(Test Bank) Hesi Rn Exit Exam | April 2023 V3 ( Version 3 ) New Full Exam Questions And Answers Guaranteed A+

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HESI RN EXIT EXAM-EXAM PACK COMBINED FROM 2019/2020/2021 ACTUAL EXAMS-BEST FOR 2022 EXIT EXAM REVIEW HESI EXIT COMPREHENSIVE PROCTORED EXAM 1. Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? a.States having difficulty with color perception b.Presents with opacity of the lens upon assessment c.Complains of seeing a cobweb-type structure in the visual field d.Reports the need to use a magnifying glass to see small print Rationale: Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expected signs and symptoms of cataracts but do not need immediate attention. 2. When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? a.Decrease in cognitive status of the client Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status. 3. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? a.Hyperplasia of the gums, elevated white blood count, weakness Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia. Options A, B, and D state incorrect information for symptoms of leukemia. 4. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? a."Tell me about what you are feeling right now." Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client. 5. A nurse working in the emergency department admits a client with full thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? a.Prepare to assist with maintaining the airway. Rationale: High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway. 6. The nurse walks into the room and observes the client experiencing a tonic- clonic seizure. Which intervention should the nurse implement first? a.Turn the client on the side to aid ventilation. Rationale: Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure and may cause further injury to the client. 7. Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis? a.Provide a low-residue diet. Rationale: A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. 8. A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? a."I will not take my digoxin if my heart rate is higher than 100 beats/min." b."I should weigh myself once a week and report any increases." c."It is important to increase my fluid intake whenever possible." d."I should report an increase of swelling in my feet or ankles." Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure. 9. After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? a.Blood pressure, 159/98 mm Hg Rationale: A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke. 10. When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? a.Take the vital signs and obtain an O2 saturation level. Rationale: The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data. 11. The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the practical nurse (PN)? a.A client with nausea who needs a nasogastric tube inserted b.A client in hypertensive crisis who needs titration of IV nitroglycerin c.A newly admitted client who needs to have a plan of care established d.A client who is ready for discharge who needs discharge teaching Rationale: The client mentioned in option A has a need for a skill that is within the scope of practice for the PN. Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated. 12. A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) a.Abdominal obesity b.Sedentary lifestyle c.Hispanic or Asian ethnicity d.Increased triglycerides Rationale: Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). 13. Which clinical manifestation in the client with hyperthyroidism is most The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders. Options A, B, and D are all expected findings that should also be reported but are not as critical. a.Apical heart rate of 130 beats/min Rationale: The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders. 14. The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? a.The right pupil dilates after drop instillation. Rationale: Atropine is a mydriatic drug which causes pupil dilation and paralysis in preparation for surgery or examination. 15. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition? a.Levofloxacin b.Acyclovir sodium c.Fluconazole d.Esomeprazole Rationale: The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client. Fluconazole is an antifungal and is used to treat candidiasis in the HIV client. Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease. 16. When assessing a 38-year-old client with tuberculosis who is taking rifampin, which finding would be most important to report to the primary health care provider immediately? a.Orange-colored urine b.Potassium level, 4.9 mEq/L c.Elevated liver enzyme levels d.Blood urea nitrogen (BUN) level, 12 mg/dL. Rationale: Rifampin can cause hepatotoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider. Orange discoloration of the urine is an expected side effect of this medication. The potassium level is normal. A BUN level of 12 mg/dL is within defined parameters. 17. A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? a.Chills, fever, and sore throat Rationale: Cyclophosphamide is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately.18. A nurse is assessing a client with heart failure who has been prescribed digoxin for therapy. Which finding indicates an issue with the medication management? a.Serum potassium level, 2.9 mEq/L Rationale: A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low. 19. Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel? a.This drug could cause heart attack or stroke when taken by clients with certain genetic conditions. Rationale: A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects. 20. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV . Which actions should the nurse expect to implement? (Select all that apply.) a.Complete the National Institute of Health Stroke Scale (NIHSS). b.Assess the client for signs of bleeding during and after the infusion. c.Start t-PA within 6 hours after the onset of stroke symptoms. Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t- PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped 21. Which action by the nurse is consistent with culturally competent care? a.Treating each client the same regardless of race or religion b.Ensuring that all Native American clients have access to a shaman c.Understanding one's own world view in addition to the client’s d.Including the family in the plan of care for older clients Rationale: The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views. Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity. 22. The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? a.Charts some actions in advance of performing them. Rationale: Charting actions prior to implementing them is an example of fraudulent charting, and the graduate nurse should receive further education. 23. Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? a.Pulse oximetry reading of 89% Rationale: An oxygen saturation lower than 90% indicates hypoxia. 24. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? a.Fine crackles b.Wheezes c.Coarse crackles d.Stridor Rationale: Coarse crackles are caused by air passing through airways that are intermittently occluded by mucus. Fine crackles are a series of short-duration, discontinuous, high-pitched sounds. Wheezes are continuous, high-pitched, musical or squeaking- type sounds. Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway. 25. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? a.240 mL of urinary output is produced in 12 hours. Rationale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr. Ammonia odor is an expected finding. Size 14- to 18-French catheters are common sizes used in the adult female. Below the level of the bladder is the correct position for the drainage bag. 26. When blood or blood products are administered, which task can be assigned to the licensed practical nurse (PN)? a.Obtaining vital signs after infusion has begun Rationale: Blood and blood products must be initiated by the registered nurse (RN); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. 27. The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? a.Properly fitted N95 respirator or mask Rationale: The use of personal protective equipment (PPE) for airborne precautions includes a properly pre- fitted N95 respirator or mask. A surgical mask is used for preventing transmission of droplet precautions. 28. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? a.Sodium level, 125 mEq/L Rationale: The normal serum sodium level is 135 to 145 mEq/L. This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. 29. A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? a.Heart palpitations Rationale: Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency. 30. The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? a.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH. Air should first be injected into the NPH vial and then air should be inserted into the regular vial. NPH and regular insulin are compatible, and combining will reduce the number of injections. The insulin is ordered subcutaneously and NPH cannot be given IV . 31. The nurse is caring for a client in the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? a.Obtain a fingerstick blood glucose level. Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform. Options A, C, and D are skills that cannot be delegated to UAP. 32. Which disaster management intervention by the nurse is an example of primary prevention? a.Education of rescue workers in first aid Rationale: Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury. 33. The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) a.Inhalation of powder form b.Handling of infected animals c.Eating undercooked meat from infected animals d.Direct cutaneous contact with the powder Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E) 34. The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? a.Stage III Rationale: The statement above describes a stage III ulcer, which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle. A stage I ulcer includes intact skin with non-blanchable redness of a localized area. A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed. Full- thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer. 35. The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. 1.Drop prescribed number of drops into conjunctival sac. 2.Wash hands and apply clean gloves. 3.Place the dominant hand on the client’s forehead. 4.Ask the client to close the eye gently. B. 2, 3, 1, 4 Rationale: Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (2). Placing the dominant hand on the client’s forehead (3) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (1); asking the client to close the eye gently helps distribute the medication (4). 36. The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is <2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? a.Planning Rationale: Planning allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are part of the care for the client but are not the appropriate actions for formulating the expected outcome. 37. When assessing safety for the older adult, which of the following is of highest priority to the nurse? a.The client reports a history of repeated falls. Rationale: Risk assessment for falls is a critical element in caring for the older adult. Options A, B, and C are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again. 38. While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? a.Ask another nurse to take the phone call. Rationale: Another nurse should be asked to take the phone call, which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. 39. The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? a.American with Disabilities Act of 1990 Rationale: The Americans with Disabilities Act guarantees the client the right to participate in treatment planning. 40. An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? a.Empower the client to share her story of why she is here at the mental health clinic. Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. Option D is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack is argumentative. Option B suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax is likely to increase her anxiety. 41. A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? a."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." b."You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." c."For your safety and well-being, it may be necessary to share some of our conversations with the health care team." d."I am legally required to document all of our conversations in the electronic medical record." Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy. HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue. Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue. Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client. 42. Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)? a.Reorient the client to surroundings. b.Assess blood pressure every 15 minutes. c.Determine if muscle soreness is present. d.Maintain a patent airway. Rationale: The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway. Clients may be confused after ECT, but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority. Muscle soreness is an expected finding after ECT. 43. A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? a.Administer an antianxiety medication PRN. b.Assess the client's vital signs. c.Notify the primary health care provider. d.Determine coping mechanisms used in the past. Rationale: Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the client and rule out physiologic causes. Nonpharmacologic measures should be taken first. Options C and D may be considered but are not as high priority as the initial physiologic assessment. 