HESI Patient Review Susan Wilson (2) – Flashcards
Unlock all answers in this set
Unlock answersquestion
Based on Susan's assessment data and history, you identify which of the following as a priority nursing diagnosis for Susan at this time?
answer
Deficient fluid volume related to inadequate intake of fluids.
question
With regard to rupture of membranes, which questions are important?
answer
A. "What time did your 'water break'?" C. "What was the color of the fluid?"
question
Based on your assessment, you determine that the fetus is in a/an ____ presentation
answer
Cephalic/vertex/occiput
question
Based on your assessment, you position the ultrasound transducer on Susan's abdomen at the:
answer
right lower quadrant
question
Fetal heart rate increases can be associated with a variety of factors. These include:
answer
the mother receiving the drug Brethine (terbutaline) The mother receiving the drug Yutopar (ritodrine) Maternal fever or infection Fetal anemia Also, Maternal Dehydration Maternal Hyperthyroidism
question
Susan has been monitored for 15 min. Which of the following actions on your part is indicated?
answer
Continue to monitor the fetal heart rate
question
To measure the frequency contractions you examine a 10-minute strip and:
answer
determine the time from the beginning of one contraction to the beginning of the next
question
You perform a vaginal exam to check for shortening and thinning of cervix. This is called
answer
effacement / effacing
question
You also determine that the fetus is at zero station....Your response is based on the knowledge that zero station means that:
answer
the baby's presenting part is at the level of the mother's ischial spines
question
zero station means that
answer
the baby's presenting part is at the level of the mother's ischial spines
question
Based on your assessment of Susan (3 cm dilated, 80% effaced, fetus at zero station) and your interpretation of her data, you determine that she is now in which stage of labor?
answer
Stage one (until cervix is fully dilated)
question
Susan decides to rest in bed. Which of the following positions are acceptable?
answer
right lateral left lateral
question
You remind Susan that it is important for her to try to urinate every two hours. The rationale for this is that a distended bladder can:
answer
interfere with fetal descent cause difficulty in voiding after delivery increase the pain associated with uterine contractions
question
In response to the order for Stradol (butorphanol tartrate), which of the following is indicated?
answer
Administer the Stradol as ordered
question
You determine that Susan is now in which phase of stage one labor?
answer
Active phase
question
A number of factors may affect the length of time a woman's labor will last. These include:
answer
maternal activity and position the parity of the mother fetal position and size
question
What is the best nursing action to take at this time?
answer
Suggest that John take a short break and have another family member coach Susan temporarily
question
You identify this as a/an________ deceleration
answer
Early
question
Early deceleration is caused by
answer
compression of the head
question
The anesthesiologist performs the epidural procedure and Susan begins to feel almost immediate relief from painful contractions. You know that a priority nursing intervention is to:
answer
frequently monitor Susan's blood pressure for hypotension
question
Because Susan had an epidural she has not exhibited some of the signs/behaviors that otherwise characterize the transition phase. These include:
answer
amnesia between contractions diaphoresis reluctance to be touched physical shaking
question
You examine a recent strip from the fetal monitor. The abnormal fetal heart rate pattern you observe is interpreted as a ___ deceleration
answer
late
question
In response to the occurrence of a late deceleration, which of the following actions should be carried out FIRST?
answer
Turn on left side
question
At this point, which of the following would be appropriate advice for Susan?
answer
Let me help you assume the knee-chest position if the urge to push is uncomfortable Don't push yet. Pant through contractions if you need to
question
Based on your assessment of this male neonate, you determine that his 1-minute Apgar score is
answer
9
question
As Susan and John admire their new son, you notice a sudden gush of blood from Susan's perineum and an apparent lengthening of the umbilical cord. You recognize that these signs indicate
answer
separation of the placenta
question
After the placenta has been expelled, Dr. Cooper asks you to start a Pitocin (oxytocin) drip, at a concentration of 10 units in 1000 mL Lactated Ringer's. You know that Pitocin (oxytocin) is administered at this time to:
answer
stimulate uterine contractions
question
Susan's pitocin drip is infusing with an infusion pump at a rate of 60 mL per hour ___ milliunit of drug is infusing per minute
answer
10
question
The correct term for the cone shape of a vaginally-delivered infant's head is
answer
molded
question
The newborn is prone to hypothermia because:
answer
Newborns have a large body surface to body weight ratio Blood vessels are close to the skin surface There is minimal subcutaneous fat
question
John asks "Why does he need to have a shot already?" Your explanation to John is based on the knowledge that:
answer
Vitamin K is needed to prevent bleeding problems in the early neonatal period Newborns are unable to synthesize vitamin K due to absence of intestinal flora at birth
question
apply erythromycin ophthalmic ointment to the newborn's eyes to:
answer
protect the infant from gonorrheal or chlamydial infection
question
Which of the following assessments would be considered normal at this time?
answer
Fundus is firm, at the midline, and two fingerbreadths below the umbilicus
question
At the next assessment, Susan's uterus is midline. The fundus feel boggy at one fingerbreadth below the umbilicus, what should you do first?
answer
Massage Susan's uterus
question
the vaginal discharge that occurs during the postpartum period (puerperium), which and consists of blood, tissue, and mucous, is called
answer
lochia
question
Which of the following is the expected progression of lochial changes during the puerperium?
answer
Rubra, serosa, alba
question
The term that describes the expected gradual reduction in size of the uterus after delivery as it contracts to return to normal size is
answer
involution
question
When John describes to you the advantages he sees in breastfeeding, you agree when he says:
answer
breastfed babies experience fewer respiratory illnesses than formula-fed babies breastfed babies are not likely to have allergies to their mother's breast milk breastfeeding is more economical
question
Which of the following statements would indicate that Susan understands correct information on breastfeeding?
answer
To break suction, I will insert my finger into the corner of Jason's mouth before removing him from the breast When Jason has a growth spurt, he will want to nurse more often which will increase my milk supply
question
After delivery, a declining level of estrogen allows for rising levels of the hormone responsible for milk production. You know that the hormone that stimulates milk production is
answer
prolactin
question
The hormone responsible for milk ejection is
answer
oxytocin
question
Susan expresses concern about engorged breasts. Some of her friends have told her that it's painful. You discuss engorgement with Susan and suggest:
answer
to help avoid engorgement, feed Jason at least every 2-3 hours around the clock to help avoid engorgement, make sure Jason is positioned for good milk transfer during feedings if engorgement occurs, express some milk prior to feedings to facilitate latching-on
