HESI RN OB Exam ( Hesi Maternal Health )

The correct answer is: Perform fundal massage.

Explanation:

The finding of a completely saturated perineal pad within 15 minutes after delivery indicates excessive bleeding, which may be a sign of uterine atony—a common cause of postpartum hemorrhage. One of the first actions the nurse should take is to perform fundal massage to help stimulate uterine contraction and reduce bleeding. Atonic or relaxed uterine muscles fail to constrict the blood vessels at the site of the placenta, leading to excessive blood loss.

Why the Other Choices Are Incorrect:

Encourage the client to void.

Encouraging the client to void is important if there is a suspicion of bladder distention, which can contribute to bleeding, but the immediate priority for a saturated pad is to address possible uterine atony with fundal massage. A full bladder could contribute to uterine displacement but is not the primary cause of excessive bleeding.

Notify the healthcare provider.

While notifying the healthcare provider is important if excessive bleeding persists after fundal massage, the first action is to try to control the bleeding through physical intervention (fundal massage). This helps address the most likely cause of the bleeding.

Assess blood pressure.

Assessing blood pressure is important, particularly if the client shows signs of hypovolemic shock (such as low blood pressure), but the first action should focus on stopping the bleeding through uterine massage. If the bleeding continues, further assessments like blood pressure and notifying the healthcare provider would follow.

Summary:

The first action to take when a multiparous client has a saturated perineal pad within 15 minutes after delivery is to perform fundal massage. This will help address uterine atony, a common cause of excessive postpartum bleeding.

The correct answer is: Obtain a serum glucose level.

Explanation:

The client is exhibiting classic signs of hyperglycemia and possibly early diabetic ketoacidosis (DKA), including anorexia, drowsiness, polydipsia, and frequent urination. In a child with known type 1 diabetes mellitus, these symptoms warrant immediate assessment of blood glucose levels to determine the severity and guide further treatment. Prompt identification of elevated glucose is critical to prevent complications.

Why the Other Choices Are Incorrect:

Offer age-appropriate toys:

While comfort measures are important in pediatric care, they do not address the client’s urgent physiological needs. Toys would not be appropriate as a primary action in this situation.

Suggest diapers for bedtime use:

Bedwetting in this case is a symptom of poor glucose control, not a behavioral issue. Diapers do not address the underlying problem and may delay appropriate medical evaluation and intervention.

Bring orange juice and crackers:

This intervention is appropriate for hypoglycemia, not hyperglycemia. Providing carbohydrates when a child is already hyperglycemic could worsen the situation and increase the risk of DKA.

Summary:

The most appropriate action is to obtain a serum glucose level (A), as the child is showing signs of possible hyperglycemia or diabetic ketoacidosis. Early detection is essential for preventing serious complications. The other options do not address the critical clinical concern.

The correct answer is: A platelet count of 67,000/mm³

Explanation:

A platelet count of 67,000/mm³ is critically low and poses a significant risk for complications with epidural anesthesia. Epidural placement requires puncturing the epidural space, and a low platelet count increases the risk of spinal epidural hematoma, which can lead to compression of the spinal cord and permanent neurological damage. The normal platelet range is 150,000–400,000/mm³, and most anesthesiologists require a minimum platelet count of 80,000–100,000/mm³ before safely administering an epidural. Because this client has thrombocytopenia (platelet count <100,000/mm³), the healthcare provider must be informed immediately to determine alternative pain management strategies.

Why the Other Choices Are Incorrect:

Cervical dilation of 5 cm with 90% effacement

This indicates that the client is in active labor, which is an appropriate stage for epidural placement. Epidurals are generally administered when the cervix is at least 4 cm dilated to ensure that labor is well-established. This finding does not require urgent reporting.

White blood cell count of 12,000/mm³

A WBC count of 12,000/mm³ is slightly elevated but normal in pregnancy and labor due to physiological leukocytosis. It does not indicate an infection or any contraindication for epidural administration. Therefore, it is not a critical finding that needs to be reported immediately.

Hemoglobin of 12 mg/dL and hematocrit of 38%

These values are within normal limits for pregnancy and do not pose any risk for epidural administration. They do not require immediate attention or reporting.

Summary:

The most critical assessment finding is a platelet count of 67,000/mm³ (D) because it significantly increases the risk of epidural hematoma, which can lead to spinal cord compression and permanent neurological damage. The other findings are within normal limits or do not affect the safety of epidural placement.

The correct answer is: Prepare the family to explore ways to cope with the imminent death of the infant.

