Maternal HESI Exam

The correct answer is: Let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.

Explanation:

The behaviors described by the expectant father, such as rubbing the abdomen, talking to the baby, and reprimanding the baby for moving too much, are normal aspects of maternal bonding. These behaviors are commonly seen when the mother begins to feel fetal movement, typically around 18-25 weeks of pregnancy. As the fetus becomes more active, many mothers begin to form a connection and may talk to or interact with the baby, even though it may seem unusual or humorous to others. These actions are part of the maternal-fetal attachment process and are not signs of mental instability or abnormal behavior. The expectant father’s concerns are valid, but they reflect a normal, healthy response to pregnancy, and the nurse can reassure him that this is part of the process of bonding with the baby.

Why the other options are incorrect:

Reassure him that these are normal reactions to pregnancy and suggest that she discuss his concerns with the childbirth education nurse. This option is partially correct but unnecessarily refers the mother to a different resource, the childbirth education nurse. While the behavior described is normal, it doesn't require further counseling from a specialized nurse, as it is a typical part of pregnancy. The best approach is reassurance and education, rather than redirecting the mother to another professional.

 Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. Ambivalence about pregnancy refers to mixed feelings (both positive and negative) that some women experience. While ambivalence is common in pregnancy, the behavior described in this scenario does not reflect ambivalence; it seems more related to the maternal bonding process that happens once fetal movement is felt. Thus, the recommendation in this option isn't quite appropriate.

Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. This suggestion is unnecessary. The behaviors described are normal and do not indicate any issues that would require observation or monitoring. There is no reason to involve the nurse at the next prenatal visit unless more concerning symptoms arise.

Summary:

The behaviors described by the expectant father—rubbing the abdomen, talking to the baby, and reprimanding the baby—are part of normal maternal bonding during pregnancy, especially after the mother starts to feel fetal movement. These actions are typical and demonstrate the mother's emotional connection with the baby. The nurse should reassure the father that this is normal and not a cause for concern.

The correct answer: Demonstrate self-administration of insulin.

Explanation

Pregnant women with Type 2 diabetes mellitus are typically switched from oral hypoglycemic agents to insulin during pregnancy because:

Most oral hypoglycemic agents cross the placenta and may pose teratogenic risks to the fetus.

Insulin is the preferred treatment during pregnancy as it provides better glycemic control without crossing the placenta.

Poorly controlled diabetes during pregnancy increases the risk of macrosomia (large baby), congenital anomalies, and neonatal hypoglycemia.

Since the client was previously using oral medications, she may not have experience with insulin injections, making it essential for the nurse to demonstrate and teach self-administration of insulin first to ensure proper management.

Why the other options are incorrect:

Describe diet changes that can improve the management of her diabetes:

Dietary management is important, but it is not the first priority since the client now requires insulin therapy. While carbohydrate control and balanced meals help manage blood sugar, insulin education is more urgent because the client must learn how to administer insulin safely to prevent hyperglycemia or hypoglycemia.

 Inform the client that oral hypoglycemic agents are teratogenic during pregnancy:

It is true that some oral agents are teratogenic, but not all (e.g., metformin is sometimes used in pregnancy). Simply informing the client about teratogenicity does not directly help her manage her diabetes now that she needs insulin therapy. This information should be included in education but is not the most critical immediate intervention.

Evaluate the client's ability to do glucose monitoring:

Blood glucose monitoring is essential, but before evaluating her ability to monitor glucose, the nurse must first teach her how to use insulin properly. Without insulin knowledge, glucose monitoring alone will not prevent complications.

Summary:

 Since oral hypoglycemics are discontinued in pregnancy, insulin becomes the primary treatment for Type 2 diabetes. Teaching self-administration of insulin is the most important intervention to ensure the client can safely and effectively manage her blood sugar. 

The correct answer: Exercise in a swimming pool.

