HES I Mental Health RN Exam – Accurate Questions with Verified Answers | Guaranteed, Exams of Nursing

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HESI Mental Health RNACCURATE

QUESSTIONS WITH VERIFIED ANSWERS

GUARANTEED PASS GRADED A.

The RN leading a group session of adolescence clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try and talk, and talks about his pets at home. What nursing action is best for the RN to take? A. Explore the clients feelings about his pets and home life B. Encourage his peers to help involve him in the activity C. Give the client permission to leave and return in 10 minutes D. Redirect him by encouraging him to read from the handout. D. Redirect him by encouraging him to read from the handout. A male adolescent was admitted to the unit two days ago for depression. When the mental health RN tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the RN to take? A. Report the behavior to the next shift B. Offer to play a game of cards with the client C. Document the behavior in the chart D. Plan to talk with the client till the next day. B. Offer to play a game of cards with the client A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the clients discharge plan? A. Do not take any over the counter meds. B. Eat a high carb, low fat, low protein diet. C. Call the crisis hotline if feeling alone. D. Avoid exposure to large crowds A. Do not take any over the counter meds. After receiving treatment for anorexia, a student asks the school RN for permission to work in the school cafeteria as part of the schools work study program. What action should the RN take? A. Refer the student to a psychiatrist for further discussion B. Recommend assignment to the receptionists office C. Suggest the student work in the athletic department D. Determine the parents opinion of the work assignment B. Recommend assignment to the receptionists office During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. what intervention is most important for the RN to implement during the admission process? A. Assist the client in developing alternative skills B. Remain calm and use a matter-of-fact approach C. Ask the client why she is so anxious

D. Administer a PRN sedative to help relieve her anxiety A. Assist the client in developing alternative skills A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The clients plan of care should include what priority problem? A. Acute confusion B. ineffective community coping C. Disturbed sensory perception D. self-care deficient A. Acute confusion The occupational health nurse is working with a female employee who was just notified that her child was involved in a MVA and taken to the hospital. The employee states "i cant believe this, what should i do?" What response is best for the RN to provide in this crisis? A. Tell me what you think should happen B. How serious was the collision C. What do you think you should do D. Call for transportation to the hospital D. Call for transportation to the hospital A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What priority nursing problem for admission to the psychiatric unit? A. Ineffective sexual patterns B. Impaired environmental interpretation C. Disturbed sensory perception D. Compromised family coping. A. Ineffective sexual patterns The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing the clients dressing? A. Provide detailed through explanations when cleansing the wound B. Preform the dressing change in a nonjudgmental manner C. Ask in a non-threatening manner why the client cut own abdomen D. Request another staff member assist with the dressing change B. Preform the dressing change in a nonjudgmental manner An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the last 2 days and a weight loss of 9 pounds in the last month. Which client goal is most important to achieve within the first three days of treatment? A. Meet scheduled appointment with dietitian B. Sleep at least 6 hours a night. C. Understand the purpose of medication regimen D. Describes the reason for hospitalization

B. Sleep at least 6 hours a night. When preparing to administer to domestic violence screening tool to a female client which statement should the RN provide? A. If you partner is abusing you, i need to ask you these questions B. State law mandates that i ask if you are a victim of domestic violence C. The HCP needs to know if you are experiencing any domestic violence D. All clients are screened for domestic violence because it so common in society. D. All clients are screened for domestic violence because it so common in society. A young female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is febrile, denies chills, and all laboratory values are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic, and calls her a hypochondriac. Which response is best for the RN to provide? A. Unless your sister has a medical degree, ignore her comments. B. I can hear that your sisters comments are over-whelming you C. Do you think its possible you could be a hypochondriac D. Besides your sisters comments, what else in your life is troubling you D. Besides your sisters comments, what else in your life is troubling you An RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development? A. establishing rapport with the group members B. clarifying the nurses role and clients responses C. Discussing ways to use the new coping skills learned D. Helping clients identify areas of problem in their lives. D. Helping clients identify areas of problem in their lives. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement? A. Isolate the client from other clients B. Administer PRN sedative C. Avoid recognizing the behavior. D. Escort the client to his room D. Escort the client to his room A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription? A. Blood pressure readings of 90/62 mmHgto 92/58 mmHg B. Pulse rate of 68-78mmHg C. Temperature of 99.5-99.7 degrees F D. Respiration of 24 breaths per minute A. Blood pressure readings of 90/62 mmHgto 92/58 mmHg

