) “That is called a cephalhematoma. It can cause jaundice as it is absorbed.” D) “That is called caput succedaneum. It will have to be drained.” 9.A 39-week-gestational multigravida is admitted to labor and delivery with spontaneous rupture of membranes (SROM) and contractions occurring every 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate (FHR) has ranged between 170 and 180 beats/minute. What action should the nurse implement? A) Obtain a blood specimen for hemoglobin B) Take an oral maternal temperature ? C) Straight catheterize the client D) Send amniotic fluid for analysis 10. An obviously pregnant woman walks into the hospital’s emergency department entrance, shouting, “Help me! Help me! My baby is coming! I’m so afraid!” The nurse determines if delivery is indeed imminent. What action is most important for the nurse to take? A) Determines the gestational age of the fetus B) Assess the amount and color of the amniotic fluid C) Obtain peripheral IV access and begin administration of IV fluids D) Provide clear, concise instructions in a calm, deliberate manner 11. During a routine prenatal health assessment for a client in her third trimester, the client reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage? A) Palpate suprapubic area for fetal head position B) Insert straight urinary catheter to drain bladder C) Test the fluid with a nitrazine strip D) Scan the bladder for urinary retention 12. A client who is 3-weeks postpartum tells the nurse, “I am so tired all the time. I didn't know having a baby would be so hard.” What response should the nurse provide? A) It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps. B) It is normal to feel tired for the first couple weeks. Be patient with yourself and rest more. C) You should not be doing any housework. Are any of your family members helping you? D) Adjusting to a new baby can be difficult. Tell me more about any help you are receiving. 13. The home health nurse visits a client who delivered a full term baby three days ago. The mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curd-like patches on the newborn’s oral mucous membranes. What action should the nurse implement? A) Discuss the need for medication to treat curd-like oral patches B) Suggest switching the infant’s formula C) Assess the baby’s blood glucose level D) Remind mother not put the baby to bed with a propped bottles 16. Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,317 grams), weighs 7 lbs (3,175 grams) today. 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. 17. A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is requesting pain medication. Review of the client’s record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push. Vaginal examination reveals that the client’s cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement? A) Discontinue the Pitocin infusion B) Medicate the client with an additional 1 mg of Stadol IV push C) Notify the healthcare provider D) Instruct the client to use deep breathing during a contraction 18. A women who delivered a 9 pound baby boy by cesarean section under spinal anesthesia is recovering in the postanesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina in observed by the nurse. Which action should the nurse implement? A) Massage the fundus vigorously B) Assess her blood pressure C) Apply ice pack to perineum D) Let the infant breast feed 21. When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include? A) Exercise for 15 minutes before starting the counting to help increase fetal movement B) Count the movements once daily, for one hour, before breakfast C) Avoid caffeinated drinks for 24 hours before conducting the kick test. D) If 10 kicks are not felt within one hour, drink orange juice and count for another hour. 23. A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height in measured at 29 cm. Based on these findings, what actions the nurse implement? A) Notify the healthcare provider of the finding B) Document the finding in the medical record C) Schedule the client for a biophysical profile D) Request another nurse measure the fundus 24. The nurse is performing a newborn assessment. Which symptoms, if present in newborn, would indicate respiratory distress? A) Abdominal breathing with synchronous chest movement B) Shallow and irregular respirations C) Flaring of the nares D) Respiratory rate of 50 breaths per minute 25. The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client? A) Administration of Pitocin B) Artificial rupture of the membranes C) Amnioinfusion for the baby D) Administration of antibiotics 26. The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first? A) Check the pH of the vaginal fluid B) Review the fetal heart rate pattern C) Palpate the client’s bladder D) Determine cervical dilation ? 27. The nurse’s assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, irritability, and mottled, cool skin. Which intervention should the nurse implement first? A) Position a radiant warmer over the crib B) Assess the infant’s blood glucose level C) Nipple feed 1 ounce 5% glucose in water D) Place the infant in a side-lying position 28. Which content should the nurse plan to include in a nutrition class for pregnant adolescents? (Select all that apply) A) Take iron and calcium supplements daily ? B) Gain no more than 15 pounds during the pregnancy C) Increase food intake by 300 to 400 calories/day ? D) Take folic acid supplements daily ? E) Maintain current protein intake ? 