Herzing University HESI Maternity

Question 1 of 44

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

A. Encourage voiding

B. Notify healthcare provider

C. Inspect the perineal pad

D. Monitor vital signs

Correct Answer:

Rationale:

Question 2 of 44

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

A. Insert a Foley catheter with a urimeter to monitor hourly output

B. Have calcium gluconate immediately available

C. Provide a quiet environment with subdued lighting.

D. Assess deep tendon reflexes (DTRS) every 4 hours.

Correct Answer:

Rationale:

Question 3 of 44

A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?

A. Determine fetal position by performing Leopold maneuvers.

B. Assess the fetal heart rate and client's contraction pattern

C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration

D. Perform sterile vaginal examination to determine dilatation

Correct Answer:

Rationale:

Question 4 of 44

The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

A. Hemoglobin and hematocrit

B. Abdominal contour and bowel sounds

C. Heart rate and blood pressure

D. Urinary output and IV fluid intake

Correct Answer:

Rationale:

Question 5 of 44

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

A. Flaring of the nares

B. Shallow and irregular respirations

C. Respiratory rate of 50 breaths per minute

D. Abdominal breathing with synchronous chest movement

Correct Answer:

Rationale:

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