OB/PEDs HESI

A newborn infant is receiving immunizations prior to discharge. Which action should the nurse implement?

Obtain signed consent from the mother for the administration of hep B vaccine

· A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. Which is the priority nursing problem for this client?

Risk for injury

· During a high school class on substance abuse, a student tells the group "if I tried cocaine, I know I could handle it I know when to stop"- what response is best for the nurse to provide?

Denial of an addiction problem is often the first response to the behavior

· An older client presents to a clinic appointment with weight loss, increased confusion, and insomnia. The clients daughter reports that the symptoms began shortly after the recent death of the clients brother. Which information should the nurse provide?

The client delirium may be due to depression and it possibly reversible

· A primigravida client who is at 33 weeks gestation presents to the labor and delivery unit with complaints of a headache. The initial assessment findings include: blood pressure 144/96 mm Hg, facial edema, and 3+ pitting edema in lower extremities. Which assessment should the nurse perform next?

Temp, pulse, and respirations

· A pregnant woman who is at 10 weeks gestation and is 35 years of age tells the nurse that she is concerned about the possibility of having a baby with down syndrome. Which information should the nurse provide this client?

Chronic callus sampling at 12 weeks gestation is the earliest screening test used to identify down syndrome

· A couple who is trying to have a baby asks the nurse when they are most likely to conceive a child. The woman has a regular 35-day menstrual cycle, and the first day of her last menstrual period was on January 16. Which information should the nurse provide?

Plan to have intercourse on February 7 as this is when ovulation should occur

· A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?

Prepare for a c-section

· A neonate whose mother is addicted to heroin received morphine for signs of neonatal abstinence syndrome (NAS). After this course of opioid therapy, the healthcare provider prescribed clonidine. Which intervention is most important for the nurse to include in the plan of care?

Monitor neonate's vital signs, slop, feeding, and weight gain patterns

· During a well-baby clinic visit, the mother of a 6-month-old infant asks the nurse if she can have prescription for poly vi sol with fluoride. Though the infant is still breastfeeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain?

Water source used with supplement feedings

· The mother of a child who is hospitalized with croup and is in a mist tent brings the child's favorite stuffed animal to the hospital. What action should the nurse take?

Allow the child to have the stuffed toy in the tent

· The school nurse is preparing a teaching activity about nutrition for school-age children, 9 to 11 years of age. Which activity is best for the nurse to include in this teaching plan?

Ask the children to classify pictures of snacks as good or bad foods

· A female client with obsessive-compulsive disorder complains that she feels "driven" to check the locks on her front door at least six times every night. Which response is best for the nurse to provide?

What are your thoughts when you are checking the locks?

A diabetic client delivers a full-term, large-for-gestational-age (LGA) infant who is jittery. Which action should the nurse take first?

Obtain the newborn's blood glucose level

· The nurse is assessing a newborn who was precipitously delivered at 36 weeks gestation. The newborn is tremulous tachycardic and hypertensive. Which assessment action is most important for the nurse to implement?

Obtain a drug screen for cocaine

· A 7 year old male is referred to the school clinic because he fainted on the playground. His height is 3 feet 7 inches (107.5cm), he weighs 55 pounds (25kg), and his body mass index (BMI) is 20.9. Which assignment finding is most important to the nurse to address?

Since age 3 he has experienced exercise induced asthma

· An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?

Assist the client in developing on emergency safety plan

· A female client presents in the emergency department and states "I was raped tonight." Which intervention is most important for the nurse to implement?

Instruct client to remove all clothing carefully

· An adolescent who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the clients plan of care?

Initiate caloric and nutritional therapy

· The nurse is administering a treatment to a child experiencing an asthma attack. The child is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid base balance?

Respiratory alkalosis

· A 16 year old male is admitted after a motor vehicle collision with 50% burns over his body. One liter of normal saline is prescribed to infuse over 4 hours. The drop factor is 60 drops per mL. the nurse should regulate the infusion to administer how many drops per minute?

60gtt/1 x 1000mL/4hrs x 1hr/60 min= 60000/240= 250 drops/min

· A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non stress test (NST). The nurse begins a contraction stress test (CST) with an oryta infusion. Which finding is most important for the nurse to report to the healthcare provider?

A pattern of fetal late decelerations

· A client on the mental health unit has been scowling and rapidly pacing up and down the halls for several minutes. Which behaviors are most important for the nurse to monitor?

Argumentativeness and use of profanity

· A middle aged male who drinks a fifth of liquor every night is confronted at a prearranged family intervention with the family, healthcare provider, and nurse. When the healthcare provider leaves the room to make arrangement for the hospitalization admission, the client shouts at the nurse that he sees no reason for hospitalization. How should the nurse respond?