Explanation:

For a patient with juvenile rheumatoid arthritis (JRA), the primary goal is to maintain joint mobility, strength, and function while minimizing stress on the joints. Aquatic therapy is an ideal exercise regimen for individuals with JRA because the buoyancy of the water supports the body, reducing strain on the joints and providing resistance for muscle strengthening. Additionally, the warmth of the water can help reduce pain and inflammation, making it a highly beneficial exercise option.

Why the other options are wrong:

 Begin a training program lifting weights and running: While strengthening exercises are important for JRA, weightlifting and running can be too stressful on the joints, especially during flare-ups. High-impact exercises like running could exacerbate pain and lead to joint damage. Resistance training using lighter weights and low-impact activities are more suitable.

Splint affected joints during activity: Splinting joints is generally used to help immobilize joints during rest or to prevent deformity, not during active exercises. Splints can restrict mobility, and it is more beneficial to encourage the adolescent to engage in active exercises that promote movement and flexibility rather than immobilizing the joints during activity.

 Perform passive range of motion exercises twice daily: While passive range of motion (ROM) exercises may be beneficial for maintaining joint flexibility, active exercises (like swimming) are more beneficial for strengthening muscles and improving overall joint function. Passive exercises alone may not provide enough strength-building or mobility benefits for someone with JRA.

Summary:

For a 16-year-old with juvenile rheumatoid arthritis, exercising in a swimming pool is the most appropriate regimen to strengthen muscles, improve joint mobility, and reduce stress on the joints. It offers both low-impact resistance and pain relief, making it an ideal exercise choice for managing JRA symptoms.

The correct answer is: tachycardia and a feeling of nervousness.

Explanation:

Terbutaline sulfate (Brethine) is a beta-adrenergic agonist commonly used to treat preterm labor by inhibiting uterine contractions. Its primary side effects are related to its systemic beta-adrenergic effects, which include tachycardia (increased heart rate) and a feeling of nervousness or jitteriness. These side effects occur due to the stimulation of beta receptors in the heart, leading to an increased heart rate and feelings of anxiety or restlessness.

Why the other options are incorrect:

drowsiness and bradycardia: Terbutaline sulfate does not typically cause drowsiness or bradycardia (slow heart rate). In fact, tachycardia (fast heart rate) is a more common side effect of terbutaline due to its beta-agonist action on the heart.

 depressed reflexes and increased respirations: Terbutaline sulfate does not generally cause depressed reflexes. While it may slightly increase respiratory rate, this is not a primary side effect of the drug. It is more likely to cause increased heart rate (tachycardia) rather than changes in respiratory rate.

 a flushed, warm feeling and a dry mouth: While terbutaline may cause some flushing or warmth as a side effect, dry mouth is not a primary or common side effect. The more significant side effects are tachycardia and nervousness, which are beta-adrenergic effects.

Summary:

The primary side effects of terbutaline sulfate (Brethine) are related to its action as a beta-agonist, leading to tachycardia and a feeling of nervousness. These effects are common and should be monitored during administration, as they can be distressing to the patient.

Correct Answer: Assist the client to the hands and knees position

Explanation:

The occiput posterior (OP) fetal position means that the back of the baby's head is pressing against the mother's sacrum, causing intense back pain (back labor). The hands-and-knees position (all-fours position) helps by rotating the baby into a more favorable position (occiput anterior), relieving maternal discomfort, and facilitating labor progression. This position also reduces pressure on the sacrum and promotes optimal fetal descent.

Explanation of Incorrect Options:

 "Perform effleurage during contractions"

Incorrect because effleurage (light stroking on the abdomen) is primarily used for mild labor pain relief, especially in early labor. However, it is not effective in relieving severe back pain caused by an OP fetal position.

"Place the client in lithotomy position"

Incorrect because the lithotomy position (lying on the back with legs in stirrups) does not help with fetal rotation and may increase back pain by applying more pressure on the sacrum. This position is usually reserved for delivery, not for managing labor discomfort.