44. The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? a.High level of anxiety present b.History of previous suicide attempt c.Family history of depression d.Self-care deficit is noted Rationale: A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan. Options A, C, and D may also be risk factors but are not as significant as a history of previous attempts. 45. A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important? a.Administer a dose of benztropine mesylate PRN. b.Determine if the client has increased photosensitivity. c.Provide comfort measures for sore muscles. d.Assess the client for visual and auditory hallucinations. Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with chlorpromazine. It is most important for the nurse to administer an anticholinergic such as benztropine mesylate to reverse these effects. Options B, C, and D may be appropriate interventions but are not as urgent as option A. 46. A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? a.Two-month-old who is unable to roll from back to abdomen b.Ten-month-old who cannot sit without support c.Nine-month-old who cries when his mother leaves the room d.Eight-month-old who has not yet begun to speak words Rationale: As a developmental milestone, infants should sit unsupported by 8 months. The milestone of rolling over is achieved at 5 to 6 months for most infants. Stranger anxiety is common from 7 to 9 months. Speaking a few words is expected at about 12 months. 47. Which vaccination should the nurse administer to a newborn? a.Hepatitis B b.Human papilloma virus (HPV) c.Varicella d.Meningococcal vaccine Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge. HPV is not recommended until adolescence. Varicella immunization begins at 12 months. Meningococcal vaccine is administered beginning at 2 years. 48. Which vital sign in a pediatric client is most important to report to the primary health care provider? a.Newborn with a heart rate of 140 beats/min b.Three-year-old with a respiratory rate of 28 breaths/min c.Six-year-old with a heart rate of 130 beats/min d.Twelve-year-old with a respiratory rate of 16 breaths/min Rationale: The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min. Options A, B, and D are all within normal range for those ages. 49. The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? a.0.5 mL b.0.5 mL c.5 mL d.9 mL Rationale: 15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 mL = 9 mL 50. The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 mL. What is the correct dosage as indicated on the figure? a.30 mL b.15 mL c.10 mL d.5 mL Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL 51. The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all that apply.) a.Ventricular septal defect (VSD) b.Patent ductus arteriosus (PDA) c.Coarctation of the aorta d.Tetralogy of Fallot e.Transposition of the great vessels Rationale: Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). (A, B, and C) are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. 52. Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? a.Limit fluids to prevent infection to the surgical site. b.Place the infant in the prone position. c.Provide a low-residue diet to limit bowel movements. d.Cover sac with a moist sterile dressing. Rationale: The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum. Fluids should be increased postoperatively to prevent dehydration. A high-fiber diet should be implemented to prevent constipation. After the repair, the sac is no longer exposed, so option D does not apply. 53. When caring for a hospitalized child with type 1 diabetes mellitus, which intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? a.Teach the signs and symptoms of hypoglycemia. b.Assess for polydipsia, polyphagia, and polyuria. c.Check the blood glucose level every 4 hours. d.Evaluate the need for a snack between meals. Rationale: Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances. Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP. 54. The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? a.An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents b.A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose c.A women at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency d.A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn Rationale: The women with epigastric pain should be called first. One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. Options A, B, and C are less serious and should be called after option D. 55. Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? a.Accelerations in response to fetal movement b.Early decelerations in the second stage of labor c.Fetal heart rate of 130 beats/min between contractions d.Late decelerations with absent variability and tachycardia Rationale: Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous. 130 beats/min is an expected heart rate. Options A and B are not as critical. 56. When caring for a client in labor, which finding is most important to report to the primary health care provider? a.Maternal heart rate, 90 beats/min b.Fetal heart rate, 100 beats/min c.Maternal blood pressure, 140/86 mm Hg d.Maternal temperature, 100.0°F Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress because the average FHR at term is 140 beats/min, and the normal range is 110 to 160 beats/min. Options A, C, and D are normal findings for a woman in labor. 57. Which interventions should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) a.Maintain bed rest for the first 6 hours after delivery. b.Palpate and massage the fundus to maintain firmness. c.Have client empty bladder if fundus is above umbilicus. d.Check perineal pad for color and consistency of lochia. e.Apply ice pack or witch hazel compresses to the perineum. Rationale: The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C). 58. In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? a.A consistent fasting blood sugar level between 80 and 85 mg/dL b.A 2-hour postprandial level >120 mg/dL c.Client reports taking a 30-minute walk after dinner d.Client describes eating pattern of four to six meals daily Rationale: Two-hour postprandial levels >120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value >120 mg/dL should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal. Options C and D are healthy behaviors for a woman with gestational diabetes. 59. The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individuals? (Select all that apply.) a.An Rh-negative woman who has had a miscarriage at 24 weeks b.The father of a baby of an Rh-positive fetus c.An Rh-negative mother after delivery of an Rh- positive infant with a negative direct Coombs test d.An Rh-positive infant within 72 hours after birth e.An Rh-negative mother with a negative antibody titer at 28 weeks Rationale: (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D). 60. When assessing a normal newborn, which findings should the nurse expect? (Select all that apply.) a.Umbilical cord contains one vein and two arteries b.Slightly edematous labia in the female newborn c.Absence of Babinski reflex d.Presence of white plaques on the cheeks and tongue