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Rhenis Nursing

HESI Maternity

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Exam Details

Title HESI Maternity

Type Nursing

Category RN Nursing Exams

Subcategory HESI Exams (RN)

Domain Maternal & Newborn (RN hesi)

Fragment N/A

Module RN-NURSING

Status active

Rating 95.00%

Attempts 15

Year 2025

Duration 150 min

Questions 10

Pass Score 90%

Difficulty Intermediate

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1 :
A client at 28-weeks’ gestation whose hemoglobin level is 10.7 g/dL (107 g/L) and hematocrit is 32% (0.32 volume fraction), tells the nurse that she eats plenty of green vegetables. When the client asks the nurse how the low-level value might affect her pregnancy, which information should the nurse provide?
Reference range:
Hemoglobin [12 to 16 g/dl (120 to 160 g/L): pregnant greater than 11 g/dl (110 g/L)]
Hematocrit [37% to 47% (0.37 to 0.47 volume fraction): pregnant greater than 33% (0.33 volume fraction)]

Plasma volume increases, making the blood count appear low.

It might be necessary to take an iron supplement twice daily.

Increasing intake of protein might improve these values.

Almost all women at 28-weeks’ gestation have anemia.

Hint : 🧠Focus on how blood volume changes during pregnancy rather than only diet.

Correct Answers:

Plasma volume increases, making the blood count appear low.

Rationale :

🩸In pregnancy, plasma volume increases more than red blood cell mass, which causes hemodilution and a lower measured hemoglobin and hematocrit.

📈This pattern is called physiologic anemia of pregnancy, and it is common around the late second trimester and third trimester.

🧪Because the client’s values are only mildly below the pregnancy reference range, the key explanation is the normal volume expansion effect rather than severe iron-deficiency anemia.

📃Teaching that hemodilution can make labs “look low” helps the client understand why her intake of green vegetables may not fully prevent this expected lab shift.

📌Core Message

In late pregnancy, rising plasma volume can cause hemodilution that lowers measured hemoglobin and hematocrit even when nutrition is reasonable.

2 :
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

Determine cervical dilation.

Check the pH of the vaginal fluid.

Review the fetal heart rate pattern.

Palpate the client's bladder.

Hint : 🚻Consider what must be verified to prevent an unexpected birth risk before the client leaves the bedside.

Correct Answers:

Determine cervical dilation.

Rationale :

🚼In active labor, an urge to use the bathroom can occur when the fetal presenting part applies pelvic pressure, which may signal labor progression.

🧤Checking cervical dilation first protects the client from an unexpected precipitous birth outside the controlled delivery environment.

🩺Once dilation is reassessed, the nurse can then proceed with safe ambulation and supportive steps like assessing FHR and bladder status.

✅This prioritization supports both maternal safety and newborn safety by reducing the risk of an unassisted delivery.

📌Core Message

Reassessing cervical dilation first promotes maternal–fetal safety before allowing bathroom use during progressing labor.

3 :
A nurse is caring for a client.

History and Physical
Home Medications
Nurses' Notes
Vital Signs

A 29-year-old female client, gravida 1 para 1 (G1P1), is admitted to the obstetric unit following a vaginal delivery at 2100 hours at 38 weeks and 1 day of gestation. She delivered a male infant weighing 8 lb 6 oz (3,799 g) and measuring 20 inches (50.8 cm) in length.

The client experienced spontaneous rupture of membranes at home 12 hours prior to delivery. Upon arrival to the labor and delivery unit, cervical dilation was 5 cm with regular uterine contractions. Intravenous oxytocin was administered to augment labor, and a spinal epidural was placed for pain management. The client labored for 10 hours prior to delivery.

Estimated blood loss was 300 mL. A urinary catheter was removed following delivery, with a urine output of 500 mL. The client sustained a first-degree perineal laceration, which was repaired using local anesthesia. She plans to bottle-feed her infant.

