Maternal HESI Exam

The correct answer is: At 30-weeks gestation

Explanation:

Childbirth preparation classes are ideally attended later in pregnancy, typically around 30 weeks gestation. This timing is optimal because it allows the expectant parents to retain the information they learn in the class, ensuring it is fresh in their minds when labor begins. Additionally, it provides an opportunity for the couple to practice the techniques they will use during labor, such as breathing exercises and relaxation methods, closer to the time they will need them. This also allows the couple to address any specific concerns or questions they may have as the due date approaches.

Why the other options are incorrect:

At 16-week gestation Attending childbirth classes at 16 weeks is too early in the pregnancy. At this point, the couple may not have specific concerns or need to focus on labor preparation techniques. Information learned at this stage may be forgotten by the time labor arrives. It is generally more beneficial to attend classes later when the pregnancy is more advanced.

At 20-weeks gestation While attending classes at 20 weeks may be beneficial for some couples, it is still earlier than the ideal time. At 20 weeks, the couple may not yet need to focus on specific labor techniques or the preparation needed for the birth. The information learned may be too early to retain effectively until closer to the delivery date.

At 24-weeks gestation Although 24 weeks gestation is later than 16 weeks, it is still earlier than the recommended time of 30 weeks. By 24 weeks, the couple may not yet be as focused on the practical aspects of childbirth, and it may still be a little too early to retain and practice the information that will be critical in the weeks leading up to delivery.

Summary:

The best time for expectant parents to attend childbirth preparation classes is around 30 weeks gestation. At this time, they can better retain information, practice skills for labor, and address specific questions or concerns closer to their due date. While earlier times like 16, 20, or 24 weeks may seem appropriate, they are generally too early for the most effective learning and preparation for childbirth.

Correct Answer: Leopold maneuvers

Explanation:

Leopold maneuvers are systematic abdominal palpations performed to determine the fetal position, presentation, and lie. This is crucial before applying an external fetal monitor because the transducer should be placed over the fetal back, where fetal heart tones are best heard. By performing Leopold maneuvers first, the nurse can accurately position the external transducer to ensure effective fetal monitoring.

Explanation of Incorrect Options:

"Assessment of dilation and effacement."

Incorrect because cervical dilation and effacement are assessed via a vaginal examination, which is not required before applying an external fetal monitor. These factors are important for labor progression but do not affect the placement of the transducer.

"Sterile speculum exam."

Incorrect because a sterile speculum exam is typically performed to assess for rupture of membranes, cervical changes, or vaginal infections, not for fetal monitoring. This procedure is not necessary prior to placing an external fetal monitor.

 "Nitrazine test."

Incorrect because a Nitrazine test is used to detect rupture of membranes (amniotic fluid leakage) by checking the pH of vaginal secretions. This test does not impact fetal heart rate monitoring and is not a prerequisite for external fetal monitoring.

Summary:

Before applying an external fetal monitor, the nurse should perform Leopold maneuvers to determine the best location for the transducer, making Option B the correct answer. The other options involve unnecessary procedures that do not contribute to proper transducer placement.

Correct Answer: Apply cold compresses to both breasts for comfort.

Explanation:

The client is experiencing engorgement, which is a common condition that occurs two to five days postpartum due to increased blood flow, lymphatic congestion, and milk production. Even though she is bottle-feeding and not breastfeeding, she can still experience engorgement. Cold compresses or ice packs help reduce swelling, inflammation, and discomfort by constricting blood vessels and decreasing milk production.

Explanation of Incorrect Options:

 Instruct the client to run warm water on her breasts.

Warm water and heat can increase circulation and stimulate milk flow, which may worsen engorgement and prolong discomfort. This approach is more beneficial for a breastfeeding mother who needs to encourage milk let-down but is not recommended for a non-breastfeeding mother.

Wear a loose-fitting bra to prevent nipple irritation.

A tight, supportive bra is recommended for non-breastfeeding mothers to minimize breast movement and reduce discomfort. A loose-fitting bra does not provide adequate support and may lead to increased swelling and pain.

 Express small amounts of milk to relieve pressure.

Milk expression (whether manually or with a pump) stimulates further milk production and prolongs engorgement. For a mother who is bottle-feeding, it is best to avoid expressing milk so that lactation can naturally suppress over time.