Tell the client that monitoring and medication management during detoxification is best provided in the hospital

· The nurse is teaching the parents of an adolescent with depression about the warning signs of suicide. Which statement by the parents indicates and understanding of the teaching provided?

Indirect statements about feeling hopeless are just as serious as direct statements about suicide

· A primigravida client asks the nurse about exercising during pregnancy to help her prepare for labor. Which recommendation should the nurse provide?

Stretching exercises are good preparation for labor

· A child diagnosed with strep throat 3 days ago arrives to the clinic grimacing and crying. The parent tells the nurse that the child is experiencing pain and discomfort even with comforting and a light touch. The child is exhibiting shortness of breath and appears anxious. Which finding warrants immediate intervention by the nurse?

Pulse ox of 88% 02 saturation

· The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize. Which is the priority nursing action to implement when the client is admitted to the labor and delivery suite?

Take the client's temperature

· The nurse is planning a class for pregnant women in their first trimester of pregnancy. Which information is most important for the nurse to include in this class?

If any vaginal bleeding occurs, notify the healthcare provider immediately

· The nurse is preparing a young couple and their 24 hour old infant for discharge from the hospital. In conducting discharge teaching which intervention is most important for the nurse to implement?

Evaluate infant feeding techniques prior to discharge

· The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. Which action is most important for the nurse to take?

Encourage the mother to hold and spend time with her baby

· A mother calls the clinic nurse and reports that after each breastfeeding, her 5 day old infant has a bowel movement that is yellow, sticky and smells like sour milk. Which information should the nurse provide?

Instruct the mother to continue breastfeeding because the stool is normal

· Which action is most important for the nurse to implement to prevent bleeding in the neonate during the first hour after birth?

Administer phytonadione (Vitamin K) IM

· Breastfeeding woman who delivered her infant two weeks ago develops masses in her left breast. A cephalosporin antibiotic is prescribed after consultation with the infants pediatrician. Which instructions regarding breastfeeding should the nurse provide?

Initiate feeding on the unaffected breast first

· The nurse is consoling a client who is at 6 weeks gestation and is experiencing morning sickness but does not want to take any drugs for this discomfort which herbal supplement is likely to help this client with the nausea she is experiencing?

Ginger

· The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

Change the clients position

· Following a vaginal delivery, the nurse places the neonate under the radiant water, provides naso-oralpharyngeal suction, and dries the neonate skin to elicit spontaneous respiration. The newborn heart rate is 100 beats/minutes and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement first?

Provide positive pressure ventilation

· The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hall ways. Which nursing intervention is most important at this time?

Alert the assignment staff to closely monitor client and intervene as needed to reduce risk of self-mutilation

· A couple who are both carriers of phenylketonuria (PKU) have a 2 year old daughter with PKU. The couple tell the nurse that they believe their next baby is sure not to be affected. What information should the nurse provide the couple?

Each conception has a 25% chance for the child to be affected

· A female client who is 5 feet 5 inches tall and weight 72 pounds presents to the emergency department after a syncopal episode at home. She has poor skin turgor with tenting, and blood pressure is 80/50 mmHg. What action should the nurse implement first?

Calculate body mass index

· An older female client with a history of alcoholism tells the nurse that she was at shopping mall all day yesterday. However, her son reports that she slept until early afternoon, then watched television until bedtime. Based on these findings, the nurse can conclude that the client is exhibiting which type of behavior?

Confabulation

· The nurse is teaching the parents of a child with cystic fibrosis about home care. Which interventions should the nurse ensure the parents understand about managing the child's respiratory secretions?

Percussion and postural drainage

· The nurse is providing teaching to a client and family about schizophrenia before discharge from an inpatient facility. The nurse should instruct the family to notify the healthcare provider when which behavior is observed?

Social withdrawal

A client who has type 1 diabetes and is at 10 weeks gestation comes to the prenatal clinic complaining of a headache, nausea, sweating, feeling shaky, and being tired all the time. What actions should the nurse take first?

Check the blood glucose level

A client who is 3 weeks postpartum continues to have moderate lochia rubra. The nurse determines her uterus to be 1 cm below the umbilicus. Which pathophysiological cause is most likely contributing to these findings?

Retained placental fragments

· Which type of anesthesia used with a client in labor produces a loss of sensation only to the vaginal and perineum?

Pudendal block

· A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Assess and report the client's electrolyte status to the healthcare provider

· A client who is 4 hours post spontaneous vaginal birth has excessive blood loss. She has a history of asthma, controlled with inhaler as needed. Her current vital signs are: Temp: 99.1F, HR: 104, RR: 20, and BP: 148/92. Which medication should the nurse expect to administer to this client?

