Question

A client at 28-weeks’ gestation whose hemoglobin level is 10.7 g/dL (107 g/L) and hematocrit is 32% (0.32 volume fraction), tells the nurse that she eats plenty of green vegetables. When the client asks the nurse how the low-level value might affect her pregnancy, which information should the nurse provide?

Reference range:

Hemoglobin [12 to 16 g/dl (120 to 160 g/L): pregnant greater than 11 g/dl (110 g/L)] Hematocrit [37% to 47% (0.37 to 0.47 volume fraction): pregnant greater than 33% (0.33 volume fraction)]

Answer 1

Correct Answers:

Plasma volume increases, making the blood count appear low.

Rationale :

🟦 Placing a nightlight improves visibility during nighttime ambulation, which significantly reduces the risk of falls in older adults.

🟦 Many falls occur in low-light conditions when clients get up at night to use the bathroom or move around the home.

🟦 Adequate lighting supports environmental safety by helping the client identify obstacles and changes in floor level.

🟦 This intervention is simple, effective, and strongly recommended for fall prevention in the home.

🧩 Other options

🟦 Setting water heater to 130°F — Too hot; increases burn risk (recommended ≤120°F).

🟦 Wearing socks at night — Increases slipping risk; non-skid footwear is safer.

🟦 Covering extension cord with a rug — Creates a tripping and fire hazard, especially with oxygen equipment.

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Answer 2

Correct Answers:

Review the fetal heart rate pattern.

Rationale :

🟦 In active labor, fetal well-being is the priority, especially before allowing ambulation or a position change such as walking to the bathroom.

🟦 Reviewing the fetal heart rate (FHR) pattern ensures the fetus is tolerating labor and that no acute compromise (e.g., decelerations) is present.

🟦 Changes in maternal position or activity can affect uteroplacental perfusion and fetal oxygenation; therefore, fetal status must be verified first.

🟦 Confirming a reassuring FHR supports safe decision-making and aligns with maternal–fetal safety principles.

🧩 Other options

🟦 Determine cervical dilation — Important, but not the immediate priority before ambulation.

🟦 Check vaginal fluid pH — Indicated if membrane rupture is suspected, which is not stated.

🟦 Palpate the bladder — Useful later; does not supersede fetal assessment.

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Answer 3

Correct Answers

Blank 1 Correct Option: Polydipsia
Blank 2 Correct Option: Warm, Flushed Skin

Rationale :

🟦 Polydipsia):

🟦 Polydipsia (excessive thirst) is a classic sign of hyperglycemia, which is particularly concerning in this client with a history of poorly controlled gestational diabetes requiring insulin.

🟦 Although the current blood glucose is 140 mg/dL, postpartum hormonal shifts can cause rapid glucose fluctuations, increasing the risk of hyperglycemia.

🟦 Ongoing thirst may indicate inadequate glycemic control or developing metabolic imbalance.

🟦 This finding warrants continued blood glucose monitoring and possible adjustment of insulin therapy.

🟦 🌡️ Warm, Flushed Skin):

🟦 Warm, flushed skin in the immediate postpartum period may be an early indicator of infection or developing postpartum complications, especially with a history of prolonged labor and ruptured membranes for 12 hours.

🟦 Although the temperature is only mildly elevated, postpartum clients—particularly those with diabetes—are at increased risk for infection due to impaired immune response.

🟦 Early identification allows prompt evaluation for endometritis or systemic infection.

🟦 Close monitoring of temperature trends and additional symptoms is essential for timely intervention.

🧩 Why the other options are NOT priority concerns (brief):

🟡 Urine output — 400 mL of clear, yellow urine indicates adequate renal perfusion and hydration.

🟡 Moderate lochia — Expected finding after vaginal delivery.

🟡 Blood loss — Estimated blood loss of 300 mL is within normal limits for vaginal birth.

🟡 Weight loss — Not present or documented as a concern.

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Answer 4

Correct Answers

Frequent urination [ Hyperglycemia ]
Hunger [ Hypoglycemia ]
Fatigue [ Hyperglycemia ]
Sweating [ Hypoglycemia ]
Headache [ Hypoglycemia ]
Abdominal pain [ Hyperglycemia ]
Dry mouth [ Hyperglycemia ]

Rationale :

🟦 Frequent Urination → Hyperglycemia

🟦 Hyperglycemia causes osmotic diuresis as excess glucose is excreted by the kidneys, pulling water with it.