Summary:

Engorgement in a bottle-feeding mother should be managed with cold compresses, a supportive bra, and avoidance of breast stimulation to help decrease swelling and discomfort. Since warm water and milk expression stimulate milk production, they are not recommended for a mother who is not breastfeeding. Wearing a loose-fitting bra does not provide adequate support. 

Correct Answer: Weak cry without any tears.

Explanation:

Dehydration in an infant is characterized by signs of fluid loss and inadequate hydration. In a 6-week-old infant, one of the most critical indicators of dehydration is a weak cry without tears. Normally, infants begin producing tears by two to three weeks of age, so a lack of tears when crying, especially combined with a weak cry, strongly suggests dehydration. This occurs due to reduced fluid volume in the body, leading to decreased moisture production. Projectile vomiting, a hallmark of pyloric stenosis, leads to excessive fluid loss, which can result in dehydration and electrolyte imbalances. If left untreated, dehydration can cause poor perfusion, lethargy, and even shock.

Why the Other Options Are Incorrect:

Bulging fontanel

A bulging fontanel typically suggests increased intracranial pressure, which may be due to conditions such as hydrocephalus, meningitis, or intracranial hemorrhage. In dehydration, the fontanel is more likely to be sunken, not bulging, due to reduced fluid volume.

Visible peristaltic wave

A visible peristaltic wave across the abdomen is a classic sign of pyloric stenosis, but it does not directly indicate dehydration. It occurs due to forceful gastric contractions attempting to push food past the narrowed pyloric sphincter, not due to fluid loss.

Palpable mass in the right upper quadrant

A palpable "olive-shaped" mass in the right upper quadrant is another hallmark sign of pyloric stenosis. However, this finding reflects hypertrophy of the pylorus, not the hydration status of the infant.

Summary:

The correct answer is Weak cry without any tears because it directly indicates dehydration in an infant with pyloric stenosis. The other options are related to the underlying condition but do not specifically indicate dehydration. Bulging fontanel suggests increased intracranial pressure, visible peristaltic waves indicate pyloric obstruction, and a palpable mass is characteristic of pyloric stenosis but not dehydration.

The correct answer is: Cephalohematoma.

Explanation:

Cephalohematoma refers to a collection of blood between the baby's skull and the periosteum (a membrane covering the bones). This condition is commonly seen after assisted deliveries like those using forceps. It typically appears as swelling on the head that does not cross the suture lines because it is confined by the sutures of the skull. The swelling is often due to the rupture of blood vessels during the delivery process.

Why the other options are wrong:

Caput succedaneum: Caput succedaneum is a condition where there is generalized swelling of the soft tissues of the baby's head, which usually crosses the suture lines. This condition occurs as a result of pressure from the cervix during delivery and is generally more diffuse and not confined to one area, unlike cephalohematoma. It also usually resolves quickly after birth.

Hydrocephalus: Hydrocephalus refers to an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles of the brain, leading to increased head size. This condition does not present as swelling on the head due to forceps use and is not associated with the delivery process. The swelling observed in hydrocephalus is more related to increased intracranial pressure and would not be localized as described in the scenario.

Microcephaly: Microcephaly is a condition where a baby's head is smaller than expected due to abnormal brain development. This condition is congenital, meaning it is present at birth, and is not caused by delivery methods. Microcephaly would not result in localized swelling or redness on the head as described in the scenario.

Summary:

The red marks with swelling that do not cross the suture lines are indicative of cephalohematoma, a common birth-related condition that occurs due to the use of forceps during delivery. The swelling is confined to one area, as it is limited by the sutures of the skull, and this differentiates it from conditions like caput succedaneum, which affects the soft tissues and crosses the sutures. Hydrocephalus and microcephaly are unrelated conditions that do not align with the symptoms described.

Correct Answer: "Your healthcare provider should direct treatment options for herbal therapy."

Explanation:

During pregnancy, herbal therapy can pose potential risks to both the mother and fetus. Some herbs have pharmacological effects that may interfere with pregnancy or interact with prescribed medications. Because the safety of many herbs during pregnancy has not been well studied, it is essential that a healthcare provider approves any herbal treatments to prevent potential harm. This ensures that the client receives safe and evidence-based care.

Explanation of Incorrect Options:

"Herbs are a cornerstone of good health to include in your treatment."