29. The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drip to augment a clients labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? A) uterus is soft B) contraction duration of 100 seconds C) four contractions in 10 minutes D) Early deceleration of fetal heart rate 30. A new mother who is breastfeeding her 4-week old infant and has type 1 diabetes, reports that her insulin needs have decreased since the birth of her child. What action should the nurse implement? A) Inform her that a decreased for insulin occurs while breastfeeding B) Advice the client to breastfeed more frequently C) Counsel her to increase her caloric intake D) Schedule an appointment for the client with diabetic nurse educator 31. A diabetic client delivers a full-term large-for-gestation-age (LGA) infant who is jittery. What action should the nurse take first? A) Administer oxygen B) Feed the infant glucose water (10%) C) Obtain a blood glucose level D) Decrease environmental stimuli 32. The postpartum admission prescription for a client who delivered a healthy newborn includes one liter of lactated ringers with oxytocin 20 units to infuse over 8 hours. How many milliunits /minute is the clients receiving? 33. A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which actions should the nurse implement? A) Schedule weekly prenatal appointments B) Contact social services for a temporary shelter C) Obtain a hemoglobin and hematocrit level D) Have the client transported to the hospital 34. The nurse is planning a class for pregnant women in the first trimester of pregnancy. Which information is most important for the nurse to include in the class? A) Plan rest periods and increase sleep time to 8 hours per day when fatigued B) If any vaginal bleeding occurs, notify the healthcare provider immediately C) Since eating often relieves nausea, carry low fat snacks to eat whenever nausea occurs D) If morning dizziness occurs, rise slowly and sit on the side of the bed for one minute 35. When assessing a pregnant woman at 39-weeks gestation who is admitted to labor and delivery, which finding is most important to report to the health care provider? A) +1 proteinuria B) 130/70 blood pressure C) +1 pedal edema D) 101.2 F oral temperature 36. A client who suspects she is pregnant tells the nurse she has a peptic ulcer that is being treated with misoprostol (Cytotec), a synthetic prostaglandin E drug. How should the nurse respond? A) “You may be at risk for having a spontaneous miscarriage” ? B) “You may have an increased chance of having preeclampsia” C) “This medication will have no effect on your unborn child” D) “You may experience postpartum hemorrhaging after delivery” 38. After delivery of a normal infant, the mother tells the nurses that she would like to use oral contraceptives. Which finding in the client’s health history is a contraindication of the use of contraceptives? A) Previously used an intrauterine device (IUD) B) Reported history of stroke within the family C) Diagnosed with diabetes mellitus 2 years ago D) Smoked cigarettes prior to becoming pregnant ? 39. When planning care for a laboring client, the nurse identifies the need to withhold solid foods while the client is in labor. What is the most important reasons for this nursing intervention? A) Nausea occurs from analgesics used during labor B) Autonomic nervous system stimulation during labor decreases peristalsis C) An increased risk of aspiration can occur if general anesthesia is needed D) Gastric emptying time decreases during labor. 40. The parents of a male newborn have signed an informed consent for circumcision. Which intervention should the nurse implement upon completion of the circumcision? A) Place petroleum gauze dressings on the site ? B) wrap the infant in warm receiving blankets C) Give a PRN dose of liquid acetaminophen D) Offer a pacifier dipped in glucose water 42. At 6 weeks gestation, the rubella titer of a client medication indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? A) After the client stops breastfeeding B) Immediately, at 6-weeks gestation, to protect this fetus C) After the client reaches 20-weeks gestation D) Early postpartum, within 72 hours of delivery 44. A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and cervix dialed 3 cm. The nurse’s assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin (Pitocin) drip. Which data is most important for the nurse to monitor? A) Client’s hourly blood pressure B) Preparation for emergency cesarean birth C) Intensity, interval, and length of contractions D) Checking the perineum for bulging 45. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority? A) Hyperthermia B) Hyperbilirubinemia C) Polycthemia D) Hypoglycemia 47. A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin (Glucophage), menotropins (Repronex, Menopur), and human chorionic gonadotropin (hCG). Which side effects should the nurse tell the client to report immediately? A) Episodes of headache and irritability B) Nausea and vomiting C) Rapid increase in abdominal girth D) Persistent daytime fatigue M 48. At 0600 while admitting a woman for a scheduled repeat caesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? A) Contact the client’s obstetricianaz B) Ensure preoperative lab results are available C) Inform the anesthesia care provider D) Start prescribed IV with Lactated Ringer’s