NURS FUNDAMENTA- Hesi Maternity exam-graded A

1. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. · Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 · Ampicillin 1 gram IV push q8h. · Betamethasone (Cel ...

1. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. · Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 · Ampicillin 1 gram IV push q8h. · Betamethasone (Celestone) 12 mg deep IM · Butorphanol (Stadol) 1 mg IV push q2h PRN pain 2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? · Carrots · Chicken · Yogurt · Cheese 3. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? · Respiratory rate of 22 breaths/min · A large amount of lochia rubra · Blood pressure 149/90 · Positive Homan’s sign 4. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? · Pain level · Blood pressure · Infusion site · Contraction pattern 5. One day after vaginal delivery of a full term baby, a postpartum client’s white blood cell count is 15.000/mm. What action should the nurse take first? · Check the differential, since the WBC is normal for this client · Assess the client’s temperature, pulse, and respirations q4h · Assess the client’s perineal area for signs of a perineal hematoma · Notify the healthcare provider, since this finding is indicative of infection 6. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? · Discuss the need for cortisol and aldosterone replacement therapy after discharge · Support the parents in their decision to assign sex of their child according to their preference · Offer information about ultrasonography and genotyping to determine sex assignment · Explain that corrective surgical procedures consistent with sex assignment can be delayed 7. A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer? 13 8. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? · Alert the neonatal team and prepare for neonatal resuscitation · Notify the healthcare provider from the client’s bedside · Obtain written consent for an emergency cesarean section · Draw a blood sample for stat hemoglobin and hematocrit 9. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? · Turn the client to her left side · Contact the healthcare provider · Assess the fetal heart rate · Check the cervical dilation 10. A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? · Decrease the oxytocin infusion rate · Determine current cervical dilation · Request placement of the epidural · Give a bolus of intravenous fluids 11. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide? Maternal blood pressure 12. A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother? Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on. 13. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client’s teaching plan? A. Oral contraceptive use for at least one year. 14. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? C. Betamethasone (Celestone) 12 mg deep IM. 15. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this fiding? B. Both the lower uterine segment and the fundus must be massaged. 16. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet? B. Chicken. 17. The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? CONTINUED.........................