This statement is incorrect because it implies that herbal therapy is always safe, which is not true during pregnancy. Some herbs can cause uterine contractions, bleeding, or fetal harm, and others may interact with medications, making them potentially dangerous.

"Touch is also therapeutic in relieving discomfort and anxiety."

While touch therapy, such as massage or acupressure, can be beneficial for relaxation, this response does not address the client’s specific question about herbal therapy. It shifts the focus to an unrelated topic instead of providing appropriate guidance on herbal use.

"It is important that you want to take part in your care."

Although encouraging client involvement in care is important, this response does not provide specific guidance regarding herbal therapy use. It lacks the necessary direction for the client to make an informed and safe decision.

Summary:

Because some herbs may be unsafe during pregnancy, it is essential that a healthcare provider evaluates and approves any herbal treatments to protect both the mother and the baby. The correct response is  "Your healthcare provider should direct treatment options for herbal therapy." as it ensures the client receives safe and evidence-based guidance regarding herbal therapy.

The correct answer is: a decrease in respiratory rate from 24 to 16.

Magnesium sulfate is administered to manage severe pregnancy-induced hypertension (PIH) and prevent seizures in preeclampsia. It acts as a central nervous system (CNS) depressant, reducing neuromuscular excitability and stabilizing the maternal condition. A therapeutic drug level is indicated by a mild decrease in respiratory rate within a safe range, signifying appropriate CNS depression without respiratory compromise.

Why the other options are incorrect:

 4+ reflexes is incorrect because hyperreflexia (4+ reflexes) is a sign of worsening preeclampsia, not therapeutic magnesium levels. Magnesium sulfate should cause a slight reduction in deep tendon reflexes (DTRs), ideally bringing them to normal (2+) or slightly diminished (1+), but not absent (0), which would indicate toxicity.

 Urinary output of 50 mL per hour is incorrect because while adequate urine output (at least 30 mL per hour) is important for preventing magnesium toxicity, 50 mL per hour does not directly indicate a therapeutic magnesium level. Urine output is monitored to ensure proper magnesium excretion and to detect toxicity, but it is not a primary indicator of therapeutic effect.

A decreased body temperature is incorrect because magnesium sulfate does not significantly affect body temperature. If a client has a drop in temperature, another cause should be investigated.

Summary:

A therapeutic level of magnesium sulfate is indicated by a decrease in respiratory rate from 24 to 16, which suggests effective CNS depression without respiratory compromise. Other signs of therapeutic magnesium levels include mildly reduced deep tendon reflexes (not absent or exaggerated) and stable urine output.

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.

The correct answer is: Calcium

Explanation:

The child in question is exhibiting muscular irritability and oozing blood from the surgical incision after receiving multiple blood transfusions. These symptoms are concerning for a potential hypocalcemia (low calcium levels), which can result from citrate toxicity in patients who have received multiple blood transfusions. Citrate is used as an anticoagulant in blood transfusions, and when large volumes of blood are transfused, citrate can bind to calcium in the blood, leading to hypocalcemia. Symptoms of hypocalcemia include:

Muscular irritability

Tetany (muscle spasms)

Twitching

Oozing blood from the surgical incision (due to impaired blood clotting)

Therefore, calcium levels are the most important serum value to check in this situation. If hypocalcemia is confirmed, calcium replacement therapy should be initiated to correct the imbalance and prevent further complications.

Why not the other options?

CO combining power: This refers to the carbon monoxide binding capacity of hemoglobin and is not directly related to the symptoms described here. It's not the most relevant lab value in the case of muscular irritability and bleeding post-transfusion.

Sodium: While sodium imbalances can cause neurological symptoms (such as confusion or seizures), it is less likely to explain the muscular irritability and oozing blood seen in this child, especially in the context of multiple blood transfusions.

Chloride: Like sodium, chloride imbalances can affect the body’s acid-base balance, but it does not directly contribute to the symptoms of muscular irritability and bleeding observed in the context of the child’s history.

Summary:

The most important serum value to assess in this scenario is calcium, as the child’s symptoms of muscular irritability and oozing blood from the surgical incision are likely related to hypocalcemia following multiple blood transfusions. The nurse should report the calcium level to the healthcare provider to assess for potential citrate toxicity and initiate treatment if necessary.