The client has a history of gestational diabetes mellitus diagnosed at 18 weeks’ gestation via a routine glucose challenge test. At diagnosis, her hemoglobin A1C (HbA1C) was 11.4% (normal: < 7%). Oral glyburide therapy was initiated at 5 mg/day and titrated to a maximum dose of 20 mg/day without adequate glycemic control. Insulin therapy was subsequently started and effectively managed her blood glucose levels.

She also has a history of depression. The client reports no known drug allergies.

Paroxetine 40 mg

Prenatal vitamin

Regular insulin

Insulin glargine

2330:

The client has oxytocin infusing via an intravenous line in the right forearm. A bedpan is used due to reported numbness in the lower extremities. Lochia is moderate and red in color. The client’s skin is warm and flushed. She reports extreme thirst. The nurse assists the client into bed, ensures comfort, and provides a pitcher of water at the bedside.

2100:

Temperature: 99.5°F (37.5°C)

Heart rate: 72 beats/min

Respiratory rate: 16 breaths/min

Blood pressure: 130/78 mm Hg

Oxygen saturation: 97% on room air

Blood glucose: 140 mg/dL

Height: 5 ft 7 in (170.2 cm)

Weight: 187 lb (84.8 kg)

2230:

Urine output: 400 mL, clear yellow

The nurse considers the client’s initial presentation along with her history and physical assessment findings. Complete the sentence by selecting the appropriate responses from the word choices below. The nurse recognizes that the client findings ofandrequire follow-up.

Hint : 🔍Link the client’s thirst and skin signs to a likely metabolic imbalance.

Correct Answers

Blank 1 Correct Option: Polydipsia
Blank 2 Correct Option: Warm, flushed skin

Rationale :

💧Marked polydipsia in a client with recent gestational diabetes can indicate hyperglycemia and osmotic fluid shifts needing prompt glucose assessment.

🌡️A warm, flushed skin finding can accompany elevated blood glucose and dehydration-related vasodilation signals.

🩸In contrast, moderate lochia can be expected early postpartum, and the documented urine output is not clearly alarming by itself for hypovolemia.

💁‍♂️Therefore, the combination of polydipsia and flushing is the most concerning pattern that warrants follow-up for glycemic instability.

📌Core Message

In a postpartum client with gestational diabetes, polydipsia plus warm, flushed skin should trigger concern for hyperglycemia.

4 :
A nurse is caring for a client.

History and Physical
Home Medications
Nurses' Notes
Physical Assessment
Vital Signs

She also has a history of depression. The client reports no known drug allergies.

Paroxetine 40 mg

Prenatal vitamin

Regular insulin

Insulin glargine

2330:

2240:

A physical assessment is completed. The client reports feeling weak and fatigued and asks if she may have food, stating that she is very hungry.

Neurological:

Alert and oriented.

Pupils equal and reactive to light.

The client reports blurred vision.

Bilateral lower extremity numbness extending through the L5 dermatome.

Integumentary:

Skin warm and flushed.

Breasts:

Soft with protruding nipples.

Abdomen:

Uterus firm at the level of the umbilicus and midline.

Bilateral abdominal striae noted.

Bowel:

Upper bowel sounds active; lower bowel sounds sluggish.

The client has not passed flatus.

Perineum:

First-degree laceration well-approximated with sutures and no redness.

Vaginal bleeding is light rubra.

Mild labial edema noted; ice pack applied for comfort.

2100:

Temperature: 99.5°F (37.5°C)

Heart rate: 72 beats/min

Respiratory rate: 16 breaths/min

Blood pressure: 130/78 mm Hg

Oxygen saturation: 97% on room air

Blood glucose: 140 mg/dL

Height: 5 ft 7 in (170.2 cm)

Weight: 187 lb (84.8 kg)

2230:

Urine output: 400 mL, clear yellow

2240:

Temperature: 99.2°F (37.3°C)

Heart rate: 72 beats/min

Respiratory rate: 14 breaths/min

Blood pressure: 124/74 mm Hg

Oxygen saturation: 97% on room air

Pain:

3/10 abdominal cramping and general discomfort

4/10 headache

Intake:

400 mL water

120 mL juice

The nurse reviews the assessment findings. For each client finding, select whether it is most consistent with hypoglycemia or hyperglycemia. Each row must have only one option selected.

