A Nurse Is Reviewing a Medical Record of a Client Who Has Diabetes Mellitus
Exam (elaborations)
HESI Leave Exam 3 – Question and Answers with Rationales
HESI Leave Examination 3 – Question and Answers with Rationales A home care nurse is instructing a customer with hyperemesis gravidarum about measures to ease nausea and vomiting. The nurse tells the client to: A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? A customer with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: A nurse instructs a pregnant client near foods that are high in folic acid. Which item does the nurse tell the customer is the all-time source of folic acid? A nurse is providing instructions to a mother of an baby with seborrheic dermatitis (cradle cap) about the treatment of the condition. The nurse tells the mother to: A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse offset: A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal belch. The nurse tells the client: A rubella antibody screen is performed in a pregnant client, and the results signal that the client is not immune to rubella. The nurse tells the customer that: A nurse is monitoring a client who delivered a healthy newborn 12 hours agone. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The near advisable nursing activity would exist to: A nurse is assessing the uterine fundus of a client who has just delivered a infant and notes that the fundus is boggy. The nurse massages the fundus and then presses to expel clots from the uterus. To foreclose uterine inversion during this procedure, the nurse: A nurse is monitoring a client after vaginal commitment notes a constant trickle of bright-red blood from the client'southward vagina. In which order would the nurse perform the following deportment? Assign the number 1 to the first action and the number five to the concluding. A nonstress examination is performed, and the md documents "accelerations lasting less than 15 seconds throughout fetal movement." The nurse interprets these findings every bit: A stillborn infant was delivered a few hours ago. After the birth, the family unit remains together, holding and touching the babe. Which statement by the nurse is appropriate? A nurse is providing nutritional counseling to the pregnant customer with a history of cardiac disease. What does the nurse advise the customer to consume? A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which of the post-obit clients does the nurse recognize every bit being at risk for the evolution of disseminated intravascular coagulation (DIC)? Select all that utilise. A delivery room nurse is preparing a client for cesarean delivery. The client is placed on the delivery room tabular array, and the nurse positions the client: A nurse is preparing to perform the Leopold maneuvers on a meaning client. The nurse should first: A nurse is assessing the lochia of a client who delivered a viable newborn i 60 minutes agone. Which blazon of lochia would the nurse expect to note at this time? A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the female parent to: When, during the normal postpartum grade, would the nurse await to note the fundal assessment shown in the effigy? A nurse assists the primary healthcare provider in performing an amniotomy on a customer in labor. In which order should the nurse perform the following deportment afterward the amniotomy? Assign the number ane to the first action and the number v to the concluding action. A licensed practical nurse (LPN) is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the LPN to contact the registered nurse? A nurse in the labor room is preparing to treat a client with hypertonic uterine dysfunction. The nurse is told that the customer is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the intendance of this client? A nurse is preparing to care for a customer experiencing dystocia. To which of the post-obit interventions does the nurse give priority? A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sex activity: A pregnant woman reports to the clinic complaining of loss of ambition, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: A nurse midwife performs an assessment of a pregnant customer and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the cess findings and determines that the fetal presenting role is: A nurse performing an cess of a meaning client is preparing to take the customer'southward claret pressure. The nurse positions the client: A nurse is performing an assessment of a client who is at twenty weeks of gestation. The nurse asks the client to void, then measures the fundal top in centimeters. Which approximate measurement does the nurse expect to meet? A nurse teaching a pregnant client nigh the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: A nurse is assisting a doc in performing a physical examination of a client who has merely been told that she is meaning. The dr. tells the nurse that the Goodell sign is present. The nurse understands that this sign is indicative of: A nurse performing an cess of a meaning client prepares to auscultate the fetal heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are fetal heart sounds audible with the use of this device? A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to exam for ballottement? After the delivery of a newborn, a nurse performs an initial assessment and determines that the Apgar score is 8. The nurse interprets this score as indicating that the infant: A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the customer to: A nurse is caring for a client in labor who has sickle jail cell anemia. Which intervention does the nurse implement to assist prevent a sickling crunch? A nurse teaches a new female parent how to perform umbilical cord care and how to recognize the signs of a string infection. Which of the following findings does the nurse tell the mother is an indicator of infection? A licensed practical nurse is performing assessments every thirty minutes on a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings would prompt the LPN to contact the registered