The RN on the evening shift receives report that a client is scheduling for electro convulsant treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT? A. Hold all bedtime medications B. Keep the client NPO after midnight C. implement elopement precautions D. Give the client an enema at bedtime B. Keep the client NPO after midnight A client with depression remains in bed most of the day, and declines activities. Which nursing problem has the greatest priority for this client? A. Loss of interest in diversional activity B. social isolation C. Refusal to address nutritional needs. D. Low self-esteem C. Refusal to address nutritional needs The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued? A. Lithium (Lithotabs) B. Benzotropine (Cogentin) C. Alprazolam (Xanax) D. Magnesium( Milk of Magnesia) B. Benzotropine A female client requests that her husband be allowed to stay in the room during the admission assessment. When interviewing the client, the RN notes a discrepancy between the clients verbal and nonverbal communication. What action does the RN take? A. Pay close attention and document the nonverbal messages B. Ask the client's husband to interpret the discrepancy C. Ignore the nonverbal behavior and focus on the clients verbal messages D. Integrate the verbal and nonverbal messages and interpret them as one. A. Pay close attention and document the nonverbal messages A male client approaches the RN with an angry expression on his face and raises his voice saying " My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I'm going to punch him out!" The RN recognizes that the client is using which defense mechanism? A. Denial B. Projection C. Rationalization D. Splitting B. Projection

A male client with bipolar disorder wo began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN find him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement? A. Report the clients serum lithium level to the HCP B. Encourage the client to suck on hard candy to relieve the symptoms C. No action is needed since polydipsia is a common side effect D. Tell the client that drinking from the faucet is not allowed. A. Report the clients serum lithium level to the HCP The Rn is teaching a client about the initiation of the prescribed abstinence therapy using disulfiram (Antabuse). What information should the client acknowledge understanding? A. Completely abstain form heroin or cocaine use B. Remain alcohol free for 12 hours prior to the first dose. C. Attend monthly meetings of alcoholics anonymous D. Admit to others that he is a substance user B. Remain alcohol free for 12 hours prior to the first dose. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? A. Have you lost interest in things that you used to enjoy B. Is your ability to think or concentrate decreased? C. How many continuous hours do you sleep at night D. Do you hear sounds or voices that others do not hear? D. Do you hear sounds or voices that others do not hear? During an annual physical by the occupational RN working in a corporate clinic, a male employee tells the RN that is high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered "getting even" with other drivers. How should the RN respond? A. "Anger is contagious and could result in major confrontation" B. "Try not to let your anger cause you to act impulsively" C. "Expressing your anger to a stranger could result in an unsafe situation" D. "It sounds as if there are many situations that make you feel angry" D. "It sounds as if there are many situations that make you feel angry" A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this clients plan of care? A. Encourage substitution of positive thoughts and negative ones B. Establish trust by providing a calm, safe environment C. Progressively expose the client to larger crowds D. Encourage deep breathing when anxiety escalates in a crowd B. Establish trust by providing a calm, safe environment

Which nursing actions are likely to help promote the self-esteem of a male client with modern depression? A. Ask the client what his long term care goals B. Discuss the challenges of his medical condition C. Include the client in determining treatment protocol. D. Encourage the client to engage in recreational therapy. E. Provide opportunities for the client to discuss his concerns A. Ask the client what his long term care goals D. Encourage the client to engage in recreational therapy. E. Provide opportunities for the client to discuss his concerns A male client is admitted to the psychiatric unit for the recurrent negative symptoms of chronic schizophrenia and medication adjustment of Risperidone (Risperdal). When the client walks to to the nurses station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the RN take? A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril) B. Offer the client a prescribed physical therapy hot pack for musclespasms. C. Direct client occupational therapy to distract him form somatic complaints D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia A mental health worker is caring for a client with escalating aggressive behavior. Which action by the MHW warrant immediate intervention by the RN? A. Is attempting to physically restrain the patient B. Tells the client to go to the quiet area of the unit C. Is using a loid voice to talk to the client D. remains at a distance of 4 feet from the client A. Is attempting to physically restrain the patient A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When the PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the RN implement first? A. Transport of the client to the seclusion room B. Quietly approach the client with additional staff members C. Take other clients in the area to the client lounge D. Administer medication to chemically restrain the patient C. Take other clients in the area to the client lounge A client is admitted to the mental health unit and reports taking extra antianxiety medication because "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? A. "What should I do? Nothing seems to help" B. "I have been so tired lately and needed help to sleep" C. "I really think that I don't need to be here." D. "I don't want to walk. Nothing matters anymore"

