HESI LPN
HESI Maternity 55 Questions
1. A client who is 5 days postpartum is being taught about signs of effective breastfeeding. Which information should the nurse include in the teaching?
- A. Feeling a tugging sensation when the baby is sucking
- B. Expecting the baby to have two to three wet diapers in a 24-hour period
- C. The baby’s urine should appear dark and concentrated
- D. The breast should stay firm after the baby breastfeeds
Correct answer: A
Rationale: Feeling a tugging sensation while the baby is sucking indicates an effective latch and milk transfer during breastfeeding. This sensation means that the baby is effectively drawing milk from the breast. Choice B is incorrect because infants should ideally have six to eight wet diapers in a 24-hour period to show adequate hydration. Choice C is incorrect as a dark and concentrated urine may indicate dehydration, which is not a sign of effective breastfeeding. Choice D is incorrect as the breast should soften after the baby breastfeeds, indicating that the baby has effectively emptied the breast of milk.
2. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse’s highest priority in this situation?
- A. Prepare the woman for imminent birth.
- B. Notify the woman’s primary healthcare provider.
- C. Document the characteristics of the fluid.
- D. Assess the fetal heart rate (FHR) and pattern.
Correct answer: D
Rationale: The correct answer is to assess the fetal heart rate (FHR) and pattern (Choice D). When a multiparous woman's membranes rupture after 8 hours of labor, the nurse's priority is to assess the fetal well-being. Rupture of membranes can lead to potential complications such as umbilical cord prolapse. Monitoring the fetal heart rate and pattern immediately after the rupture of membranes is crucial to ensure the fetus is not in distress. This assessment helps in determining the need for immediate interventions to safeguard the fetus. Documenting the characteristics of the fluid (Choice C) may be necessary but is of lower priority compared to assessing fetal well-being. While preparing the woman for imminent birth (Choice A) is important, assessing the fetal heart rate takes precedence to ensure the fetus is not compromised. Notifying the woman's primary healthcare provider (Choice B) is also important but not the highest priority at this moment.
3. Matt is a 36-year-old male. In the past year, he has noticed that his limbs sometimes move on their own, and he has also started having trouble remembering things and doing simple calculations. Matt’s father and grandfather were also known to have similar problems during their adulthood. Matt is most likely suffering from:
- A. Phenylketonuria (PKU).
- B. Cystic fibrosis.
- C. Turner syndrome.
- D. Huntington’s disease (HD).
Correct answer: D
Rationale: Matt is exhibiting symptoms typical of Huntington’s disease (HD), a hereditary condition characterized by involuntary movements, cognitive impairment, and behavioral changes. The fact that Matt's father and grandfather had similar issues supports the genetic nature of the disease. Phenylketonuria (PKU) is a metabolic disorder that affects amino acid metabolism, not presenting with the symptoms described. Cystic fibrosis primarily affects the respiratory and digestive systems, not causing the neurological symptoms described. Turner syndrome is a genetic condition affecting females and is not associated with the symptoms described in the case of Matt.
4. At 12 hours after the birth of a healthy infant, the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. Which action should the nurse take?
- A. Check the suprapubic area for distention
- B. Inform the client to take a warm sitz bath
- C. Inspect the client's perineal and rectal areas
- D. Apply a fresh pad and check in 1 hour
Correct answer: C
Rationale: In this situation, the mother's complaint of constant vaginal pressure along with a firm fundus and moderate rubra lochia indicates a potential perineal injury or hematoma. The correct action for the nurse to take is to inspect the client's perineal and rectal areas to assess for any signs of trauma or hematoma. Checking the suprapubic area for distention (Choice A) is not the priority here since the symptoms suggest a perineal issue. Advising a warm sitz bath (Choice B) may not address the underlying issue and could potentially worsen any existing trauma. Applying a fresh pad and checking in 1 hour (Choice D) does not address the need for immediate assessment of the perineal and rectal areas in response to the reported symptoms.
5. On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?
- A. Firm, larger, and very tender to the touch
- B. Slightly firm with an immediate let-down response
- C. Soft with no change from before delivery
- D. Filling and secreting colostrum
Correct answer: D
Rationale: On the first postpartum day, the nurse is most likely to find the breasts filling and secreting colostrum. Colostrum secretion is common as the body prepares for breastfeeding in the initial days after delivery. Choice A is incorrect as breasts are not typically very tender immediately postpartum. Choice B is incorrect as an immediate let-down response is more related to lactation rather than the first postpartum day. Choice C is incorrect as the breasts typically undergo changes, such as filling with colostrum, after delivery.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99