HESI LPN
HESI Maternity 55 Questions
1. 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.
2. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?
- A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
- B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
- C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
- D. Record the findings on the chart. They are within normal limits.
Correct answer: D
Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.
3. What is a procedure for using ultrasonic sound waves to create a picture of an embryo or fetus?
- A. Phenotype
- B. Sonogram
- C. Genotype
- D. Alpha-fetoprotein (AFP) assay
Correct answer: B
Rationale: A sonogram, also known as an ultrasound, is a procedure that utilizes sound waves to generate images of a developing embryo or fetus. This imaging technique is commonly used in prenatal care to monitor fetal development and identify any potential abnormalities. Choices A, C, and D are incorrect because a phenotype refers to an individual's observable traits resulting from genetic and environmental influences, a genotype is an individual's genetic makeup, and an alpha-fetoprotein (AFP) assay is a blood test used to screen for certain birth defects.
4. When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs and symptoms of cardiac decompensation. Which critical findings would the nurse find on assessment of the client experiencing this condition?
- A. Regular heart rate and hypertension.
- B. Increased urinary output, tachycardia, and dry cough.
- C. Shortness of breath, bradycardia, and hypertension.
- D. Dyspnea, crackles, and an irregular, weak pulse.
Correct answer: D
Rationale: In pregnant women with cardiac problems, signs of cardiac decompensation include dyspnea, crackles, an irregular, weak, and rapid pulse, rapid respirations, a moist and frequent cough, generalized edema, increasing fatigue, and cyanosis of the lips and nailbeds. Choice A is incorrect as a regular heart rate and hypertension are not typically associated with cardiac decompensation. Choice B is incorrect as increased urinary output and dry cough are not indicative of cardiac decompensation, only tachycardia is. Choice C is incorrect as bradycardia and hypertension are not typically seen in cardiac decompensation; dyspnea is a critical sign instead.
5. Which of the following statements is true about Tay-Sachs disease?
- A. It is most commonly found among children in Jewish families of Eastern European background.
- B. Children who have this disease suffer from excessive production of mucus in the lungs and pancreas.
- C. It is most commonly found among children in Asian American families.
- D. Children who have this disease suffer from muscular dystrophy characterized by a weakening of the muscles.
Correct answer: A
Rationale: The correct answer is A. Tay-Sachs disease is most commonly found among Jewish families of Eastern European descent. It is a fatal genetic disorder that affects the nervous system. Choice B is incorrect because Tay-Sachs disease does not involve excessive mucus production in the lungs and pancreas. Choice C is incorrect as it states that Tay-Sachs disease is most commonly found among Asian American families, which is inaccurate. Choice D is also incorrect because Tay-Sachs disease does not cause muscular dystrophy characterized by weakening of the muscles.
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