D. "I don't want to walk. Nothing matters anymore" A male hospital employee is pushed out the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatrist RN. Which factor in the pushed employee's history is most related to the reaction that occurred? A. Is worried about losing his job to a women B. Tortured animals as a child. C. Was physically abused by his mother D. Hates to be touched by anyone C. Was physically abused by his mother The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, "I don't need to be here." and tells the RN that she believes the television talks to her. The RN should document these assessment findings in which section of the mental status exam? A. Level of concentration B. Insight and judgement C. Remote memory D. Mood and affect B. Insight and judgement A client is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the RN "I feel like I'm going to die" Which nursing problem should the RN include in this clients plan of care? A. Mood disturbance B. Moderate anxiety C. Altered thoughts D. Social isolation B. Moderate anxiety A female client who is wearing dirty clothes and has foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the RN to take? A. Offer the client a safe place to relax before interviewing her. B. Ask the client to describe why she is being stalked. C. Recommend the client talk with a social worker D. Assure the client that the HCP will see her today A. Offer the client a safe place to relax before interviewing her. At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention?

• uterine cramping
• abdominal tenderness
• systolic bp <100 mmHg
• intermittent nausea - Ans - A. Uterine cramping

A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client?

• the client may have a bladder or kidney infection
• bladder capacity increases during pregnancy
• during pregnancy a woman is especially sensitive to body functions
• the growing uterus is putting pressure on the bladder - Ans - D. The growing uterus is putting pressure on the bladder. The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first?
• check the infant's ABGs
• notify the pediatrician of the infants VS
• assess the infant's blood glucose level
• encourage the infant to take the breast or sugar water - Ans - C. Assess the infant's blood glucose level An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing intervention?
• evaluate the blood pH
• begin humidified oxygen via hood
• stimulate infant crying
• place the infant under a radiant warmer - Ans - B. Begin humidified oxygen via hood When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?
• quiet the infant before counting the HR
• listen at the apex of the heart
• count the HR for at least one full minute
• palpate the umbilical cord - Ans - C. Count the heart rate for at least one full minute The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make?
• inform the mother that the injection was prescribed by the HCP
• explore the mother's concerns about the infant receiving an injection of vitamin K
• explain that vitamin K is required by state law and compliance is mandatory
• remind the mother that all babies receive this shot and it is relatively painless - Ans - B. Explore the mother's concerns about the infant receiving an injection of vitamin K The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan?
• avoid alcohol bc it is excreted in breast milk
• avoid spicy foods to prevent infant colic
• increase caloric intake by approx. 500 calories/day

• double prenatal milk intake to improve vitamin D transfer to the infant - Ans - A. Avoid alcohol because it is excreted in breast milk Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?
• brighten the lighting so the mother can view the infant
• complete the newborn assessment as quickly as possible
• provide positive reinforcement for maternal care of infant
• encourage early initiation of breast or formula feeding - Ans - D. Encourage early initiation of breast of formula feeding A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur?
• it depends on what the causative factors are for a CHD
• we don't really know what or when CHDs occur
• they usually occur in the first trimester of pregnancy
• the heart develops in the third to fifth weeks after conception - Ans - D. The heart develops in the third to fifth weeks after conception A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide?
• many women imagine what their baby is like by interpreting fetal movements
• the fetus in utero is capable of hearing and does respond to the mothers voice
• the HCP should address her concerns about her baby hearing function
• the interaction b/w the mothers voice and the fetus's response ensures bonding - Ans - B. The fetus in utero is capable of hearing and does respond to the mother's voice A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide?
• this is a demonstration of the fetus acoustical reflux
• the fetus can respond to sound by 24 weeks
• it is a coincidence the fetus responded at the same time
• report behavior to HCP - Ans - B. The fetus can respond to sound by 24-weeks gestation A woman whose pregnancy is confirmed asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide?
• excretes prolactin and insulin
• produces nutrients for fetal nutrition
• secretes both estrogen and progesterone
• forms a protective, impenetrable barrier - Ans - C. Secretes both estrogen and progesterone

Which cardiovascular findings should the nurse assess further in a client who is at 20- weeks gestation?

