Maternal HESI Exam

The correct answer: "complete bedrest decreases oxygen needs and demands on the heart muscle tissue."

Explanation:

Mitral stenosis causes narrowing of the mitral valve, leading to increased pressure in the left atrium, reduced cardiac output, and potential pulmonary congestion. Pregnancy naturally increases blood volume and cardiac workload, which can worsen symptoms. Complete bedrest reduces physical exertion, decreases oxygen demand, and minimizes stress on the heart, helping to prevent complications such as heart failure or arrhythmias.

Why the other options are incorrect:

 "We want your body to be healthy, and this is the only way we can make sure that will happen."

This response is vague and does not provide a clear, evidence-based rationale for bedrest. The client is asking for a medical explanation, and this response does not address how bedrest specifically benefits someone with mitral stenosis.

"I know you're upset. Would you like to talk about some things you could do while in bed?"

While acknowledging the client's emotional response is important, this response does not answer the client’s question directly. It is essential to first provide the medical rationale before offering emotional support.

"Labor is difficult, and you need to use this time to rest before you have to assume all child-caring duties."

This response is incorrect because it focuses on labor and postpartum recovery rather than addressing the immediate concern of mitral stenosis and why bedrest is necessary. It does not provide the client with an accurate or relevant explanation.

Summary:

The best response is "complete bedrest decreases oxygen needs and demands on the heart muscle tissue."because it provides a clear, medical explanation for the need for bedrest in a client with Class III mitral stenosis. The other options are either too vague, fail to address the specific medical issue, or focus on emotional support rather than providing a direct answer to the client's question.

The correct answer is: A sore throat last week

Explanation:

Acute poststreptococcal glomerulonephritis (APSGN) is a kidney disorder that can develop after an infection with certain strains of Group A Streptococcus (GAS), often following a throat infection (e.g., strep throat). The immune system responds to the streptococcal infection, leading to inflammation in the kidneys, which can cause symptoms like edema, hypertension, and hematuria (blood in the urine). The most significant history in this case is a sore throat last week because it suggests a recent streptococcal infection, which is the primary risk factor for developing APSGN. APSGN typically occurs 1 to 3 weeks after a throat infection with a GAS infection, making this a key piece of history.

Why the other options are less significant:

 Back pain for a few days: While back pain can sometimes be associated with renal issues, it is less directly connected to APSGN, which is more likely to present with symptoms like edema or hematuria, rather than localized back pain.

A history of hypertension: Hypertension can be a consequence of APSGN due to fluid retention and kidney dysfunction, but a history of hypertension is less significant as an initial indicator of APSGN. The sore throat history is a more immediate clue.

Diuresis during the nights: Diuresis or increased urination can be a sign of various kidney or fluid balance issues, but in APSGN, the patient is more likely to experience oliguria (reduced urine output) or edema due to the kidney's impaired function. Diuresis is not a key feature of APSGN in the acute phase.

Summary:

The most important historical information is a sore throat last week, as it is a typical precursor to acute poststreptococcal glomerulonephritis (APSGN). The condition is often seen after a Group A streptococcal throat infection, and identifying this history helps in making the correct diagnosis.

The correct answer is: Meet the mother's physical needs and demonstrate warmth toward the infant.

Explanation:

The best nursing plan to assist a mother in bonding with her newborn involves meeting her physical needs (such as rest, comfort, and nutrition) and demonstrating warmth toward the infant. This approach promotes both the mother’s well-being and her ability to connect with her newborn. After childbirth, a mother may be tired, physically uncomfortable, and adjusting to a new role. Supporting her physical needs helps her focus on bonding with the baby. Additionally, providing warmth, both emotionally and physically, encourages the mother to feel comfortable and supported in the early stages of bonding with her infant.

Why the other options are incorrect:

Encourage the mother to provide total care for her infant. While encouraging the mother to provide care for her baby is important, asking her to take on total care immediately after birth can be overwhelming. In the first few hours postpartum, the mother may still be recovering from childbirth, and focusing on bonding rather than total care is a more appropriate goal. Gradually involving her in the care process is ideal as she adjusts.

Provide privacy so the mother can develop a relationship with the infant. While privacy can certainly be important for bonding, it is also critical to ensure the mother is not isolated. Offering privacy in a way that supports the mother and infant's interaction is necessary, but she should also have support from nursing staff to help her initiate and reinforce the bond. Over-isolation can lead to feelings of loneliness or confusion about the infant's needs.

Encourage the father to provide most of the infant's care during hospitalization. Encouraging the father to provide most of the infant's care may distract the mother from forming a bond with her baby in the critical initial period after birth. While both parents' involvement is important, it is essential to allow the mother to take the lead in the early stages, as she may feel more connected to the infant through direct interaction, particularly if she is breastfeeding.

Summary:

The best plan for promoting bonding involves meeting the mother's physical needs and demonstrating warmth toward the infant. This approach helps the mother focus on building a relationship with her newborn while addressing any immediate physical needs from childbirth.

The correct answer: TORCH screening.

Explanation:

The TORCH screening is a series of blood tests used to detect infections that could potentially harm the fetus during pregnancy. TORCH stands for:

Toxoplasmosis

Other (including syphilis, varicella, parvovirus B19, etc.)

