OB Hesi Stack 1 Flashcards
A primipara has delivered a stillborn fetus at 30-weeks gestation. To assist the parents with the grieving process, which intervention is most important for the nurse to implement?
Provide an opportunity for the parents to hold their infant in privacy
What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?
Body temperature
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?
Maternal blood pressure
A 34-week primigravida woman with preeclampsia is receiving Lactated Ringer’s 500ml with magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only.)
75ml/hr
A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
Assess bilateral lung sounds
A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, “Why is my baby sister eating my mommy’s breast?” How should the nurse respond? (Select all that apply.)
Explain that newborns get milk from their mothers in this way
Reassure the older brother that is does not hurt his mother.
Remind him that his mother breastfed him too.
The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used?
Place the infant in a warm room and use a calm approach
The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory syndrome?
Betamethasone (Celestone) 12mg deep IM
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse it include in the child’s plan of care?
Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R)
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
Change to latex-free gloves when handling infant
The healthcare provider prescribes Amoxicillin 500mg PO every 8hrs for a child who weighs 22 pounds. The available suspension is labeled, Amoxicillin Suspension 250mg/5ml. The recommended maximum dose is 50mg/kg/24hr. How many ml should the nurse administer in a single dose based on the child’s weight?
10mL
The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a sever frontal headache. Which medication should the nurse anticipate for this client?
Magnesium sulfate
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. The nurse knows that these findings are indicative of what condition?
Chorioamnionitis
A 4-year-old boy was recently diagnosed with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during the initial teaching?
Lower legs become progressively weaker, causing a waddling, unsteady gait
A male infant with a 2-day- history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is more important to implement?
Infuse normal saline intravenously
After administering varicella vaccine to a 5-year-old child, which instruction should the nurse provide the child’s parent?
Apply a cool pack to the injection site to reduce discomfort
The nurse is planning care for a 4-year-old girl who is diagnosed as having a developmental disability. What should be the primary focus of treatment for this child?
Help her achieve her maximum potential
A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement?
Remove restraints one at a time to provide range of motion exercises
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
Reassure the mother that the infant is old enough to eat iron-fortified cereal
A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child’s plan of care?
Pin and incisional care after surgery
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a V shaped appearance. What action should the nurse take first?
Change the maternal position
A postpartum client who is Rh-negative refuses to receive RhoGAM after delivery of an infant who is Rh-positive. Which information should the nurse provide this client?
RhoGAM prevents maternal antibody formation for future Rh-positive babies.
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the nurse do next?
Give the mother positive feedback about the way she administered the medication.
A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?
Weak cry without any tears
A full term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
Stimulate the infant to cry
A client at 40-weeks- gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. What information is most important for the nurse to obtain first?
Color and consistency of fluid
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first
Place the infant in a knee-chest position
A one-day-old neonate develops a cephalahematoma. The nurse should closely assess this neonate for which common complication?
Jaundice
The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediately?
Sodium of 119 mEq/L
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding?
The TSH is high because of the low production of t4 by the thyroid
The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant’s care
Respiratory rate of 76 breaths/minute
The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond?
Explain the newborn’s normal stepping reflex
During the admission procedure of a 6-year-old, the child states, I’m going to have an operation. Which response is best for the nurse to provide to this child?
Tell me what an operation is