Oxytocin

A female client comes into the Emergency Department complaining of frequent panic attacks the last few days and states that her life is out of control. She is currently taking alprazolam 1mg twice daily and sertraline 200 mg daily for anxiety. Which assessment is most important for the nurse to obtain?

If the client has any thoughts about ending her life

· When developing a teaching plan for a client at 8 week gestation, what instruction has the highest priority?

Call the clinic if you have any vaginal bleeding or cramping

· A young adult male client is admitted for substance abuse treatment. He repeatedly violates the unit rules, and when confronted about his behaviors, smiles and says "I should know better." What response is best for the nurse to provide?

The unit rules are not flexible. You must comply with these guidelines

· The night shift nurse reports to the on-coming day shift nurse that an older client who is characteristically argumentative and demanding was compliant during the night and slept through vital signs and other physical assessments. Which intervention should the day shift nurse implement?

Assess the client immediately and hourly during shift

The nurse is caring for a client in the emergency department after an assault by the spouse. The client has a history of similar emergency visits. Which action best assists the client?

Develop a plan for initiating a rapid exit

· An older client with Alzheimer's disease (AD) is experiencing hallucinations and delusions. Which non pharmacological approach should the nurse implement?

Use distraction and therapeutic communication skills

· A 34 week primigravida woman with preeclampsia is receiving lactate ringers 500 mL with magnesium sulfate 20 grams at the rate of 3 grams/hr. How many ml/hr should the nurse program the infusion pump?

500mL/20g x 3g/1hr=1500/20=75ml/hr

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currenty using the same diaptyagin that she used before becoming pregnant. Which information should the nurse provide this client?

Use an alternate form of contraception until a new diaphragm is obtained

The healthcare provider prescribes zidovudine 100 mg by mouth five times daily for a pregnant woman who is HIV positive. What should the nurse administer ? (Enter numerc value only.)

10

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge?

Evaluate infant feeding techniques prior to discharge.

A 30-year-old primigravida delivers a 9-pound (4082 gram) infant vaginally after a 30 hour labor. What is the priority nursing action for this client?

Observe for signs of uterine hemorrhage

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse do first?

Prepare for a cesarean section.

At 0600 while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a

nurse take first?.

Inform the anesthesia care provider

The nurse is caring for a postpartal client who is exhibiting symptoms of a spinal headache 24 hours following delivery of a normal newborn. Prior to the anesthesiologist's arrival on the unit, which action should be perform?

Place procedure equipment at bedside

The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces (22 kg), has a head circumference of 13 Inches (33 cm), and a chest circumference of 10 inches (25 4 cm). Based on these findings, assessment for which condition has the highest priority?

Hypoglycemia

While assessing a 40 week gestation primigravida in active labor the client's membranes ruptured spontaneously and the nurse notes that the amnionic fluid is meconium stained. Which additional finding is most important for the nurse to report to the healthcare provider?

Maternal blood pressure of 130/85 mmHo

The nurse is caring for a 35-week gestation infant delivered by cesarean section 2 hours 200 The nurse observes the infant's respiratory rate is 72 breath/minute with nasal flaring, grunting, and retractions. The nurse should recognize these findings indicate which complication?

Transient tachvonea of the newborn

A primipara client at 42-weeks gestation is admitted for induction. Within one hour after initiating an oxytocin infusion, her cervix is 100% effaced and 6 cm dilated, contractions are occuring every 1 minute with a 75 second duration, The nurse stops the oxytocin and starts oxygen. After 30 minutes of uterine rest, the contractions are occurring every 5 minutes with 20 second duration. Which intervention should the nurse implement?

Restart oxytocin infusion rate per protocol.

A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?

Contractions decrease with walking.

A multigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is Lactated Ringer's 1,000 mL with oxytocin 20 units. The nurse set the pump to deliver how many mLmour? (Enter numeric value only.)

12

A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?

Begin oxytocin 4 hours after misoprostol is given.

The nurse is caring for a client whose fetus died in utero at 32 weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures. What is important for the nurse to take?

Encourage the mother to hold and spend time with her baby.

Following a minor motor vehicle collision, a client at 36-weeks gestation is brought to the emergency center. She is lying supine on a backboard, is awake, and denies any complaints. Her blood pressure is 80/50 mmg and heart rate is 130 beats/minute. Which action should the nurse implement first?

Tilt the backboard sideways to displace the uterus laterally.

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?

"That is called caput succedaneum. It will absorb and cause no problems."