🟦 This leads to increased urine output and fluid loss.

🟦 In postpartum clients with a history of poor glycemic control, this finding requires follow-up.

🟦 It often occurs alongside polydipsia and dehydration.

🟢 Hunger → Hypoglycemia

🟢 Hunger is an early adrenergic response to low blood glucose levels.

🟢 The body signals the need for glucose to restore energy supply to the brain.

🟢 Insulin use increases the risk of hypoglycemia, especially postpartum when insulin needs can drop rapidly.

🟢 This symptom aligns with the client’s report of being “very hungry.”

🟣 Fatigue → Hyperglycemia

🟣 Hyperglycemia leads to cellular glucose deprivation despite high serum glucose levels.

🟣 Cells are unable to effectively use glucose for energy, resulting in fatigue and weakness.

🟣 Persistent fatigue is common when blood glucose remains elevated.

🟣 This is especially concerning in a client with recent insulin therapy adjustments.

🟥 Sweating → Hypoglycemia

🟥 Sweating is a classic sympathetic nervous system response to hypoglycemia.

🟥 Low blood glucose triggers catecholamine release, causing diaphoresis.

🟥 This is an early warning sign that requires prompt intervention.

🟥 It often occurs with tremors, anxiety, and palpitations.

🟠 Headache → Hypoglycemia

🟠 The brain depends almost exclusively on glucose for energy.

🟠 Hypoglycemia leads to neuroglycopenic symptoms, including headache.

🟠 Headache may occur before more severe symptoms such as confusion or loss of consciousness.

🟠 This finding warrants immediate blood glucose evaluation.

🟤 Abdominal Pain → Hyperglycemia

🟤 Hyperglycemia, especially when severe or prolonged, can cause gastrointestinal discomfort.

🟤 It may be associated with slowed gastric emptying and metabolic imbalance.

🟤 Abdominal pain is more consistent with elevated glucose than low glucose states.

🟤 This symptom should prompt monitoring for worsening hyperglycemia.

🟨 Dry Mouth → Hyperglycemia

🟨 Dry mouth results from dehydration caused by osmotic diuresis in hyperglycemia.

🟨 Fluid loss through frequent urination reduces salivary secretion.

🟨 This finding aligns with the client’s report of being extremely thirsty.

🟨 It reflects inadequate intracellular hydration due to elevated glucose levels.

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Answer 5

Correct Answers

Notify the healthcare provider [ Indicated ]
Encourage the client to breastfeed [ Not Indicated ]
Administer 60 units glargine insulin [ Not Indicated ]
Provide the client with milk to drink [ Indicated ]
Administer 8 units regular insulin [ Not Indicated ]

Rationale :

🟦 Notify the healthcare provider — Indicated

🟦 The client is showing mixed but concerning glucose-related symptoms (hunger, sweating, headache, fatigue) in the immediate postpartum period.

🟦 Insulin requirements often drop sharply after delivery, increasing the risk for hypoglycemia.

🟦 The provider must be notified to reassess insulin dosing and glucose monitoring orders.

🟦 Early communication helps prevent severe glycemic events.

🟩 Encourage the client to breastfeed — Not Indicated

🟩 The client is bottle-feeding, and no desire to breastfeed has been expressed.

🟩 Breastfeeding is a client choice and should not be encouraged if it does not align with the client’s plan.

🟩 This intervention is not relevant to the current priority of glycemic management.

🟥 Administer 60 units glargine insulin — Not Indicated

🟥 This is a large dose of long-acting insulin, which could cause severe hypoglycemia postpartum.

🟥 The client is already showing possible hypoglycemic symptoms.

🟥 Insulin doses must be re-evaluated after delivery, not automatically continued.

🟥 Administering this dose would be unsafe at this time.

🟠 Provide the client with milk to drink — Indicated

🟠 The client reports hunger, weakness, sweating, and headache, which are classic signs of hypoglycemia.

🟠 Milk provides both carbohydrates and protein, making it appropriate for treating mild hypoglycemia.

🟠 This is a safe, immediate nursing intervention while awaiting glucose confirmation or provider guidance.

🟠 Oral intake is appropriate because the client is alert and oriented.

🟣 Administer 8 units regular insulin — Not Indicated

🟣 Regular insulin would lower blood glucose further, worsening suspected hypoglycemia.