Explanation:

Anencephaly is a severe congenital condition where much of the brain and skull are absent, and the infant will not survive for long after birth. The primary concern for the nurse should be to help the family prepare for the imminent loss of the infant. This involves providing emotional support and exploring ways to cope with the impending death, such as discussing palliative care options and ensuring the family has the time and support they need to say goodbye. This approach prioritizes compassionate care and acknowledges the reality of the situation in a supportive, respectful manner.

Why the Other Choices Are Incorrect:

Ensure that measures to facilitate the attachment process are offered: While bonding is important for all families, in cases of anencephaly, the infant is not expected to survive for long. Therefore, while emotional support is crucial, the focus should shift to helping the family cope with the loss, rather than focusing solely on attachment, which may not be appropriate in this case due to the infant’s prognosis.

Provide emotional support to facilitate the consideration of fetal organ donation: Although organ donation can be an option for some families, the focus at this time should be on preparing the family for the immediate loss of the infant. The nurse should provide support as the family processes their grief and help them with decisions, including the potential for organ donation if that is something they wish to explore. However, the priority is supporting the family’s emotional needs in the face of the infant's impending death.

Inform the family about multiple corrective surgical procedures that will be needed: Anencephaly is not a condition that can be corrected with surgery. There are no surgical procedures available to fix the condition. Providing information about corrective surgeries would be misleading and may cause confusion or false hope. The nurse should instead focus on supporting the family through this difficult time and provide information about the infant's condition and prognosis.

Summary:

The most appropriate action is to prepare the family to explore ways to cope with the imminent death of the infant (B). The nurse should offer compassionate care and emotional support to help the family navigate the end of life for their newborn. This includes helping them prepare for the loss and discussing options like palliative care.

The correct answer is: Count the heart rate for at least one full minute.

Explanation:

When assessing a newborn infant's heart rate, it is essential to count the heart rate for at least one full minute to obtain an accurate measurement. This is especially important because newborns may have variable heart rates that fluctuate, and shorter counting periods could miss irregularities or abnormalities. A full minute allows for a more reliable assessment of the infant's heart rate, ensuring that transient changes do not skew the result.

Why the Other Choices Are Incorrect:

Quiet the infant before counting the heart rate.

While it is important to ensure the infant is as calm as possible to prevent agitation from affecting the heart rate, this is not the most critical factor. The primary goal is to accurately measure the heart rate, which can be done even if the infant is slightly unsettled, though a calm state is preferred.

Palpate the umbilical cord.

Palpating the umbilical cord is generally used to assess the infant's circulatory function and the presence of a heartbeat. However, it is not the most reliable or preferred technique for assessing heart rate in a newborn. The most accurate method is to listen to the heart rate directly, either via auscultation at the chest or using a stethoscope.

Listen at the apex of the heart.

While listening at the apex is a good technique to assess heart sounds, it is not the most important step for ensuring an accurate heart rate measurement. The crucial step is to count the heart rate for a full minute, which can be done at the apex of the heart but is secondary to the time spent counting.

Summary:

The most important action for accurately assessing a newborn’s heart rate is to count the heart rate for at least one full minute (A). This ensures the most accurate and reliable measurement of the infant's heart rate. Other methods like quieting the infant or palpating the umbilical cord are supplementary but not as critical as the duration of the heart rate count.

The correct answer is: One fetal movement noted in an hour.

Explanation:

In a client at 41 weeks gestation, a decrease in fetal movement can be an indication of fetal distress or potential compromise. Reduced fetal movement is a significant concern and requires further assessment. At this gestational age, the fetus should be moving regularly, and a reduction in movement can be a sign that the fetus is experiencing stress or hypoxia. The nurse should immediately assess the fetal heart rate (FHR) and consider performing additional diagnostic tests such as nonstress tests (NST) or biophysical profile (BPP) to evaluate fetal well-being.

Why the Other Choices Are Incorrect: 

Score of eight on the biophysical profile. A score of 8 on a biophysical profile is considered normal and indicative of fetal well-being. The test measures fetal heart rate, movement, tone, breathing, and amniotic fluid. A score of 8 suggests that the fetus is doing well and is not a cause for concern in this context.

Cervix dilated 2 cm and 50% effaced. Cervical dilation and effacement in early labor are normal findings. At 41 weeks, it is not unusual for the cervix to be partially dilated and effaced as the body prepares for labor. This does not indicate a problem that requires further assessment.

Fetal heart rate of 116 bpm. A fetal heart rate of 116 bpm is within the normal range (typically between 110 and 160 bpm). This is a reassuring sign and does not require further assessment unless other signs of distress are present.

Summary:

The most concerning finding in a client at 41 weeks gestation is one fetal movement noted in an hour (B), as decreased fetal movement can signal fetal distress or compromise. This requires prompt further assessment, such as fetal heart rate monitoring or additional testing, to ensure fetal well-being. The other findings (A, C, D) are within normal limits and do not require immediate further intervention

The correct answer is: Decreased muscular spasticity.