A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2 F (38.4° C), with severe abdominal or uterine tenderness on palpation nurse knows that these findings are indicative of which condition?

Chorioamnionitis

An unlicensed assistive personnel (UAP) reports to the charge nurse that a client who delivered a 7- pound (3, 175 gram) infant 12 hours ago is reporting a severe headache. The client's blood pressure is 110/70 mm Hg. respiratory rate is 18 breaths/minute, heart rate is 74 beats/minute, and temperature is 98 6° F (37° C). The client's fundus is firm and one fingerbreadth above the umbilicus. Which action should the charge nurse implement first?

Notify the healthcare provider of the assessment findings.

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

Prevent hemorrhagic disorders

A 16 year old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Keep an airway at the bedside

A pregnant client presents to the antepartal clinic complaining of brownish vaginal bleeding. The nurse notes that she has a greatly enlarged uterus and is complaining of severe nausea. The client reports that her last period was "about 2 and a half months ago." Vital signs are: temperature 98.7* F. (37°C) pulse rate 70 beats/minute, respiratory rate 18 breaths/minute, and blood pressure 190/110 mmg. Based on these findings which laboratory value should the nurse review?

hCG values.

A woman who is 28 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment warrants immediate intervention by the nurse?

Sinus tachycardia

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?

Change the client's position

An ambulatory client at 39 weeks gestation presents to the emergency center with an obvious injury to her arm that occurred as the result of a fall. Which concurrent symptom is a priority for the nurse to assess?

Ecchymotic knees

At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client?

Early postpartum, within 72 hours of delivery.

A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method provides the greatest degree of accuracy?

Visualization of implantation by vaginal ultrasound.

The nurse is planning discharge teaching for 4 mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period?

A primiparous woman who has recently immigrated to the U.S. with her spouse

Following the vaginal delivery of a 10-pound (4536 gram) infant, the nurse assesses a new mothers vaginal bleeding and fines that she has saturated two pads in 30 minutes and has a boggy uterus. What should the nurse implement first?

Perform fundal massage until firm.

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. Which action should the nurse implement?

Inform her that a decreased need for insulin occurs while breastfeeding.

A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse-midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcare provider since the infant is healthy, and she is not having any complications. The woman's history indicates that both previously born infants were Rh-negative. Which response should the nurse provide?

The newborn's blood type should be tested to determine the need for RhoGAM.

A newborn's head circumference is 12 inches (30 5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and was a breech presentation delivered by cesarean section. What action should the nurse take based on these data?

Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.

A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (FM) are consistent with hypotonic dystocia, and the healthcare provider prescribes an oxytocin drip. Which data is most important for the nurse to monitor?

Intensity, interval, and length of contractions

A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide.

Explain that a sonogram should be scheduled for definitive results

The nurse is caring for a chest following an emergency cesarean delivery under general anesthesia. Which assessment finding occurring in the first 8 hours after delivery, is most critical and requires immediate intervention?

Respiratory rate of 12 breaths/minute

The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting and scant dark brown vaginal discharge. Which action should the nurse take?

Collect urine sample

The nurse is conducting a home health of a client who delivered 3 weeks ago and is formula feeding the infant. Which observations should the nurse find most concerning?

The clients eyes are red from crying and infant is fussing in the crib.

A client who is 32 weeks gestation arrives at the clinic; reporting nausea and vomiting for the past 24 hours. The nurse reviews the recent and observers there has been a rapid weight gain over the weeks. Which action should the nurse implement next?

Obtain a blood pressure

The nurse's assessment of a preterm infant reveals decreased muscle tone, signs of respiratory difficulty, imitability, and mottled, cool skin. Which intervention should the nurse implement first?

Assess the infant's blood glucose level

Digoxin is prescribed to 3-month-old with congenital heart disease. RN should teach parents to do what if they miss giving a dose of this med?

If less than four hours have elapsed, give the missed dose.

During admission of newborn, RN identifies localized swelling that does not cross suture line on the posterior area of the parietal bone. What action should RN implement?

Notify doctor of cephalhematoma

In assessing child with suspected bacterial meningitis, RN should anticipate a recent history of which problem?

An ear ache

Mother brings 3-month-old to clinic because baby does not sleep through the night. Which finding is most significant in planning care for this family?

Diaper area shows severe skin breakdown

While caring for laboring patient on continuous fetal monitoring, RN notes fetal heart rate pattern that falls & rises abruptly with "V" shaped appearance. What is the first RN action?

Change maternal position

A 32 week multipara with a history of preeclampsia arrives to the clinic for her routine appointment. The RN observes patient has an elevated blood pressure of 155/90 mmHg. Which action should RN take?

Collect a urine specimen to screen for protein.