🟣 There is no current elevated blood glucose value to justify insulin administration.

🟣 Insulin should never be given based on symptoms alone without confirmed hyperglycemia.

🟣 This intervention could place the client at risk for acute hypoglycemic crisis.

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Answer 6

Correct Answers:

Monitor for temperatures greater than 100.4" F (38° C).
Check blood sugar before breastfeeding.
Schedule a glucose tolerate test in 6 weeks.
Wear a medical-alert bracelet.

Rationale :

🟦 💎 Wear a medical-alert bracelet —

💎 Wearing a medical-alert bracelet ensures rapid identification of the client’s diabetes history in emergency situations.

💎 This is especially important postpartum, when glucose levels can fluctuate and hypoglycemia may occur unexpectedly.

💎 Emergency responders rely on this information to deliver safe, appropriate treatment.

💎 This demonstrates the client understands long-term self-safety and risk prevention.

🟦 💎 Monitor for temperatures greater than 100.4°F (38°C) —

💎 Postpartum clients are at increased risk for infection, particularly with a history of prolonged labor and diabetes.

💎 Monitoring for fever allows early detection of endometritis, wound infection, or systemic infection.

💎 Prompt reporting of elevated temperature supports timely intervention and reduces complications.

💎 This reflects understanding of postpartum warning signs.

🟦 💎 Check blood sugar before breastfeeding —

💎 Breastfeeding can lower maternal blood glucose levels, increasing the risk for hypoglycemia.

💎 Checking blood sugar beforehand helps the client prevent symptomatic hypoglycemia.

💎 This practice supports safe glucose management during lactation.

💎 The statement shows understanding of how feeding affects glucose control.

🟦 💎 Schedule a glucose tolerance test in 6 weeks —

💎 Clients with gestational diabetes require a postpartum glucose tolerance test to assess for persistent diabetes.

💎 The 6-week timeframe aligns with clinical guidelines once pregnancy-related insulin resistance resolves.

💎 Early testing allows timely diagnosis and long-term management if diabetes persists.

💎 This demonstrates understanding of follow-up care and prevention.

❌ Statements that do NOT indicate understanding (brief):

Insulin requirements increase with lactation — Insulin needs usually decrease postpartum.

Eat 15 g carbohydrates if glucose <150 mg/dL — Treatment threshold is <70 mg/dL, not 150.

Avoid low-dose contraceptives postpartum — Low-dose options may be appropriate depending on individual risk.

Eat 500 additional calories daily — Applies to breastfeeding clients; this client is bottle-feeding.

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Answer 7

Correct Answers:

Provide positive pressure ventilation.

Rationale :

🟢 The newborn has a heart rate of 100 beats/min, which is adequate but is not breathing spontaneously.

🟢 According to neonatal resuscitation guidelines, apnea or ineffective respirations require immediate positive pressure ventilation (PPV).

🟢 Initial steps such as warming, drying, suctioning, and tactile stimulation have already been performed without success.

🟢 PPV helps establish effective lung expansion and oxygenation, which is the priority at this point.

🟢 Early ventilation prevents hypoxia, acidosis, and bradycardia in the newborn.

❌ Start IV infusion in a scalp vein

IV access is not the immediate priority in an apneic newborn. Establishing ventilation comes first.

❌ Assist neonatologist with intubation

Intubation is reserved if PPV is ineffective. Less invasive ventilation is attempted first.

❌ Give blow-by oxygen via cannula

Blow-by oxygen does not correct apnea. The infant requires assisted ventilation, not supplemental oxygen alone.

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Answer 8

Correct Answers:

Take an oral maternal temperature.

Rationale :

🔴 A sustained fetal heart rate of 170–180 beats/min indicates fetal tachycardia.

🔴 One of the most common causes is maternal infection, especially after spontaneous rupture of membranes (SROM).

🔴 Checking the maternal temperature helps identify chorioamnionitis or maternal fever.

🔴 Maternal hyperthermia directly increases fetal metabolic rate and heart rate.

🔴 Early identification allows prompt intervention to reduce fetal compromise.

❌ Obtain a blood specimen for hemoglobin

Hemoglobin levels do not explain acute fetal tachycardia. Infection must be ruled out first.

❌ Send amniotic fluid for analysis

This is not a first-line bedside intervention. Maternal assessment takes priority.

❌ Straight catheterize the client

Bladder distention may affect labor progress, not fetal heart rate.