Client Findings	Hypoglycemia	Hyperglycemia
Frequent urination
Hunger
Fatigue
Sweating
Headache
Abdominal pain
Dry mouth

Hint : 🧩Separate adrenergic signs from dehydration/diuresis signs to sort hypoglycemia vs hyperglycemia.

Correct Answers

Frequent urination [ Hyperglycemia ]
Hunger [ Hypoglycemia ]
Fatigue [ Hyperglycemia ]
Sweating [ Hypoglycemia ]
Headache [ Hypoglycemia ]
Abdominal pain [ Hyperglycemia ]
Dry mouth [ Hyperglycemia ]

Rationale :

🚽Hyperglycemia causes osmotic diuresis, leading to frequent urination and contributing to dry mouth from fluid loss.

🍽️Hypoglycemia triggers adrenergic symptoms like hunger and sweating as the body responds to low blood glucose.

🧠A headache can occur with hypoglycemia because the brain is sensitive to reduced glucose availability.

🤢More systemic hyperglycemia can cause fatigue and abdominal pain, especially when metabolic stress increases and dehydration worsens cellular dysfunction.

📌Core Message

Hypoglycemia tends to cause adrenergic symptoms while hyperglycemia tends to cause dehydration and osmotic diuresis patterns.

5 :
A nurse is caring for a client.

History and Physical
Home Medications
Nurses' Notes
Physical Assessment
Vital Signs
Orders
Laboratory Results

She also has a history of depression. The client reports no known drug allergies.

Paroxetine 40 mg

Prenatal vitamin

Regular insulin

Insulin glargine

2230:

Oxytocin is infusing via an IV line in the right forearm. A bedpan is used due to numbness in the lower extremities. Lochia is moderate and rubra in color. Skin is warm and flushed. The client reports extreme thirst. She is assisted into bed, made comfortable, and provided with a pitcher of water at the bedside.

2240:

A physical assessment is completed. The client reports feeling weak and fatigued and requests food, stating that she is very hungry.

2250:

The client is reassessed. The fundus remains firm with light rubra lochia, and lower-extremity numbness has improved. Capillary blood glucose is measured, and the client is provided with a boxed lunch. The client has consumed the entire water pitcher; it is refilled. Oxytocin infusion is completed, and the IV line is saline-locked.

2300:

Phlebotomy collects blood samples for the prescribed hemoglobin and hematocrit.

Neurological:

Alert and oriented.

Pupils equal and reactive to light.

Reports blurred vision.

Bilateral lower-extremity numbness extending to the L5 dermatome.

Integumentary:

Skin warm and flushed.

Breasts:

Soft with protruding nipples.

Abdomen:

Uterus firm at the level of the umbilicus and midline.

Bilateral abdominal striae present.

Bowel:

Upper bowel sounds active; lower bowel sounds sluggish.

No passage of flatus reported.

Perineum:

First-degree laceration well-approximated with sutures and no redness.

Vaginal bleeding is light rubra.

Mild labial edema present; ice pack applied for comfort.

2100:

Temperature: 99.5°F (37.5°C)

Heart rate: 72 beats/min

Respiratory rate: 16 breaths/min

Blood pressure: 130/78 mm Hg

Oxygen saturation: 97% on room air

Blood glucose: 140 mg/dL

Height: 5 ft 7 in (170.2 cm)

Weight: 187 lb (84.8 kg)

2230:

Output: 400 mL urine, clear yellow

2240:

Temperature: 99.2°F (37.3°C)

Heart rate: 72 beats/min

Respiratory rate: 14 breaths/min

Blood pressure: 124/74 mm Hg

Oxygen saturation: 97% on room air

Pain:

3/10 abdominal cramping and general discomfort

4/10 headache

Intake:

400 mL water

120 mL juice

2250:

Intake: 120 mL water

Output: 200 mL urine mixed with lochia

Admit to postpartum unit

Complete oxytocin bolus (30 units oxytocin in 500 mL 0.9% sodium chloride), then saline-lock IV if bleeding is within normal limits; follow facility protocol for maintenance lock

Blood glucose monitoring before meals and at bedtime (AC/HS)

Diet: Consistent carbohydrate, medium

Hemoglobin and hematocrit by venipuncture 2 hours post-delivery

Morning labs: CBC, CMP, HbA1C

Acetaminophen 650 mg PO every 6 hours PRN for uterine cramping (first-line)

Naproxen 500 mg PO every 12 hours PRN for uterine cramping (second-line)

Glycerin-witch hazel 50% topical pads PRN every 2 hours for perineal pain/itching

Benzocaine 20% topical spray PRN up to four times daily for perineal pain

Aluminum hydroxide/magnesium hydroxide/simethicone 15 mL PO every 6 hours PRN indigestion

Magnesium hydroxide 30 mL PO daily PRN constipation

Oxygen via nasal cannula 1–5 L/min PRN to maintain SpO₂ ≥ 92%

Test	Result	Reference Range
Glucose	278 mg/dL (15.43 mmol/L)	70–110 mg/dL (3.89–6.11 mmol/L)

The nurse notifies the healthcare provider of the elevated blood glucose level and analyzes the findings. Complete the statements by selecting the most appropriate options from the lists below. The nurse recognizes that in the firsthours postpartum, the insulin requirement should. She also notes that the client is most at risk fordue to gestational diabetes.

Hint : 🧪Use the loss of placental hormones to predict the direction of insulin needs, then connect persistent hyperglycemia to a key complication.

Correct Answers

Blank 1 Correct Option: 24
Blank 2 Correct Option: Decrease
Blank 3 Correct Option: Infection

Rationale :

🧬After delivery, the loss of placental hormones rapidly reduces insulin resistance, so insulin requirements typically decrease in the early postpartum period.

⏱️The most clinically fitting timeframe in the options for this immediate change is the first 24 hours, when metabolic shifts are most pronounced in postpartum physiology.

🦠Poorly controlled blood glucose increases susceptibility to infection by impairing immune function and delaying normal healing.

💁‍♂️Given the client’s elevated glucose and history of gestational diabetes, prioritizing infection risk is more directly tied to hyperglycemia than cardiomyopathy or hemorrhage in this context.

📌Core Message

Early postpartum loss of placental hormones lowers insulin resistance, so insulin needs fall while hyperglycemia raises infection risk.

6 :
A nurse is caring for a client.

Select which plan of care recommendations are indicated or not indicated at this time. Each row must only have one response option selected.

Plan of Care Recommendation	Indicated	Not Indicated
Notify the healthcare provider
Encourage the client to breastfeed
Administer 60 units glargine insulin
Provide the client with milk to drink
Administer 8 units regular insulin

Hint : 🧭Prioritize actions that address high glucose safely while avoiding unnecessary carbohydrate intake or excessive basal insulin.

Correct Answers

Notify the healthcare provider [ Indicated ]
Encourage the client to breastfeed [ Indicated ]
Administer 60 units glargine insulin [ Not Indicated ]
Provide the client with milk to drink [ Not Indicated ]
Administer 8 units regular insulin [ Indicated ]

Rationale :

📣With a glucose of 278 mg/dL, provider notification is indicated to obtain or confirm a safe treatment plan.

🤱Encouraging breastfeeding is indicated because it can support improved glucose utilization and postpartum metabolic regulation when appropriate.

💉A fixed high dose like 60 units glargine is not indicated without individualized postpartum reassessment because insulin needs decrease after delivery and excessive basal insulin increases hypoglycemia risk.

🥛Providing milk is not indicated as a corrective step for hyperglycemia because it adds carbohydrates, whereas a targeted regular insulin correction can be indicated when ordered or protocol-based for elevated blood glucose.