Rubella

Cytomegalovirus (CMV)

Herpes simplex virus (HSV)

The concern in this scenario is that the pregnant client is changing the cat's litter box daily, which could expose her to toxoplasmosis, an infection caused by the Toxoplasma gondii parasite. This parasite can be transmitted through cat feces and poses a risk to the fetus if contracted during pregnancy. The TORCH screening would be appropriate to check for toxoplasmosis as well as other infections that can affect pregnancy.

Why the other options are incorrect:

Biophysical profile: This test combines an ultrasound with a nonstress test (NST) to assess the baby's well-being, but it is not specific for detecting infections like toxoplasmosis. It is typically ordered if there are concerns about fetal distress or growth problems, not for assessing infection risk from external sources like cat litter.

Fern test: This is used to detect amniotic fluid leaking during pregnancy by examining the fluid under a microscope. It’s not related to infections or exposure to toxoplasmosis, so it wouldn’t be used in this case.

 Amniocentesis: This test involves taking a sample of amniotic fluid to check for genetic disorders, infections, and other fetal concerns. However, it is not routinely done for a client who is concerned about toxoplasmosis or other infections unless there are specific indications like abnormal findings in earlier screenings or tests.

Summary:

Given the client's exposure to cat litter, TORCH screening is the most appropriate test to screen for infections, particularly toxoplasmosis, which can be harmful to both the pregnant client and the fetus. This will help identify any risks that could affect the pregnancy and guide further management.

Correct Answer: Provide an opportunity for the parents to hold their infant in privacy.

Explanation:

The most important nursing intervention in assisting grieving parents after a stillbirth is to provide an opportunity for them to hold their infant in privacy. This acknowledges their loss, validates their emotions, and allows them to begin the grieving process. Research and bereavement best practices show that allowing parents to see, hold, and create memories with their baby helps with emotional healing. Parents should be given time to say goodbye in their own way while ensuring that support is available. If they decline to hold their baby, their decision should be respected, and alternative ways to honor their loss (e.g., photos, footprints, handprints) can be offered.

Why the Other Options Are Incorrect:

Assist the couple in completing a request for autopsy.

While discussing an autopsy may be appropriate, it should not be the primary intervention at this moment. Parents need emotional support first, and discussions about medical procedures should come after their initial emotional needs are addressed.

 Encourage the couple to seek family counseling within the next few weeks.

Grief counseling can be beneficial, but it is not the immediate priority in the first moments after the loss. Many parents are not ready to process counseling information right away; their primary need is acknowledging their loss and saying goodbye.

Explain the possible causes of fetal demise.

Explaining the causes of stillbirth is important, but not the priority in the immediate aftermath of delivery. Parents are typically in shock and not ready for a detailed medical explanation at this moment. The nurse should wait until the parents are emotionally ready before discussing potential causes.

Summary:

Providing an opportunity for the parents to hold their infant supports grief processing and emotional healing. The other options involve important steps but should be introduced later, after addressing the parents' immediate emotional needs.

Correct Answer: Extend the leg and dorsiflex the foot.

Explanation:

Leg cramps are common during labor, often due to fatigue, decreased circulation, or pressure on nerves from the position of the baby. The best intervention is to extend the leg and dorsiflex the foot (pull the toes toward the head), which stretches the calf muscle and helps relieve the cramp. This method works by counteracting the muscle contraction causing the cramp and promoting blood flow.

Explanation of Incorrect Options:

"Ask if she takes a daily calcium tablet."

While calcium deficiency can contribute to leg cramps, asking about supplementation does not immediately relieve the cramp. This would be a long-term prevention strategy, not an immediate intervention during labor.

"Lower the leg off the side of the bed."

Lowering the leg does not directly stretch the affected muscle or provide relief from the cramp. This position may even reduce circulation and worsen discomfort.

"Elevate the leg above the heart."

Although elevation helps with swelling, it does not address the muscle contraction causing the cramp. Without stretching the muscle, the cramp will persist.

Summary:

The most effective way to relieve a leg cramp during labor is to extend the leg and dorsiflex the foot, which stretches the muscle and improves circulation. Other options either do not provide immediate relief or are more relevant for prevention rather than treatment.

Correct Answer: Each pregnancy carries a 50% chance of inheriting the disorder.

Explanation:

An autosomal dominant disorder occurs when a single mutated gene from one parent is sufficient to cause the condition. The affected parent has one normal allele and one mutated allele (Aa), while the unaffected parent has two normal alleles (aa). The inheritance pattern follows Mendelian genetics:

50% chance (1 in 2) that the child inherits the mutated gene and develops the disorder (Aa).

50% chance (1 in 2) that the child inherits the normal gene and does not have the disorder (aa).

There are no carriers in autosomal dominant inheritance—if the child inherits the mutated gene, they will have the disorder.

Explanation of Incorrect Options:

Males inherit the disorder with a greater frequency than females.

 Autosomal dominant disorders do not depend on sex chromosomes, so males and females have equal chances of inheriting the disorder. X-linked dominant disorders (e.g., Rett syndrome) or X-linked recessive disorders (e.g., hemophilia) do show differences in male vs. female inheritance patterns.