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Answer 9

Correct Answers:

Assist the mother to elicit a rooting reflex in the infant.

Rationale :

🟣 The rooting reflex helps the newborn locate the nipple and begin feeding.

🟣 Stimulating this reflex supports early latch and effective breastfeeding.

🟣 Early breastfeeding promotes uterine contraction and bonding.

🟣 Assisting with positioning and reflexes increases maternal confidence.

🟣 This intervention directly supports the mother’s stated breastfeeding goal.

❌ Permit privacy for the mother and infant to bond

Bonding is important but does not actively assist with breastfeeding initiation.

❌ Evaluate the infant's sucking reflex then give the infant to the mother

Assessment alone does not help initiate feeding. Hands-on assistance is needed.

❌ Place a small amount of glucose water on the breast

Glucose water interferes with breastfeeding and is not recommended.

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Answer 10

Correct Answers:

Rubella vaccination.

Rationale :

🟢 The client is rubella non-immune, placing her at risk for congenital rubella syndrome in future pregnancies.

🟢 Rubella vaccination is indicated in the postpartum period because it is a live attenuated vaccine and cannot be given during pregnancy.

🟢 Administering the vaccine now allows the mother to develop protective antibodies before a subsequent pregnancy.

🟢 The client’s hemoglobin and hematocrit are within acceptable postpartum limits, eliminating the need for transfusion.

🟢 Providing the vaccine before discharge ensures long-term maternal and fetal protection.

❌ Hepatitis B immunoglobulin

This is indicated only if the mother is hepatitis B surface antigen positive. The client’s results are negative.

❌ Blood transfusion

The hemoglobin and hematocrit values are within normal postpartum ranges. There is no evidence of hemorrhage or anemia.

❌ Penicillin G potassium

GBS prophylaxis is administered during labor, not postpartum. Antibiotics are not routinely given after delivery for GBS positivity alone.

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Plan of Care Recommendation	Indicated	Not Indicated
Notify the healthcare provider
Encourage the client to breastfeed
Administer 60 units glargine insulin
Provide the client with milk to drink
Administer 8 units regular insulin

HESI Maternity

No.

2 :
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 :
A nurse was assessing a patient

Correct Answers

4 :
Patient data

Correct Answers

🟦 Frequent Urination → Hyperglycemia

🟢 Hunger → Hypoglycemia

🟣 Fatigue → Hyperglycemia

🟥 Sweating → Hypoglycemia

🟠 Headache → Hypoglycemia

🟤 Abdominal Pain → Hyperglycemia

🟨 Dry Mouth → Hyperglycemia

5 :
Patient data

Correct Answers

🟦 Notify the healthcare provider — Indicated

🟩 Encourage the client to breastfeed — Not Indicated

🟥 Administer 60 units glargine insulin — Not Indicated

🟠 Provide the client with milk to drink — Indicated

🟣 Administer 8 units regular insulin — Not Indicated

6 :
The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

9 :
While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement?

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Client Findings	Hypoglycemia	Hyperglycemia
Frequent urination
Hunger
Fatigue
Sweating
Headache
Abdominal pain
Dry mouth

HESI Maternity

No.

2 : The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 : A nurse was assessing a patient

Correct Answers

4 : Patient data

Correct Answers

🟦 Frequent Urination → Hyperglycemia

🟢 Hunger → Hypoglycemia

🟣 Fatigue → Hyperglycemia

🟥 Sweating → Hypoglycemia

🟠 Headache → Hypoglycemia

🟤 Abdominal Pain → Hyperglycemia

🟨 Dry Mouth → Hyperglycemia

5 : Patient data

Correct Answers

🟦 Notify the healthcare provider — Indicated

🟩 Encourage the client to breastfeed — Not Indicated

🟥 Administer 60 units glargine insulin — Not Indicated

🟠 Provide the client with milk to drink — Indicated

🟣 Administer 8 units regular insulin — Not Indicated

6 : The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

9 : While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement?

2 :
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated, 50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

3 :
A nurse was assessing a patient

4 :
Patient data

5 :
Patient data

6 :
The nurse starts discharge teaching. Which findings indicate the client understands the discharge teaching? Select all that apply.

9 :
While on the delivery table, a primipara tells the nurse that she wishes to breastfeed her infant. To assist the new mother with her goal, which intervention is best for the nurse to implement?