• decrease in pulse rate
• decrease in BP
• increase in heart sounds
• increase in RBC production - Ans - A. Decrease in pulse rate A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and is not sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results?
• having an irregular menstrual cycle
• using an anticonvulsant for epilepsy
• taking the pregnancy test too early
• being under too much stress at work - Ans - B. Using an anticonvulsant for epilepsy Which gastrointestinal findings should the nurse be concerned about in a client at 28- weeks gestation?
• pica
• pyrosis
• ptyalism
• decreased peristalsis - Ans - A. PICA During a preconception counseling session for women trying to get pregnant in 3 to 6 months, what information should the nurse provide?
• discontinue all forms of contraception
• make sure to include adequate folic acid in the diet
• lose weight so more is gained during pregnancy
• continue to take any meds that are taken regularly - Ans - B. Make sure to include adequate folic acid in the diet Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy?
• protein helps the fetus grow while I'm pregnant
• gestational diabetes is prevented by eating protein
• anemia is averted by consuming enough protein
• my baby will develop strong teeth after he is born - Ans - A. "Protein helps the fetus grow while I am pregnant." A client in her second trimester of pregnancy asks if it is safe for her to have a drink with dinner. How should the nurse respond to the client?
• during second trimester beer can be consumed without harm to the fetus
• wine can be consumed several times a week after the first trimeter
• only one drink with the evening meal is not harmful to the fetus

• abstinence is strongly recommended throughout the pregnancy - Ans - D. Abstinence is strongly recommended throughout the pregnancy A female client who wants to deliver at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide?
• birth in the home setting is the preference for a using a midwife for delivery
• the pregnancy should progress normally and be considered low risk
• natural child birth without analgesia is used to manage pain during labor
• an obstetrician should also follow the client during pregnancy - Ans - B. The pregnancy should progress normally and be considered low risk When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth?
• only the woman and her midwife should be present during the delivery
• the woman should live no more than 15 min from the hospital
• the woman's extended family should be allowed to attend the home birth
• medical backup should be available quickly in case of complications - Ans - D. Medical backup should be available quickly in case of complications The nurse is discussing the stages of labor with a group of women in the last month of pregnancy and provides examples of different positional techniques used during the second stage of labor. Which position should the nurse address the best advantage of gravity during delivery?
• walking
• squatting
• kneeling
• lithotomy - Ans - B. Squatting A client in the first stage of labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?
• notify the HCP
• help her breathe into a paper bag
• administer oxygen via nasal cannula
• tell the client to show her breathing - Ans - B. Help her breathe into a paper bag A client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal disturbance, what action should the nurse take?
• escort the client to the bathroom
• offer the client a bed pan
• perform a nitrazine test
• clean the perineal area - Ans - C. Perform a nitrazine test

A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to 70 mmHg at the peak. Based on this information, what action should the nurse implement?

• notify HCP
• bring delivery table to room
• prepare to administer oxytocin
• document findings - Ans - D. Document the findings in the client record A multiparous client has been in labor for 8 hours when her membranes rupture. What action should the nurse implement first?
• prepare client for imminent birth
• asses FHR and pattern
• document characteristics of fluid
• notify HCP - Ans - B. Assess the fetal heart rate and pattern Which action should the nurse implement caring for a newborn immediately after birth?
• keep newborn airway clear
• foster parent-newborn attachment
• administer eye prophylaxis and vitamin k
• dry the newborn and wrapping in blanket - Ans - A. Keep the newborn's airway clear During an assessment of a multiparous client who delivered an 8 lb 7 oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next?
• perform fundal massage
• assess bp
• notify the HCP
• encourage the client to void - Ans - A. Perform fundal massage The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply) - Ans - B. Chest breathing with nasal flaring C. Diaphragmatic with chest retraction F. Grunting heard with a stethoscope What action should the nurse implement when caring for a newborn receiving phototherapy?
• reposition every 6 hr
• place eye shield over eyes
• limit intake of formula
• apply oil based lotion to skin - Ans - B. Place an eyeshield over the eyes Which finding indicates to the nurse that a 4 day old infant is receiving adequate breast milk?
• gain 1-2 oz per week

• saturates 6-8 diapers per day
• rests for 6 hours b/w feedings
• defecates at least once per 24 hours - Ans - B. Saturates 6 to 8 diapers per day The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand?
• plan for a possible cesarean birth
• arrange for home uterine monitoring
• make arrangements for care at home
• report uterine cramping or low backache - Ans - D. Report uterine cramping or low backache A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client?
• contraction stress test
• internal fetal monitoring
• abdominal ultrasound
• lecithin-sphingmyelin ratio - Ans - C. Abdominal ultrasound The nurse is planning for the care of a 30 year old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcome?
• mothers age
• amount of insulin required prenatally
• degree of glycemic control during pregnancy
• number of years since diabetes was diagnosed - Ans - C. Degree of glycemic control during pregnancy A client with asthma who is 8 hours post delivery is experiencing postpartum hemorrhage. Which prescription should the nurse administer?
• oxytocin
• ibuprofen
• fentanyl
• hemabate - Ans - A. Oxytocin (Pitocin) The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32 weeks gestation who has severe preeclampsia with pulmonary edema. What action should the nurse implement?
• assess fetal response to procedure
• note any complaint of sudden chest pain
• monitor for premature ventricular contractions
• observe for maternal bp changes - Ans - C. Monitor for premature ventricular contractions

A client at 28 weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage?