nurse? A licensed practical nurse (LPN) is monitoring a client in the third trimester of pregnancy who has a diagnosis of severe preeclampsia. Which finding would prompt the LPN to contact the registered nurse? A pregnant client is seen in the dispensary for the first time. This is the customer's first pregnancy, and the client tells the nurse that she has diabetes mellitus. The nurse provides education to the client regarding health care during pregnancy. Which statements by the client bespeak the need for farther educational activity? Select all that employ. During a prenatal visit, the nurse notes that an adolescent significant client with diabetes mellitus has lost 10 lb during the showtime 15 weeks of gestation. The nurse discusses the weight loss with the client, and the client states, "I don't swallow regular meals." The appropriate response is: A nurse provides information about the handling for hypoglycemia to a client with gestational diabetes who volition exist taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: A nurse is reviewing the criteria for early belch of a newborn infant. Which of the following, if noted in the babe, would indicate that the criteria for early discharge have been met? Select all that apply. A client admitted to the motherhood unit 12 hours ago has been experiencing strong contractions every 3 minutes but has remained at station 0. The fetal heart rate on admission was 140 beats/min and regular. The fetal heart rate is slowing, and a persistent nonreassuring fetal heart rate pattern is present. The appropriate nursing activity in this situation is: Immediately after the delivery of a newborn babe, the nurse prepares to deliver the placenta. The nurse initially: A multigravida woman with a history of multiple cesarean births is admitted to the motherhood unit in labor. The client is experiencing excessively strong contractions, and the nurse monitors the client closely for uterine rupture. Which assessment findings are indicative of consummate uterine rupture? Select all that utilise. A client is admitted to the hospital for an emergency cesarean commitment. Contractions are occurring every 15 minutes, the customer has a temperature of 100° F, and the client reports that she final ate 2 hours agone. The client also states that "everything happened and then fast" and that she has had no preparation for the cesarean delivery. Which of the post-obit deportment should the nurse take first? A nurse assists a pregnant customer who is in the second trimester into a lithotomy position on the examining tabular array in the obstetrician's function. The customer of a sudden becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: A nurse is caring for a client in precipitous labor. In which position does the nurse place the customer? A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: A nurse working in a prenatal dispensary is reviewing the records of several clients scheduled for prenatal visits today. Which client does the nurse identify every bit being at risk for abruptio placentae? Select all that apply. A nurse caring for a customer in labor performs an assessment. The client is having consistent contractions less than 2 minutes apart. The fetal eye rate (FHR) is 170 beats/min, and fetal monitoring indicates a pattern of decreased variability. In light of these findings, the appropriate nursing activeness is: A nurse provides instructions regarding postpartum exercises to a client who has delivered a newborn vaginally. The nurse tells the client that: A nurse is assessing the respiratory rate of a newborn. Which finding would the nurse document as normal? A licensed practical nurse is monitoring a newborn who has been admitted to the nursery. The LPN notes that the inductive fontanel measures iv cm across and bulges when the infant is at rest. In light of this observation, what is the most advisable nursing action? A nurse is assessing a newborn infant with a diagnosis of gastroschisis. The nurse expects to note that the bowel is located: A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically look to note in the newborn? A woman existence seen in the prenatal clinic and complains of morn sickness that continues throughout the solar day. What does the nurse tell the client to practice to overcome this discomfort? A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the customer in measures to convalesce the discomfort. Which statement past the client indicates an understanding of these self-care measures? A licensed practical nurse (LPN) is profitable the registered nurse (RN) in assessing a pregnant client'south deep tendon reflexes and a reflex of 2 is noted. Based on this finding, the LPN anticipates that the RN volition have which activity? A woman in labor all of a sudden experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately: Subsequently a vaginal delivery, a adult female all of a sudden begins to mutter of severe pelvic pain and farthermost fullness in the vagina, and the nurse suspects uterine inversion. The nurse immediately prepares to: A nurse is performing an assessment of a meaning woman to determine whether labor has begun. For which sign of truthful labor does the nurse appraise the client? A nurse is preparing to appraise the fetal heartbeat in a pregnant woman who is at gestational week 12. Which piece of equipment does the nurse utilize to assess the fetal heartbeat? A client arrives at the clinic for her offset prenatal assessment. The client tells the nurse that the first mean solar day of her last menstrual flow (LMP) was September 19, 2013. Using Nagele's Rule, the nurse calculates the estimated date of delivery as: A pregnant customer is positive for HIV. The customer asks the nurse whether her newborn volition contract the virus. The appropriate response is: A delivery room nurse performing an initial cess on a newborn note that the ears are low fix. In calorie-free of this finding, which nursing activeness is advisable initially? A nurse is reviewing the medical tape of a meaning customer with sickle cell anemia. To which of the