Explanation:

Baclofen is a muscle relaxant commonly prescribed to manage symptoms of cerebral palsy (CP), specifically to reduce muscular spasticity. The primary action of baclofen is to help relax tight or stiff muscles, which are a hallmark of CP. Therefore, a decrease in muscular spasticity is the best indicator that the drug is effective. The PN should assess for a reduction in muscle stiffness, improved range of motion, and more fluid movement as signs of effectiveness.

Why the Other Choices Are Incorrect:

Increased appetite:

Increased appetite is not a typical or primary effect of baclofen. While some medications can lead to changes in appetite, this is not an expected therapeutic effect of baclofen in treating CP.

Sufficient urinary output:

Urinary output is generally unrelated to the action of baclofen. Baclofen does not directly affect renal function or urinary output, so this finding is not a reliable indicator of its effectiveness.

Fewer temper outbursts:

While baclofen may help with overall muscle relaxation, it is not specifically designed to manage emotional or behavioral symptoms like temper outbursts. If temper outbursts improve, it may be due to other factors, not necessarily the effects of baclofen.

Summary:

The best indication that baclofen is effective is decreased muscular spasticity (D), which aligns with its intended therapeutic effects in managing the symptoms of cerebral palsy. The other options are not directly related to the drug’s primary actions.

The correct answer is: Determine the firmness of the fundus.

Explanation:

Postpartum bleeding can occur for several reasons, but one of the most common causes of early postpartum hemorrhage is uterine atony, where the uterus fails to contract effectively after delivery. The nurse should first assess the fundus to check if it is firm or boggy (soft). If the uterus is soft and boggy, it may be the cause of the bleeding, and the nurse can then implement interventions such as uterine massage to encourage contraction.

Why the Other Choices Are Incorrect:

Inform the healthcare provider of the bleeding. While informing the healthcare provider may be necessary later, the first priority is to assess the cause of the bleeding. This assessment is critical for determining the appropriate intervention. The nurse should first evaluate the fundus before notifying the healthcare provider.

Give oxytocin (Pitocin) intravenously. Oxytocin is often used to help the uterus contract and reduce bleeding. However, the first step is to assess the fundus to determine whether the bleeding is due to uterine atony. If the fundus is found to be soft or boggy, oxytocin or other interventions may be warranted. Without first assessing the fundus, it’s premature to administer oxytocin.

Assess the vital signs for indicators of shock. While monitoring vital signs is important, it is not the first step. If the bleeding is significant enough to cause shock, the nurse will notice changes in vital signs. However, the immediate concern is identifying the cause of the bleeding, and assessing the fundus is the first step in this process.

Summary:

The most important action is to assess the firmness of the fundus to determine if uterine atony is causing the bleeding. If the uterus is boggy, the nurse can perform uterine massage and then consider other interventions such as oxytocin or informing the healthcare provider. This approach ensures the most effective management of postpartum hemorrhage.

The correct answer is: Massage the fundus and expel retained lochia and clots.

Explanation:

A boggy and displaced fundus is a sign of uterine atony, which can lead to excessive bleeding (postpartum hemorrhage). The first action in this case should be to massage the fundus to stimulate uterine contractions and help the uterus firm up. This helps reduce the risk of hemorrhage. Additionally, massaging the fundus can also help expel any retained lochia and clots, which may be contributing to the uterine atony. If massaging the fundus does not resolve the issue, further interventions like increasing oxytocin or addressing a distended bladder can be considered.

Why the Other Choices Are Incorrect:

Take the vital signs and open the IV infusion rate of oxytocin:

Although increasing the oxytocin infusion is important to help the uterus contract, the first priority is to manually massage the fundus. Vital signs should also be monitored, but massaging the fundus takes precedence as it directly addresses the potential cause of the boggy, displaced fundus.

Notify the registered nurse (RN) that the client's bladder is distended:

While a distended bladder can contribute to uterine displacement and atony, the first priority is to address the uterine atony by massaging the fundus. After massaging the fundus, checking for bladder distention and assisting the client to void or performing a bladder scan would be appropriate.

Put the infant to breast to suckle and stimulate oxytocin secretion:

Suckling can help stimulate oxytocin release, which in turn helps the uterus contract. However, manual massage of the fundus is a more immediate and direct intervention to address the boggy uterus. While suckling may be beneficial in the longer term, it is not the first action to take in this situation.

Summary:

The first action should be to massage the fundus and expel retained lochia and clots (D). This addresses the immediate concern of uterine atony and potential postpartum hemorrhage, which are the primary risks in this scenario. The other interventions are important but should be considered after the immedate issue is addressed.