📌Core Message

For postpartum hyperglycemia, prioritize provider notification and appropriate correction insulin while avoiding excess carbohydrates and unsafe basal dosing.

7 :
A nurse is caring for a client.

History and Physical
Home Medications
Nurses' Notes
Assessment
Vital Signs
Orders
Laboratory Results

The client experienced spontaneous rupture of membranes at home 12 hours prior to delivery. Upon arrival to the labor and delivery unit, her cervical dilation was 5 cm with regular uterine contractions. Intravenous oxytocin was administered to assist with labor progression, and a spinal epidural was placed for pain management. The client labored for 10 hours prior to delivery.

Estimated blood loss was 300 mL. The urinary catheter was removed after delivery, with a total output of 500 mL. The client sustained a first-degree perineal laceration, which was repaired using local anesthetic. She is bottle-feeding the infant.

The client has a history of gestational diabetes mellitus diagnosed at 18 weeks’ gestation using the routine glucose challenge test. At diagnosis, her hemoglobin A1C (HbA1C) was 11.4% (normal < 7%). Oral glyburide therapy was initiated at 5 mg/day and increased to a maximum dose of 20 mg/day; however, this did not adequately control her blood glucose levels. Insulin therapy was subsequently initiated and successfully managed her blood glucose.

She also has a history of depression. The client reports no known drug allergies.

Paroxetine 40 mg

Prenatal vitamin

Regular insulin

Insulin glargine

2230:

Oxytocin is infusing via an intravenous line in the right forearm. A bedpan is used due to numbness in the lower extremities. Lochia is moderate and red. Skin is warm and flushed. The client reports extreme thirst. She is assisted into bed, made comfortable, and a pitcher of water is placed at the bedside.

2240:

A physical assessment is completed. The client reports feeling weak and tired and asks if she can have food because she is very hungry.

Neurological:

Alert and oriented.

Pupils reactive to light.

Reports blurred vision.

Bilateral leg numbness extending through L5.

Integumentary:

Skin warm and flushed.

Breasts:

Soft with protruding nipples.

Abdomen:

Uterus firm at the level of the umbilicus and midline.

Bilateral abdominal striae present.

Bowel:

Upper bowel sounds active; lower bowel sounds sluggish.

Has not passed flatus.

Perineum:

Laceration well-approximated with sutures and no redness.

Vaginal bleeding is light rubra.

Mild labial swelling present; ice pack applied for comfort.

2250:

Client reassessed. Fundus remains firm with light rubra lochia. Lower extremity numbness has improved. Blood glucose is checked, and the client is provided a boxed lunch. She has consumed the entire water pitcher, which is refilled. Oxytocin infusion is completed, and the IV line is saline locked.

2300:

Phlebotomy draws blood for prescribed hemoglobin and hematocrit.

2305:

The healthcare provider is notified, and new prescriptions are pending. The client reports increased abdominal and perineal pain at the site of the sutures.

2310:

Regular insulin and insulin glargine are administered. Breastfeeding education is provided, including benefits for glucose management. The client agrees to breastfeed and is assisted; an adequate latch is achieved.

Day 1 Postpartum

0100:

Client completes breastfeeding. Naproxen is administered for pain control. Lochia remains light, and the fundus is firm at the umbilicus. Denies numbness. Ambulates to the bathroom without difficulty.

0600:

Blood is drawn for prescribed laboratory tests. The client reports pain is well controlled.

0730:

The client reports she has ordered breakfast and is ready for insulin if needed. Blood glucose is checked, and 4 units of regular insulin are administered as prescribed.

0800:

The nurse checks back with the client and observes that breakfast consisted of blueberry pancakes with syrup, an apple, orange juice, and yogurt.

