NURS 206 HESI: Saunders Online Review Focus on Maternity (ALL CORRECT ANSWERS) 2021

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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.Correct A Assessing the client’s fundus B Checking the client’s vital signs C Contacting the health care provider D Changing the client’s peripads E Documenting the findings
Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client’s fundus. Once it has been determined that the bleeding is not the result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has compromised the client’s condition. Next the nurse would contact the health care provider and report the bleeding, fundal height and condition, and vital signs. After contacting the health care provider the nurse would attend to the client’s comfort needs, including, in this case, frequent changes of peripads. The nurse would document the findings once assessment and implementation had been completed and the client’s condition was considered stable.
Test-Taking Strategy: Think about the normal and abnormal postpartum assessment findings related to lochial flow. A constant trickle of bright-red lochia indicates bleeding, and further assessment to determine the origin of bleeding should be performed and the results reported to the health care provider. Once the health care provider has been contacted, the client’s comfort needs and documentation would be the final priority. Review postpartum assessment findings and actions to take if they are abnormal if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Perfusion
HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 441). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
12.ID: 6A nonstress test is performed, and the health care provider documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as: A Normal B Reactive C Nonreactive Correct D Inconclusive
Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording.
Test-Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 309). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
13.ID: 2A 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? A “I know how you feel.” B “This must be hard for you.” Correct C “Now you have an angel in heaven.” D “You’re young. You can have other children.”
Rationale: Therapeutic communication helps the mother, father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Maternity/Postpartum
Giddens Concepts: Communication, Coping
HESI Concepts: Communication, Grief and Loss
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 30-31, 566). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
14.ID: 7A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? A Water and pretzels B Low-fat cheese omelet C Nachos and fried chicken D Apple and whole-grain toast Correct
Rationale: The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition.
Test-Taking Strategy: Use the process of elimination and note that the client has a history of cardiac disease. Recalling the concepts of care of the client with cardiac disease and noting that the question involves a client who is pregnant will direct you to the correct option. Review dietary requirements and examples of foods containing those requirements for a cardiac client who is pregnant if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Nutrition, Reproduction
HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 281, 616). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
15.ID: 7A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. A A client with septicemia Correct B A client with mild preeclampsia C A client with diabetes mellitus who delivered a 10-lb (4.5 kg) baby Incorrect D A client who had a cesarean section because of abruptio placentae Correct E A client who delivered 12 hours ago and has lost 475 mL of blood
Rationale: DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage .A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the client at risk for DIC. Thinking about the pathophysiology of DIC and the conditions listed in the options will assist in answering correctly. Review the risk factors associated with DIC if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Intrapartum
Giddens Concepts: Reproduction, Perfusion
HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 578). St. Louis: Elsevier. Awarded 1.0 points out of 2.0 possible points.
16.ID: 5A 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: A Prone B In a semi-Fowler position C In the Trendelenburg position D Supine with a wedge under the right hip Correct
Rationale: The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery.
Test-Taking Strategy: Focus on the type of surgical procedure and the anatomy of a pregnant woman. Use the process of elimination and visualize each of the positions. This will direct you to the correct option. Review care of the client undergoing a cesarean delivery if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Caregiving, Safety
HESI Concepts: Caregiving, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 428). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
17.ID: 1A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first: A Locate the fetal heart tone B Position the woman supine C Ask the client to empty her bladder Correct D Count the fetal heart rate for 1 minute
Rationale: In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman’s comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones. Counting the fetal heart rate is not associated with Leopold maneuvers.
Test-Taking Strategy: Note the strategic word “first.” Knowing that Leopold maneuvers are often used to help locate fetal heart tones and involve palpation will assist you in determining that asking the client to empty the bladder is the first action. Review the procedure for the Leopold maneuvers if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 251, 340). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
18.ID: 9A 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? A Lochia alba B Lochial clots C Lochia serosa D Dark-red lochia rubra Correct
Rationale: When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14.
Test-Taking Strategy: Use the process of elimination. Noting that the question refers to a client who gave birth 1 hour ago will direct you to the correct option. Review postpartum assessment findings and the types of lochia if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Postpartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 360, 441). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
19.ID: 1A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: A Take a cool shower just before breastfeeding B Avoid breastfeeding during the night time hours to ensure adequate rest C Gently massage the breasts during breastfeeding to help empty the breasts Correct D Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling
Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation and letdown.
Test-Taking Strategy: Focus on the subject, breast engorgement, and think about its characteristics. Use the process of elimination and visualize each of the descriptions in the options to identify the measure that will be helpful. If you had difficulty answering the question, review the measures for breast engorgement.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Postpartum
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 542). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
20.ID: 9When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure?
A 4 days after delivery B The day after delivery C Immediately after delivery Correct D When the client’s bladder is full
Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day.
Test-Taking Strategy: Focus on the figure and note that the fundus is at the level of the umbilicus. Recalling normal postpartum assessment findings in the mother and recalling the normal anatomy will assist in directing you to the correct option. If you had difficulty with this question, review normal postpartum assessment findings in regard to involution.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Postpartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 442, 668). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. [Show More]

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