• vaginal bleeding
• complaints of abdominal pain
• changes is FHR patterns
• alteration in maternal bp - Ans - C. Changes in fetal heart rate patterns A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding would require the nurse to take action?
• labor has progressed at 1 cm/hr dilation
• intensity of contractions is 130 mmHg
• contractions are lasting 60-80 seconds
• oxytocin is infusing at a rate of 30 mU/min - Ans - B. Intensity of contractions is 130 mmHg A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement?
• administer 10 L of oxytocin via face mask
• give the HCP a status report
• place client in knee-chest position
• wrap the cord with glaze soaked in saline - Ans - C. Place the client in the knee-chest position The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion?
• client needs to void
• amniotic membranes rupture
• uterine contractions occur every 8-10 min
• FHR is 180 bpm w/o variability - Ans - D. The fetal heart rate is 180 bpm without variability The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage?
• primigravida who had spontaneous birth of preterm twins
• multigravida who delivered an 8 lb 2 oz infant after 8 hour labor
• multiparous client receiving magnesium sulfate during induction for severe preeclampsia
• primiparous client who had an emergency cesarean birth due to fetal distress - Ans - C. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal?
• play soft music and talk to soothe the infant

• administer chloral hydrate for sedation
• feed every 4-6 hours to allow extra rest
• swaddle the infant snugly and hold tight - Ans - D. Swaddle the infant snugly and hold tightly The father of a newborn tells the nurse, "My son just died." how should the nurse respond?
• I am sorry for your loss
• there is an angel in heaven
• I understand how you feel
• you can have other children - Ans - A. "I am sorry for your loss." A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action?
• assess newborn reflexes for signs of neuro impairment
• leave infant in the room with the mother to foster attachment
• obtain serum glucose levels frequently while observing closely for signs of hypoglycemia
• perform a gestational age assessment to determine if the infant is large for gestational age - Ans - C. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the face and upper back of the newborn. What information should the nurse provide?
• further assessment is indicated
• petechiae occurs with forceps delivery
• an increased blood volume causes broken blood vessels
• pinpoint spots are benign and disappear within 48 hours - Ans - D. The pinpoint spots are benign and disappear within 48 hours Which finding for a client in labor at 41 weeks gestation requires additional assessment by the nurse?
• cervix dilated 2 cm and 50% effaced
• score of 8 on the biophysical profile
• fetal heart rate of 116 bpm
• one fetal movement noted in an hour - Ans - D. One fetal movement noted in an hour A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which Immunizations should the nurse administer at this time? (Select all that apply) - Ans - A. Tetanus C. Diphtheria E. Hepatitis B

A gravid client develops maternal hypotension following regional anesthesia. What interventions should the nurse implement? (Select all that apply) - Ans - A. Administer oxygen B. Increase IV fluids E. Place the client in a lateral position F. Monitor fetal status A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client?

• amniocentesis
• ultrasonography
• chorionic villus sampling
• maternal serum alpha-fetoprotein - Ans - B. Ultrasonography The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide?
• kidneys and renal function are not fully developed
• warmth promotes sleep so the infant will grow quickly
• a large body surface area favors heat loss to the environment
• thick layer of subcut fat is inadequate for insulation - Ans - C. A large body surface area favors heat loss to the environment The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take?
• ask mother why she won't look at infant
• observe the mother for other attachment behaviors
• examine the newborns eyes for ability to focus
• recognize this as a common reaction in new mothers - Ans - B. Observe the mother for other attachment behaviors The nurse notes an irregular bluish hue on the sacral area of a 1 day old Hispanic infant. How should the nurse document this finding?
• acrocyanosis
• mongolian spots
• erythema toxicum
• harlequin sign - Ans - B. Mongolian spots An infant with hyperbilirubinaemia is receiving phototherapy. What intervention should the nurse implement?
• maintain NPO
• monitor temp
• apply skin lotion as prescribed
• change t-shirt every 3 hours - Ans - B. Monitor temperature

A neonate who is receiving an exchange transfusion for hemolytic disease develops respiratory distress, tahcycardia, and a cutaneous rash. What nursing intervention should be implemented first?