2100:

Temperature: 99.5°F (37.5°C)

Heart rate: 72 beats/min

Respiratory rate: 16 breaths/min

Blood pressure: 130/78 mm Hg

Oxygen saturation: 97% on room air

Blood glucose: 140 mg/dL

Height: 5 ft 7 in (170.2 cm)

Weight: 187 lb (84.8 kg)

2330:

Output: 400 mL, clear yellow urine

2240:

Temperature: 99.2°F (37.3°C)

Heart rate: 72 beats/min

Respiratory rate: 14 breaths/min

Blood pressure: 124/74 mm Hg

Oxygen saturation: 97% on room air

Pain:

3/10 abdominal cramping and general discomfort

4/10 headache

Intake:

400 mL water

120 mL juice

2250:

Intake: 120 mL water

Output: 200 mL urine mixed with lochia

2230:

Admit to postpartum unit

Complete oxytocin bolus (30 units in 500 mL 0.9% normal saline), then saline lock IV if bleeding is within normal limits

Blood glucose checks before meals and at bedtime (AC/HS)

Diet: Consistent carbohydrate, medium

Hemoglobin and hematocrit by venipuncture 2 hours post-delivery

Morning labs: CBC, CMP, HbA1C

Acetaminophen 650 mg PO every 6 hours PRN uterine cramps (first choice)

Naproxen 500 mg PO every 12 hours PRN uterine cramps (second choice)

Glycerin-witch hazel pads PRN every 2 hours for perineal discomfort

Benzocaine 20% topical spray PRN up to four times daily

Aluminum hydroxide/magnesium hydroxide/simethicone 15 mL PO every 6 hours PRN indigestion

Magnesium hydroxide 30 mL PO daily PRN constipation

Oxygen via nasal cannula 1–5 L/min PRN to maintain SpO₂ ≥ 92%

Postpartum

Hemoglobin: 9.6 g/dL (12–16 g/dL)

Hematocrit: 36% (30–40%)

Day 2

0600:

Hemoglobin: 9.5 g/dL

Hematocrit: 34.2%

RBC: 5.0 × 10⁶/µL

WBC: 6,200/mm³

Platelets: 200 × 10³/mm³

BMP

Sodium: 138 mEq/L

Potassium: 3.6 mEq/L

Chloride: 108 mEq/L

Calcium: 9.5 mg/dL

CO₂: 26 mEq/L

BUN: 15 mg/dL

Creatinine: 0.6 mg/dL

Glucose

200 mg/dL

210 mg/dL

HbA1C

8.8% (normal < 7%)

The nurse discusses the client’s breakfast choices and provides dietary education. Complete the sentence by selecting the appropriate options from the word choices. The nurse explains that it is important to select foods likeandto avoid excessive intake of simple carbohydrates.

Hint : 🥣Pick items that emphasize protein and fiber rather than sweetened starches.

Correct Answers

Blank 1 Correct Option: Scrambled eggs
Blank 2 Correct Option: Whole-grain cereal

Rationale :

🍳Scrambled eggs are a protein choice with minimal simple carbohydrates, which helps reduce rapid postprandial glucose spikes.

🌾Whole-grain cereal provides complex carbohydrates and fiber, slowing glucose absorption compared with refined options.

🍯Foods like toast with jam, blueberry muffins, and waffles are higher in simple sugars or refined starches, increasing glycemic load. 💁‍♂️Selecting protein plus high-fiber grains supports more stable blood glucose control for diabetes-related nutrition teaching.

📌Core Message

Choosing protein and high-fiber complex carbohydrates helps prevent sharp postprandial glucose rises.

8 :
The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

Insulin requirements increase with lactation.

Eat 15 grams of carbohydrates if glucose is less than 150 mg/dL (8.3 mmol/L).

Wear a medical-alert bracelet.

Monitor for temperatures greater than 100.4°F (38°C).

Check blood sugar before breastfeeding.

Avoid low-dose contraceptives postpartum.

Schedule a glucose tolerate test in 6 weeks.

Eat 500 additional calories daily.

Hint : 📋Select statements that support safety monitoring, postpartum diabetes screening, and lactation energy needs without incorrect hypoglycemia thresholds.

