HESI LPN
HESI Maternal Newborn
1. A newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn's admission. What action should the nurse take to ensure adequate installation of the ointment?
- A. Instill a thin ribbon into each lower conjunctival sac
- B. Occlude the inner canthus after retracting the eyelids
- C. Mummy wrap the infant before instilling the ointment
- D. Stabilize the instilling hand on the neonate's head
Correct answer: A
Rationale: To ensure adequate installation of the ophthalmic erythromycin 5% ointment in a newborn, the nurse should instill a thin ribbon into each lower conjunctival sac. This method helps to ensure proper distribution and effectiveness of the medication to prevent neonatal conjunctivitis. Choices B, C, and D are incorrect. Occluding the inner canthus after retracting the eyelids, mummy wrapping the infant, or stabilizing the instilling hand on the neonate's head are not appropriate actions for ensuring the proper installation of the ointment.
2. Which drug was marketed in the 1960s to pregnant women and caused birth defects such as missing or stunted limbs in infants?
- A. Progestin
- B. Estrogen
- C. Thalidomide
- D. Oxytocin
Correct answer: C
Rationale: Thalidomide is the correct answer. Thalidomide was a drug marketed in the 1960s to pregnant women as a sedative and anti-nausea medication but tragically led to severe birth defects, including limb deformities, when taken during pregnancy. Progestin (Choice A) and Estrogen (Choice B) are hormones that are not associated with causing birth defects like Thalidomide. Oxytocin (Choice D) is a hormone that plays a role in labor and breastfeeding and is not known to cause birth defects like Thalidomide.
3. Why is a client with gestational diabetes being scheduled for an amniocentesis when the fetus has an estimated weight of eight pounds (3629 grams) at 36 weeks gestation? What information is the amniocentesis seeking to obtain?
- A. Presence of a neural tube defect.
- B. Chromosomal abnormalities.
- C. Gender of the fetus.
- D. Fetal lung maturity.
Correct answer: D
Rationale: An amniocentesis in this scenario is most likely being performed to assess fetal lung maturity. This is necessary when considering early delivery due to macrosomia (large fetal size), which is a common concern in gestational diabetes. Evaluating fetal lung maturity is crucial to determine if the fetus's lungs are developed enough to support breathing independently outside the womb. The presence of a neural tube defect and chromosomal abnormalities are not typically assessed through amniocentesis in this situation, and determining the gender of the fetus is not the primary purpose of the procedure here.
4. A client at 27 weeks of gestation with preeclampsia is being assessed by a nurse. Which of the following findings should the nurse report to the provider?
- A. Urine protein concentration of 200 mg/24 hr.
- B. Creatinine level of 0.8 mg/dL
- C. Hemoglobin level of 14.8 g/dL
- D. Platelet count of 60,000/mm3
Correct answer: D
Rationale: A platelet count of 60,000/mm3 is significantly low and can indicate HELLP syndrome, a severe complication of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelet count. HELLP syndrome requires prompt medical intervention to prevent serious maternal and fetal complications. The other findings listed are within normal limits or not directly related to the severe condition associated with HELLP syndrome.
5. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman’s vital signs, which finding would be of greatest concern to the nurse?
- A. Temperature 37.9°C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg.
- B. Temperature 37.4°C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg.
- C. Temperature 38°C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg.
- D. Temperature 36.8°C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg.
Correct answer: A
Rationale: An estimated blood loss (EBL) of 1500 ml following a vaginal birth is significant and can lead to hypovolemia. The vital signs provided in option A (Temperature 37.9°C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg) indicate tachycardia and hypotension, which are concerning signs of hypovolemia due to excessive blood loss. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, and hypotension indicates inadequate perfusion. Options B, C, and D do not exhibit the same level of concern for hypovolemia. Option B shows tachypnea, which can be a result of pain or anxiety postpartum. Option C and D have vital signs within normal limits, which are not indicative of the body's response to significant blood loss.
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