 "Apply a fetal scalp electrode"

Incorrect because there is no indication of fetal distress or the need for internal fetal monitoring at this time. The priority is maternal comfort and fetal rotation, not fetal heart rate monitoring. A fetal scalp electrode is typically used when external monitoring is inadequate or when precise tracking of the fetal heart rate is needed.

Summary:

In cases of severe back pain due to an occiput posterior (OP) fetal position, the hands-and-knees position helps rotate the baby, relieve maternal discomfort, and improve labor progress. Effleurage is not effective for back labor, the lithotomy position increases pressure and pain, and a fetal scalp electrode is not needed in the absence of fetal distress.

The correct answer is: A cephalhematoma, caused by forceps trauma and may last up to 8 weeks.

Explanation:

A cephalhematoma is a collection of blood between the baby's skull and the periosteum (the membrane covering the bones). This condition typically occurs after a difficult delivery, especially with the use of forceps or vacuum extraction. It is characterized by localized swelling on the infant's head, usually on one side, and it does not cross the suture lines of the skull. Over time, the blood is gradually reabsorbed, and the swelling typically resolves within a few weeks, although it may last up to 8 weeks in some cases.

Why the other options are incorrect:

A subarachnoid hematoma, which requires immediate drainage to prevent further complications This statement is incorrect. A subarachnoid hematoma is a type of brain hemorrhage where blood accumulates between the brain and the surrounding membrane. It is a serious condition that often requires immediate medical intervention. However, it is much rarer than a cephalhematoma and would typically present with more severe symptoms, such as changes in the infant's consciousness or neurological status. It is not a typical condition in a newborn after delivery, and it doesn't present as localized swelling on the head as described in this scenario.

Modeling, caused by pressure during labor and will disappear within 2 to 3 days Modeling refers to temporary, often asymmetrical shaping of a newborn's head due to pressure from the birth canal during delivery, especially in vaginal births. This condition is not associated with blood accumulation. Instead, it involves changes in the shape of the skull, such as a cone-shaped head. This phenomenon typically resolves on its own within a few hours to days after birth but does not cause localized swelling or blood accumulation like a cephalhematoma does.

A subdural hematoma which can result in lifelong damage A subdural hematoma is another type of blood collection in the brain, typically between the brain and the dura mater. It is associated with more severe trauma, such as a significant head injury, and can cause neurological damage. It is rare in newborns and would not present as localized edema on the head, nor would it be a condition that typically resolves without treatment. A subdural hematoma is much more serious than the cephalhematoma described here.

Summary:

The cephalhematoma is a common and benign condition in newborns that results from the accumulation of blood between the skull and periosteum. It typically resolves on its own within weeks and does not cross the suture lines. It is caused by forceps or vacuum trauma during delivery. The other options are either conditions that do not match the described symptoms or more serious issues requiring immediate intervention.

Correct Answer: You should leave the diaphragm in place for at least 6 hours after intercourse

Explanation:

A diaphragm is a barrier method of contraception that prevents sperm from reaching the cervix. It must be used correctly to ensure effectiveness. After intercourse, the diaphragm should be left in place for at least six hours to prevent sperm from entering the uterus. This allows the spermicide applied to the diaphragm to effectively immobilize sperm and reduce the risk of pregnancy. However, it should not be left in place for more than 24 hours due to the increased risk of toxic shock syndrome (TSS) and infection.

Explanation of Incorrect Options:

 "You should replace the diaphragm every 3 years"

This is incorrect because diaphragms should generally be replaced every 1 to 2 years, depending on the material and wear. Additionally, the diaphragm should be checked regularly for holes or tears, especially if it has been in use for an extended period. A woman should also get refitted for a diaphragm after childbirth, significant weight gain or loss, or pelvic surgery to ensure proper fit and effectiveness.

 "You should use an oil-based product as a lubricant when inserting the diaphragm"

This is incorrect because oil-based lubricants (such as petroleum jelly or baby oil) can degrade the diaphragm's latex material, making it more prone to tears and breakage. Instead, water-based or silicone-based lubricants should be used to ensure the diaphragm remains intact and effective.