• inform HCP
• stop the transfusion
• administer calcium gluconate
• monitor VS electronically - Ans - B. Stop the transfusion The nurse assesses a high risk neonate under a radiant warmer who has an umbilical catheter and identifies that the neonate's feet are blanched. What nursing action should be implemented?
• place socks on infant
• elevate feet 15 degrees
• wrap feet loosely in prewired blanket
• report findings to HCP - Ans - D. Report findings to the healthcare provider What nursing action should be implemented when intermittently gavage-feeding a preterm infant?
• allow formula to flow by gravity
• avoid letting infant suck on tube
• insert feeding tube through nares
• apply steady pressure to syringe - Ans - A. Allow formula to flow by gravity Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate?
• tactile stimulation
• commercial warm packs
• skin to skin contact with parent
• oral sucrose and nonnutritive sucking - Ans - D. Oral sucrose and nonnutritive sucking The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37 weeks gestation. What nursing action should be implemented first?
• provide tactile stimulation
• administer flow by 100% oxygen
• assess the functionality of the monitoring device
• evaluate the newborns color and respirations - Ans - D. Evaluate the newborn's color and respirations What action should the nurse implement with the family when an infant is born with anencephaly?
• ensure that measures to facilitate the attachment process are offered
• prepare the family to explore ways to cope with the imminent death of the infant
• inform family about multiple corrective surgical procedures that will be needed
• provide emotional support to facilitate the consideration of fetal organ donation - Ans - B. Prepare the family to explore ways to cope with the imminent death of the infant

A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time?

• ask to meed with the client and infant w/o family members present
• do a brief assessment for only the infant while family members are present
• observe interactions of family members with the newborn and each other
• reschedule the visit so mother and infant can be assessed privately - Ans - C. Observe interactions of family members with the newborn and each other A client at 39 weeks gestation is admitted to the labor and delivery unit. Her obstetrical history includes 3 live births at 39 weeks, 34 weeks, and 35 weeks. Using GTPAL, what is the most accurate summary of her history?
• 3 - 1 - 1 - 1 - 3
• 4 - 1 - 2 - 0 - 3
• 3 - 0 - 3 - 0 - 3
• 4 - 3 - 1 - 0 - 2 - Ans - B. 4- 1 - 2 - 0 - 3 A client delivers her first infant and asks the nurse if her skin changes from pregnancy are permanent. Which change should the nurse tell the client will remain after pregnancy?
• prutitus
• chloasma
• vascular spiders
• striae gravidarum - Ans - D. Striae gravidarum The nurse administers meperidine (Demerol) 25 mg IV push to a laboring client, who delivers the infant 90 minutes later. What medication should the nurse anticipate administering to the infant?
• naloxone (narcan)
• nalbuphine
• fentanyl
• promethazine - Ans - A. Naloxone (Narcan) A client in labor receives an epidural block. What intervention should the nurse implement first?
• encourage oral fluids
• assess contractions
• monitor bp
• obtain radial pulse - Ans - C. Monitor blood pressure A client is experiencing "back" labor and complains of intense pain in the lower lumbar- sacral area. What action should the nurse implement?
• perform effleurage on abdomen
• encourage pant blow breathing techniques
• apply counter pressure against the sacrum

• assist the client in guided imagery - Ans - C. Apply counter pressure against the sacrum A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement?
• emphasize that food and fluid intake should stop
• tell the woman to stay home until her membranes rupture
• ask the client to describe why she thinks she is in labor
• suggest to client to come to hospital for labor eval - Ans - C. Ask the client to describe why she thinks she is in labor A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give?
• apply ice to breasts
• wear loose fitting bra
• run warm water on breasts during shower
• express small amounts of milk from breasts - Ans - A. Apply ice to the breasts Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day?
• request help with ambulation and perineal care
• exhibit interest in learning more about infant care
• sleep most of the when the baby is not present
• be very excited and talkative about the birth experience - Ans - B. Exhibit interest in learning more about infant care A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement?
• avoid pumping breasts
• continue breastfeeding every 2 hours
• skip feeding to rest breasts
• decrease fluid intake for at least 24 hours - Ans - B. Continue breastfeeding every 2 hours The nurse is giving discharge instructions for a client following a suction for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide?
• oral contraceptives prevent reoccurrence of molar pregnancy
• pregnancy within 1 year decreases the chances of a future successful pregnancy
• diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy
• molar reoccurrences are higher if conception occurs within 1 year after an initial mutation - Ans - C. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy

The nurse is assessing a 12 hour old infant with a maternal history of frequent alcohol consumption during pregnancy. Which finding should the nurse report that is most suggestive of fetal alcohol syndrome (FAS)?

