HESI Exit Exam 3 - Question and Answers with rationale (100% Complete Helpful Guide )

HESI Exit Exam 3 - Question and Answers with rationale HESI Exit Exam 3 1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the cli ...

HESI Exit Exam 3 - Question and Answers with rationale HESI Exit Exam 3 1. A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: 2. A 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? 3. 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: 4.A 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? 5. A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: 6. A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: 7. A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: 8. A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: 9. A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to: 10. A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: 11. A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the first action and the number 5 to the last. 12. A nonstress test is performed, and the physician documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: 13. A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? 14. A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? 15. A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which of the following clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. 16. A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client: 17. A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first: 18. A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time? 19. A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: 20. When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure? 21. A nurse assists the primary healthcare provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy? Assign the number 1 to the first action and the number 5 to the last action. 22. A licensed practical nurse (LPN) is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the LPN to contact the registered nurse? 23. A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client? 24. A nurse is preparing to care for a client experiencing dystocia. To which of the following interventions does the nurse give priority? 25. A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: 26. A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: 27. A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is: 28. A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: 29. A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? 30. A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: 31. A nurse is assisting a physician in performing a physical examination of a client who has just been told that she is pregnant. The physician tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: 32. A nurse performing an assessment of a pregnant client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device? 33. A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? 34. After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant: 35. A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: 36. A nurse is caring for a client in labor who has sickle cell anemia. Which intervention does the nurse implement to help prevent a sickling crisis? 37. A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which of the following findings does the nurse tell the mother is an indicator of infection? 38. A licensed practical nurse is performing assessments every 30 minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the LPN to contact the registered nurse? 39. A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the LPN to contact the registered nurse? 40. A pregnant client is seen in the clinic for the first time. This is the client’s first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides instruction to the client regarding health care during pregnancy. Which statements by the client indicate the need for further instruction? Select all that apply. 41. During a prenatal visit, the nurse notes that an adolescent pregnant client with diabetes mellitus has lost 10 lb during the first 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, “I don’t eat regular meals.” The appropriate response is: 42. A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: 43. A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? Select all that apply. 44. A client admitted to the maternity unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing action in this situation is: 45. Immediately after the delivery of a newborn infant, the nurse prepares to deliver the placenta. The nurse initially: 46. A multigravida woman with a history of multiple cesarean births is admitted to the maternity unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of complete uterine rupture? Select all that apply. 47. A client is admitted to the hospital for an emergency cesarean delivery. Contractions are occurring every 15 minutes, the client has a temperature of 100° F, and the client reports that she last ate 2 hours ago. The client also states that “everything happened so fast" and that she has had no preparation for the cesarean delivery. Which of the following actions should the nurse take first? 48. A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician’s office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: 49. A nurse is caring for a client in precipitous labor. In which position does the nurse place the client? 50. A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: 51. A nurse working in a prenatal clinic is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify as being at risk for abruptio placentae? Select all that apply. 52. A nurse caring for a client in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal heart rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing action is: 53. A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: 54. A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? 55. A licensed practical nurse is monitoring a newborn who has been admitted to the nursery. The LPN notes that the anterior fontanel measures 4 cm across and bulges when the infant is at rest. In light of this observation, what is the most appropriate nursing action? 56. A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located: 57. A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn? 58. A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort? 59. A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures? 60. A licensed practical nurse (LPN) is assisting the registered nurse (RN) in assessing a pregnant client’s deep tendon reflexes and a reflex of 2+ is noted. Based on this finding, the LPN anticipates that the RN will take which action? 61. A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately: 62. After a vaginal delivery, a woman suddenly begins to complain of severe pelvic pain and extreme fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to: 63. A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client? 64. A nurse is preparing to assess the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse use to assess the fetal heartbeat? 65. A client arrives at the clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was September 19, 2013. Using Nagele’s Rule, the nurse calculates the estimated date of delivery as: 66. A pregnant client is positive for HIV. The client asks the nurse whether her newborn will contract the virus. The appropriate response is: 67. A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. In light of this finding, which nursing action is appropriate initially? 68. A nurse is reviewing the medical record of a pregnant client with sickle cell anemia. To which of the following information related by the client would the nurse give the highest priority? 69. A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion? 70. A licensed practical nurse (LPN) is monitoring a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the LPN take in response to this observation? 71. A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation? 72. A nurse caring for a client in the active stage of labor assesses the fetal status and notes a late deceleration on the monitor strip. In light of this finding, which nursing action is the priority? 73. Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note? 74. A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for further instruction? 75. A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC? 76. A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating interventions to be implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately: 77. A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as: 78. A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that: 79. A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: 80. A client in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which statement by the client indicates the need for further instruction? 81. A licensed practical nurse (LPN) is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is: 82. A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant? 83. A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder? 84. A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant? 85. A nurse provides instruction regarding prenatal care to a client with a history of heart disease. The nurse tells the client that: 86. A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? 87. A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify as the priority to be addressed in the plan of care? 88. A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of: 89. A nurse answers a call light in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, “I think my wife is going into shock or something! She was just lying there, and then she turned so pale, and her hands are so clammy. She said she was dizzy and sick to her stomach.” The nurse notes on the noninvasive blood pressure monitor that the woman’s pulse is 58 beats/min and her blood pressure is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing: 90. A nurse is monitoring a fetal heart rate (FHR). The nurse documents a reassuring FHR pattern in the record on noting: 91. A pregnant woman at 38 weeks’ gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing: 92. A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client’s behavior as most likely the result of: 93. A neonate is irritable, cries incessantly, and has a temperature of 99.4° F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with: 94. Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client’s history. Which of the following findings is a contraindication to administration of the medication? 95. A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client’s behavior may be a result of: 96. After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which of the following conclusions should the nurse make? 97. A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears? 98. A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up? 99. A nurse palpates the anterior fontanel of a neonate and notes that it feels soft. This nurse interprets this assessment data as: 100. A nurse notes that the laboratory report of a pregnant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation rate. Which laboratory test that would further confirm the presence of HIV does the nurse anticipate that the physician will prescribe?