The disorder occurs in 25% of pregnancies.

A 25% inheritance risk is typical of autosomal recessive disorders (e.g., cystic fibrosis, sickle cell disease), where both parents must be carriers (Aa × Aa). In contrast, autosomal dominant disorders have a 50% risk per pregnancy if one parent is affected.

All children will be carriers of the disorder.

In autosomal dominant inheritance, there are no carriers because anyone who inherits the mutated gene expresses the disorder. "Carrier" status applies to autosomal recessive conditions, where individuals can carry a mutation (Aa) without showing symptoms.

Summary:

In autosomal dominant inheritance, each child has a 50% chance of inheriting the disorder if one parent is affected. The disorder is not sex-linked, and there are no carriers. 

Correct Answer: Grief related to her perceptions about the loss of this child.

Explanation:

Grief is a natural emotional response to pregnancy loss, regardless of the stage of gestation or the circumstances surrounding it. Even though the pregnancy was only eight weeks along, the teenager may have already formed an emotional attachment to the unborn child. The psychological impact of a spontaneous abortion, also known as a miscarriage, can be profound, and feelings of sadness, loss, and mourning are common. Adolescents may have unique challenges in processing grief due to their developmental stage, lack of life experience, and potential lack of support from family or peers. The nurse should anticipate and validate these feelings while providing emotional support.

Explanation of Incorrect Options:

 Relief of ambivalent feelings experienced with this pregnancy.

While some individuals may experience relief, particularly if the pregnancy was unintended or unwanted, this is not the most universally expected response. The question does not specify that the teenager had mixed emotions about the pregnancy, so assuming relief would be an overgeneralization. Furthermore, even if some level of ambivalence existed, grief and loss are typically more prominent emotional responses, as the individual still experiences the end of a potential life and future.

 Shock because she may not have realized that she was pregnant.

Shock could be a possible response if the teenager was unaware of the pregnancy. However, the question does not indicate that she was unaware of her condition, so it is not the best answer. Additionally, by eight weeks gestation, many individuals have already experienced early pregnancy symptoms such as nausea, breast tenderness, or a missed period, making it less likely that she was entirely unaware. Even if some degree of shock occurs, it would likely be accompanied by grief, which is the more predominant emotional response.

Guilt because she had not followed her healthcare provider's instructions.

While guilt can be a part of the grieving process, it is not the most expected primary emotion. There is no indication in the question that the teenager had done anything wrong or failed to follow medical advice. Many spontaneous abortions occur due to chromosomal abnormalities or other uncontrollable factors, not due to actions taken or not taken by the individual. Therefore, while guilt may arise in some cases, it is not the most anticipated response.

Summary:

The correct answer is grief related to her perceptions about the loss of the child. Miscarriage at any stage can evoke a deep sense of loss, and the emotional response is often comparable to grief experienced after any significant loss. While other emotions such as relief, shock, or guilt may occur, grief is the most expected and predominant response. Nurses should be prepared to provide compassionate support, validate the teenager's emotions, and offer resources for coping with pregnancy loss.

Correct Answer: Place the infant in a knee-chest position.

Explanation:

An infant with tetralogy of Fallot (TOF) who becomes acutely cyanotic and hyperpneic is likely experiencing a "Tet spell," which is a sudden episode of severe cyanosis and hypoxia. The knee-chest position is the first and most important intervention for relieving a Tet spell. This position helps increase systemic vascular resistance, which reduces the amount of right-to-left shunting of blood in the heart and improves oxygenation by increasing blood flow to the lungs. In a Tet spell, the right-to-left shunt causes poorly oxygenated blood to bypass the lungs and enter the systemic circulation, leading to cyanosis. By placing the infant in the knee-chest position, the increased systemic resistance forces more blood to flow to the lungs for oxygenation, alleviating cyanosis and hyperpnea.

Why the Other Options Are Incorrect:

Administer morphine sulfate.

Morphine is used in certain cases to reduce anxiety and respiratory effort, but it is not the first action during a Tet spell. The most immediate and effective intervention is increasing systemic vascular resistance (via knee-chest position), as it directly addresses the cause of the cyanosis. Morphine should be considered after the initial positioning if needed for additional sedation and to ease respiratory effort.

Start intravenous fluids.

Intravenous fluids can be helpful in supporting blood pressure and hydration, but they are not the first action in managing a Tet spell. The primary concern is immediate relief of cyanosis, which can be best achieved with the knee-chest position to increase systemic vascular resistance.

Provide 100% oxygen by face mask.

Oxygen is a useful intervention, as it helps improve oxygenation, but the knee-chest position is the first priority in managing the acute episode. Oxygen therapy should be implemented after the knee-chest position is established, especially if cyanosis persists after repositioning.

Summary:

The correct answer is Place the infant in a knee-chest position because it immediately helps increase systemic vascular resistance, improving oxygenation and relieving the cyanosis associated with a Tet spell. Other interventions like oxygen, morphine, and fluids are secondary and should be implemented after ensuring the infant is in the optimal position.