"You should insert the diaphragm when your bladder is full"

This is incorrect because a full bladder can make insertion more difficult and uncomfortable. It is actually recommended that the woman empties her bladder before inserting the diaphragm to ensure proper placement and comfort. Additionally, urinating after intercourse can help reduce the risk of urinary tract infections (UTIs).

Summary:

The correct answer is You should leave the diaphragm in place for at least 6 hours after intercoursebecause the diaphragm must remain in place for at least six hours after intercourse to ensure sperm are effectively immobilized by the spermicide. The diaphragm should not be left in place for more than 24 hours to prevent infection. It should be replaced every 1 to 2 years, only water-based lubricants should be used, and a full bladder can make insertion uncomfortable.

The correct answer: correctly place the infant on the breast.

Explanation

The most effective way to prevent nipple soreness is to correctly place the infant on the breast. Ensuring that the infant has a proper latch is crucial for preventing nipple pain. When the baby is latched properly, the nipple and areola are positioned correctly in the infant's mouth, reducing the risk of friction and trauma to the nipple that can lead to soreness and cracking. A proper latch also helps the infant feed more effectively, which can improve overall breastfeeding success.

Why the other options are incorrect:

wear a cotton bra: While wearing a cotton bra may be comfortable and breathable, it does not directly address the prevention of nipple soreness. Nipple soreness is more related to the baby's latch and breastfeeding technique rather than the material of the bra

 increase nursing time gradually: Gradually increasing nursing time might help a mother build up endurance for longer nursing sessions, but it does not specifically target the root cause of nipple soreness. If the baby is not latched properly, soreness can occur regardless of how long the nursing session is.

manually express a small amount of milk before nursing: While manually expressing milk before breastfeeding can help if the mother has engorged breasts or if milk flow is slow, it does not directly prevent nipple soreness. In fact, a proper latch is more effective in preventing soreness than any amount of milk expression.

Summary

To prevent nipple soreness, correctly placing the infant on the breast is the most effective strategy. Ensuring a proper latch reduces friction and trauma, which helps avoid discomfort during and after breastfeeding. Proper technique should always be prioritized in breastfeeding to promote both maternal comfort and infant feeding efficiency.

The correct answer is: Keep airway equipment at the bedside.

Explanation:

Eclampsia is a serious complication of pre-eclampsia characterized by the onset of seizures (convulsions). Even though the client is not presently convulsing, the risk of seizures remains a concern for eclamptic patients. Seizures can lead to respiratory compromise and other complications, making airway management a priority. Therefore, keeping airway equipment (e.g., oxygen, suctioning devices, and intubation supplies) at the bedside is essential to ensure rapid intervention should a seizure occur.

Why the other options are incorrect:

Allow liberal family visitation: While family support is important, liberal visitation may not be appropriate in a critical situation like eclampsia. The priority is managing the client’s condition and ensuring the environment is controlled and conducive to monitoring and intervention. Family members should be informed of the patient’s condition and the visitor policy to minimize stress or distractions that may interfere with the care provided.

Monitor blood pressure, pulse, and respirations q4h: Monitoring vital signs such as blood pressure, pulse, and respirations is important, but in a client with eclampsia, frequent monitoring is required to identify signs of worsening condition. The frequency of monitoring should be much more frequent, especially in the acute phase. Blood pressure, in particular, needs to be monitored more closely in eclampsia (e.g., every 15 minutes to 1 hour) due to the risk of severe hypertension, which can lead to seizures or other complications.

Assess temperature q1h: While fever may indicate infection, the priority assessment in a patient with eclampsia is to monitor for signs of seizures, manage hypertension, and maintain airway safety. Temperature monitoring is less critical than monitoring for seizure activity or vital signs related to hypertension in this acute setting.

Summary:

For a 16-year-old patient diagnosed with eclampsia, the most important nursing intervention is to keep airway equipment at the bedside to prepare for the potential occurrence of seizures. This proactive measure is essential to ensure the safety of the client and to facilitate immediate intervention if seizures occur.