Correct Answers:

Wear a medical-alert bracelet.
Monitor for temperatures greater than 100.4°F (38°C).
Check blood sugar before breastfeeding.
Schedule a glucose tolerate test in 6 weeks.
Eat 500 additional calories daily.

Rationale :

💁‍♂️Wearing a medical-alert bracelet is correct for clients using insulin because it supports rapid recognition during hypoglycemia emergencies.

🌡️Monitoring for fever above 100.4°F supports early detection of postpartum infection, which is a key safety priority with diabetes-related healing risk.

🤱Checking blood sugar before breastfeeding supports prevention of maternal hypoglycemia, since lactation can increase glucose use and alter insulin balance.

🧪Scheduling a glucose tolerance test in 6 weeks is correct because postpartum screening detects ongoing diabetes risk after gestational diabetes.

🍽️Adding about 500 calories daily aligns with lactation energy needs, supporting maternal nutrition while maintaining structured carbohydrate management.

📌Core Message

Correct discharge teaching reinforces safety identification, infection monitoring, pre-feed glucose checks, 6-week screening, and adequate lactation calories.

9 :
Following a vaginal delivery, the nurse places the neonate under the radiant warmer, provides Naso-oropharyngeal suction, and dries the neonate's skin to elicit spontaneous respirations. The newborn heart rate is 100 beats/minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Start IV infusion in a scalp vein.

Assist neonatologist with intubation.

Provide positive pressure ventilation.

Give blow-by oxygen via cannula.

Hint : 🤦‍♂️When the issue is absent respirations, prioritize a step that creates effective air exchange.

Correct Answers:

Provide positive pressure ventilation.

Rationale :

👶When a newborn remains apneic after initial steps and stimulation, the priority is to support ventilation, since oxygenation depends first on effective air movement.

💨A heart rate of 100 beats/minute with ongoing apnea indicates the need for positive pressure ventilation to establish adequate respiratory effort.

🩺Blow-by oxygen is insufficient when there is no effective breathing, because oxygen delivery requires ventilation to reach alveoli.

💁‍♂️Therefore, initiating PPV is the correct next action to prevent worsening hypoxemia and stabilize neonatal transition.

📌Core Message

Persistent neonatal apnea after stimulation requires positive pressure ventilation to establish effective oxygenation.

10 :
A 39-week-gestational multigravida is admitted to labor and delivery with spontaneous rupture of membranes (SROM) and contractions occurring every 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate (FHR) has ranged between 170 and 180 beats/minute. Which action should the nurse implement?

Obtain a blood specimen for hemoglobin.

Take an oral maternal temperature.

Send amniotic fluid for analysis.

Straight catheterize the client

Hint : 🔥A prolonged rise in FHR after membrane rupture often points toward a maternal systemic sign you can assess quickly.

Correct Answers:

Take an oral maternal temperature.

Rationale :

🌡️Sustained fetal tachycardia can signal maternal infection such as chorioamnionitis, especially after spontaneous rupture of membranes.

🧫Checking maternal temperature is a rapid, noninvasive assessment that helps identify an evolving intrauterine infection contributing to fetal stress.

👶Because the fetus is already at +2 station with frequent contractions, timely recognition of maternal infection indicators guides urgent clinical decisions.

💢Therefore, obtaining maternal temperature is the most appropriate action to evaluate a leading cause of persistent FHR elevation.

📌Core Message

Persistent fetal tachycardia after SROM should prompt assessment for maternal infection, starting with temperature.

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Ans

2 : The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 : A nurse is caring for a client.

Correct Answers

4 : A nurse is caring for a client.

Correct Answers

5 : A nurse is caring for a client.

Correct Answers

6 : A nurse is caring for a client.

Correct Answers

7 : A nurse is caring for a client.

Correct Answers

8 : The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

2 :
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 :
A nurse is caring for a client.

4 :
A nurse is caring for a client.

5 :
A nurse is caring for a client.

6 :
A nurse is caring for a client.

7 :
A nurse is caring for a client.

8 :
The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.