NURSING MISC Focus on Maternity Health(Questions and Answers) 100% Correct, Fall 2019

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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: A. Eat foods high in calories and fat B. Lie dow... n for at least 20 minutes after meals C. Eat carbohydrates such as cereals, rice, and pasta Correct D. Consume primarily soups and liquids at mealtimes
Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea.
Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review measures to ease and prevent nausea and vomiting if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 589-590). St. Louis: Elsevier.
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2.ID: 9476908110
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? A. Clonus is present. B. Magnesium level is 10 mg/dL (4.11 mmol/L) C. D. Deep tendon reflexes are absent. E. The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent.
Test-Taking Strategy: Use the process of elimination and focus on the strategic words “medication is effective.” Recalling the actions of this medication and expected assessment findings after a client receives magnesium sulfate will direct you to this option. Review the expected assessment findings for a client receiving magnesium sulfate if you had difficulty with this question.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Evidence, Perfusion
HESI Concepts: Evidence-Based Practice/Evidence, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 594-595). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476908130
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: A. Vitamin K B. Protamine sulfate C. Calcium gluconate Correct D. Naloxone hydrochloride E.
Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid-induced respiratory depression.
Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in directing you to the correct option. Review common antidotes if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety


Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 773). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476908194
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? A. Milk B. Steak C. Chicken D. Lima beans Correct
Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the best source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review the foods high in folic acid if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Nutrition
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. 282-283). St. Louis: Elsevier.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 114, 119). St. Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476904403
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: A. Avoid the use of shampoo on the infant’s scalp B. Apply oil to the affected area on the infant’s scalp Correct C. Wash the infant’s scalp daily, using only tepid water D. Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation.
Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed-ended word “only.” To select from the remaining options, recall that this condition is characterized by the presence of scaly lesions; this will direct you to the correct option. Review the treatment for seborrheic dermatitis (cradle cap) if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Newborn
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 467-468). St Louis: Mosby.
Awarded 1.0 points out of 1.0 possible points.
6.ID: 9476901633
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: A. Documents the findings B. Contacts the health care provider C. Administers 100% oxygen by way of face mask D. Instructs the client to take several deep breaths Correct
Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the health care provider. If the deep breaths fail to increase the oxygen saturation level, the health care provider is notified and may prescribe oxygen.
Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Noting the oxygen saturation level will assist you in eliminating this option. Noting the strategic word “first” will direct you to the correct option. Review care of the client after a cesarean birth 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: Clinical Judgment, Gas Exchange
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 430-431). St. Louis: Elsevier.
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7.ID: 9476904487
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: A. To perform a vaginal douche B. To come to the clinic for a checkup C. That this is an indication of an infection D. That this is a normal postpartum occurrence Correct
Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect.
Test-Taking Strategy: Use your knowledge of expected postpartum findings to answer the question. Recalling the normal expected occurrences in regard to vaginal discharge will direct you to the correct option. Also, noting that the incorrect options are comparable or alike will direct you to the correct option. Review normal postpartum findings in regard to lochia 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/Postpartum
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. 435). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
8.ID: 9476908170
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: A. A rubella vaccine must be administered immediately B. A rubella vaccine must be administered after childbirth Correct C. She will not contract rubella if she is exposed to the disease D. She does not need to be concerned about being exposed to rubella E.
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist.
Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options, recall that rubella vaccine is a live virus; this will direct you to the correct option. Review rubella vaccine and its implications during pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Giddens Concepts: Immunity, Safety
HESI Concepts: Immunity, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 439-440). St. Louis: Elsevier.
Awarded 1.0 points out of 1.0 possible points.
9.ID: 9476908162
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: A. Contact the health care provider B. Recheck the temperature in 1 hour C. Encourage the intake of oral fluids Correct D. Tell the client that antibiotics will be prescribed
Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the health care provider or nurse midwife. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids.
Test-Taking Strategy: Use the process of elimination. Note the strategic words “12 hours ago.” Recalling that a low-grade temperature is a common postpartum assessment finding will direct you to the correct option. Review normal vital sign findings during a postpartum assessment if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Thermoregulation
HESI Concepts: Sexuality/Reproduction, Thermoregulation
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.
10.ID: 9476910071
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: A. Has the client void before the uterine assessment B. Tells the woman to bear down during fundal message C. Simultaneously provides pressure over the lower uterine segment Correct D. Asks the client to take slow, deep breaths during fundal assessment
Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal assessment and massage if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Safety
HESI Concepts: Sexuality/Reproduction, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 442, 668). St. Louis: Elsevier.
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