• an extra digit on the left hand
• corneal clouding
• flat nasal bridge
• asymmetrical bulging fontanels - Ans - C. Flat nasal bridge Which client finding should the nurse document as a positive sign of pregnancy?
• last menstrual cycle occurred 2 months ago
• urine sample with a positive pregnancy test
• presence of Braxton hicks contractions
• fetal heart tone heard with a doppler - Ans - D. Fetal heart tones (FHT) heard with a doppler A primigravida at 12 weeks gestation tells the nurse that she does not like dairy products. Which food should the nurse recommend to increase the client's calcium intake?
• canned clams
• fresh apricots
• canned sardines
• spaghetti with meat sauce - Ans - C. Canned sardines A multiparous client is experiencing bleeding 2 hours after a vaginal delivery. What action should the nurse implement next?
• determine the firmness of the fundus
• give oxytocin IV
• inform HCP for the bleeding
• assess VS for indications of shock - Ans - A. Determine the firmness of the fundus When assessing the integument of a 24 hour old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next?
• notify HCP immediately
• move newborn to isolation nursery
• document finding as erythema toxicum
• obtain culture from one of the vesicles - Ans - C. Document the finding as erythema toxicum The nurse is teaching a primigravida at 10 weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care
• risk for neonatal cerebral palsy increases with folic acid deficiencies during pregnancy
• folic acid can significantly reduce the incidence of mental retardation
• adequate folic acid during embryogenesis reduces the incidence of neural tube defects

• the incidence of congenital heart defects is related the folic acid intake deficiencies - Ans - C. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects The nurse tells a client in her first trimester that she should increase her daily intake of calcium to 1200 mg during pregnancy. The client responds, "I don't like milk." What dietary adjustments should the nurse recommend?
• increase organ meats in the diet
• eat more green, leafy vegetables
• add molasses and whole-grain breads to the diet
• choose more fresh citrus and other fruits daily - Ans - B. Eat more green, leafy vegetables A client at 35 weeks gestation visits the clinic for a prenatal check up. Which complaint by the client warrants further assessment by the nurse?
• periodic abdominal pain
• ankle edema in the afternoon
• backache with prolonged standing
• shortness of breath when climbing stairs - Ans - A. Periodic abdominal pain A client at 28 weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client?
• not necessary to keep such a close eye on weight gain
• try to exercise more bc too much weight has been gained
• increase calories in you diet to gain more weight per week
• the weight gain is acceptable for the number of weeks pregnant - Ans - D. The weight gain is acceptable for the number of weeks pregnant A multigravida client at 35 weeks gestation is diagnosed with pregnancy induced hypertension. Which symptom should the nurse instruct the client to report immediately?
• backache
• constipation
• blurred vision
• increased urine output - Ans - C. Blurred vision A 36 week gestation client with pregnancy induced hypertension is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider?
• BP of 100/60 mmHg
• FHR of 120-125 bpm contractions occurring every 30 minutes
• respiratory rate of 11 breaths/min - Ans - D. Respiratory rate of 11 breaths/minute Which procedure evaluates the effect of fetal movement on fetal heart activity?
• sonography

• contraction test
• biophysical profile
• non-stress test (NST) - Ans - D. Non-stress test (NST) The nurse notes a pattern of the fetal of the fetal heart rate decreasing after each contraction. What action should the nurse implement?
• give 10 liters of oxygen via face mask
• prepare for an emergency c-section
• continue to monitor FHR pattern
• obtain an oral maternal temp - Ans - A. Give 10 liters of oxygen via face mask A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment, the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement?
• document the color of the lochia
• observe maternal VS
• assist the client to the bathroom
• notify the HCP - Ans - D. Assist the client to the bathroom A newborn infant who is 24 hours old is on a 4 hour feeding schedule of formula. To meet daily caloric need, how many ounces are recommended at each feeding?
• 2 oz
• 4 oz
• 1.5 oz
• 3.5 oz - Ans - D. 3.5 ounces A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to give?
• dont be sad. you'll need to be strong to care for your healthy baby
• do you want to go to the nursery and see you baby
• I am sorry for you loss. do you want to talk about it
• it is always sad to lose a baby. would you like me to call your minister - Ans - C. "I am sorry for your loss. Do you want to talk about it?" A client who is at 24 weeks gestation presents to the emergency department holding her arm and complaining of pain. The client reports she fell down the stairs. Which observation should alert the nurse to a possible battering situation?
• the woman and her partner are having a loud and hostile argument
• other parts of her body have injuries that are in different stages of healing
• examination reveals a fracture to the right humorous and multiple bruises - Ans - C. Other parts of her body have injuries that are in different stages of healing What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta?
• maternal bradycardia