following information related by the customer would the nurse give the highest priority? A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to cease the infusion? A licensed applied nurse (LPN) is monitoring a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which action should the LPN take in response to this observation? A nurse assessing a significant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in lite of this ascertainment? A nurse caring for a customer in the active stage of labor assesses the fetal status and notes a belatedly deceleration on the monitor strip. In light of this finding, which nursing action is the priority? Placental abruption is suspected in a client who is experiencing vaginal haemorrhage. On assessment, which of the following findings would the nurse look to note? A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement past the female parent indicates a need for further teaching? A nurse is monitoring a pregnant customer with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to doubtable DIC? A nurse caring for a hospitalized client with a diagnosis of abruptio placentae and develops a nursing care plan incorporating interventions to exist implemented in the event of shock. If signs of shock develop, to promote tissue oxygenation, the nurse would immediately: A multigravida asks a nurse when she volition be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early on as: A 1-hour oral glucose tolerance test is performed on a meaning client, with a outcome of 155 mg/dL. The nurse tells the client that: A hepatitis B screen is performed on a significant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: A customer in the first trimester of pregnancy arrives at the clinic and reports that she has been experiencing vaginal bleeding. Threatened abortion is suspected, and the nurse provides instructions to the client regarding care. Which argument by the client indicates the need for further instruction? A licensed practical nurse (LPN) is changing the diaper of a 1-day-old total-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the footing of these findings, the nurse determines that the advisable action is: A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse programme to identify the babe? A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse inquire the customer to elicit information specific to this disorder? A nurse is conducting a home visit with a mother and her ane-calendar week-old infant, who is at risk for caused neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant? A nurse provides educational activity regarding prenatal care to a client with a history of heart disease. The nurse tells the client that: A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? A clinic nurse is developing a plan of care for a pregnant client with AIDS. Which problem does the nurse identify equally the priority to be addressed in the plan of care? A woman with severe preeclampsia delivers a good for you newborn babe and continues to receive magnesium sulfate therapy in the postpartum menstruum. Twenty-4 hours after delivery, the customer begins passing more than 100 mL of urine every hour. The nurse recognizes this book of urine output as an indication of: A nurse answers a phone call low-cal in the room of a woman who was just admitted in early latent labor. The woman is lying flat on her back on the bed. The husband reports excitedly, "I call up my married woman is going into shock or something! She was but lying there, and then she turned so pale, and her easily are then clammy. She said she was silly and sick to her tummy." The nurse notes on the noninvasive blood pressure level monitor that the woman's pulse is 58 beats/min and her blood pressure level is 90/50 mm Hg. The nurse interprets these findings as indications that the woman is experiencing: A nurse is monitoring a fetal heart rate (FHR). The nurse documents a reassuring FHR blueprint in the record on noting: A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting vivid-ruby vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing: A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her hubby arrives at the hospital. The nurse analyzes the client'southward beliefs as most likely the effect of: A neonate is irritable, cries endlessly, and has a temperature of 99.4° F. The neonate is also tachypneic, diaphoretic, feeding poorly, and hyperactive in response to environmental stimuli. The nurse determines that these signs and symptoms are consistent with: Rho(D) immune globulin (RhoGam) is prescribed for a client after commitment. Before administering the medication, the nurse reviews the client's history. Which of the post-obit findings is a contraindication to the administration of the medication? A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor just refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client'southward behavior may be a result of: Afterwards an unplanned cesarean department, the nurse finds the customer in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could non deliver vaginally. Which of the post-obit conclusions should the nurse make? A pregnant adult female reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection merely expresses business concern that her babe will be built-in with an infection. Which response should the nurse make to help ease these fears? A clinic nurse is performing an assessment of an HIV-positive pregnant adult female during the 32nd week of gestation. Which finding requires further follow-up? A nurse palpates the anterior fontanel of a neonate and notes that information technology feels soft. This nurse interprets this assessment data every bit: A nurse notes that the laboratory study of a significant client with suspected HIV infection indicates leukopenia, thrombocytopenia, anemia, and an increased erythrocyte sedimentation charge per unit. Which laboratory examination that would further ostend the presence of HIV does the nurse anticipate that the physician volition prescribe?
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