• hard, board-like abdomen
• decrease in fundal height
• decrease in abdominal pain - Ans - B. Hard, board like abdomen Which action is most important for the nurse to implement for a client at 36 weeks gestation with vaginal bleeding?
• monitor uterine contractions
• apply disposable pads under client
• determine FHR and maternal VS
• obtain blood samples for hemoglobin hematocrit levels - Ans - C. Determine fetal heart rate and maternal vital signs A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement?
• obtain precipitous delivery tray
• visualize the perineum for bulging
• call HCP for stat delivery
• instruct clients partner to stay for delivery - Ans - B. Visualize the perineum for bulging Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routinestanding order for methylergonovine maleate (Methergine)?
• pregnancy induced hypertension
• placenta previa
• gestational diabetes
• postpartum hemorrhage - Ans - A. Pregnancy induced hypertension While monitoring a client in active labor, the nurse observes a pattern of a 15-beat increases in the fetal heart rate that lasts 15 to 20 seconds and returns to baseline. Which information should the nurse report during shift change?
• fetal well being with labor progression
• signs of utter-placental insufficiency
• episodes of fetal head compression
• occurrences of cord compression - Ans - A. Fetal well being with labor progression Which nursing intervention is the priority during the fourth stage of labor?
• promote bonding
• assess for hemorrhage
• provide comfort measures
• monitor uterine contractions - Ans - B. Assess for hemorrhage The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occuring with the peak of each contraction. What action should the nurse implement?
• notify HCP of fetal status
• give oxygen at 10 L per nasal cannula

• increase flow rate of IV fluids - Ans - C. Place the client in a side-lying position What information should the nurse include about perineal self-care for a client who is 24 hours post delivery?
• use cool water to decrease swelling of the perineum
• perineal care should be done at least twice per day
• reapply ice packs to perineum after each voiding
• spray warm water from front to back using a squeeze bottle - Ans - D. Spray with warm water from front to back using a squeeze bottle Which client should the nurse report to the healthcare provider as needing a prescription for Rh Immune Globulin (RhoGAM)?
• woman whose blood group is AB Rh-positive
• newborn with rising serum bilirubin level
• newborn whose Coombs test is negative
• primigravida mother who is Rh-negative - Ans - D. Primigravida mother who is Rh- negative A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4000 grams. The client's funud is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the fundus, the fundus remains difficult to locate and the rubra lochia remains heavy. What action should the nurse implement next?
• recheck the clients VS
• notify HCP
• insert an indwelling urinary catheter
• massage the funds in 30 minutes - Ans - B. Notify the healthcare provider A client comes in to the clinic for her six week postpartum check up and complains that her left breast is eythematous and painful. The client asks, "Can I still breastfeed my baby?" What is the best response for the nurse to provide?
• advise to stop breastfeeding until the infection clears
• inform the client to continue breastfeeding
• begin all feedings with the infected breast
• tell the client to pump then discard the milk from the affected breast - Ans - B. Inform the client to continue breastfeeding While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document?
• molding
• cephalohematoma
• caput succedaneum
• bulging fontanel - Ans - B. Cephalohematoma A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first?

• ventilate with ambu bag
• perform nasal and airway suctioning
• administer supplemental oxygen
• gently rub infants feet or back - Ans - D. Gently rub the infant's feet or back The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement?
• institute contact precautions
• obtain rectal temperature
• assess for abdominal distention
• decrease the amount of the feeding - Ans - C. Assess for abdominal distention While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross the suture lines. How should the nurse document this finding?
• molding
• hemangioma
• cephalohematoma
• caput succedaneum - Ans - D. Caput succedaneum What action should the nurse implement to prevent conductive heat loss in a newborn?
• place the infant under a radiant warming system
• put a blanket on the scale when weighing the infant
• dry the newborn with warmed blanket
• position crib away from windows - Ans - B. Put a blanket on the scale when weighing the infant Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma?
• silver nitrate
• erythromycin
• ceftriaxone
• vitamin k - Ans - D. Vitamin K (AquaMEPHYTON) A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider?
• bruising
• oral intake
• hemoglobin
• bilirubin - Ans - D. Bilirubin The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (select all that apply) - Ans - B. Chest breathing with nasal flaring C. Diaphragmatic with chest retraction F. Grunting heard with stethoscope