HESI LPN
HESI Maternity 55 Questions
1. 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.
2. A pregnant client mentions in her history that she changes the cat's litter box daily. Which test should the nurse anticipate the healthcare provider to prescribe?
- A. Biophysical profile
- B. Fern test
- C. Amniocentesis
- D. TORCH screening
Correct answer: D
Rationale: The correct answer is D, TORCH screening. TORCH screening is done to detect infections such as toxoplasmosis, which can be contracted from handling cat litter and is harmful during pregnancy. Biophysical profile (choice A) is a prenatal ultrasound evaluation. Fern test (choice B) is used to assess for amniotic fluid leakage. Amniocentesis (choice C) involves taking a sample of amniotic fluid to test for genetic abnormalities and certain infections, not specifically related to toxoplasmosis from cat litter.
3. When do mothers usually feel the first fetal movements during pregnancy?
- A. At 18-20 weeks
- B. During the first month
- C. Rarely
- D. Never
Correct answer: A
Rationale: Mothers usually feel the first fetal movements, known as 'quickening,' around the 18th to 20th week of pregnancy. Feeling fetal movements during the first month is unlikely and uncommon. Therefore, option B is incorrect. Options C and D are also incorrect as mothers typically do feel fetal movements during pregnancy, just not during the first month.
4. A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital. The emergency room nurse reported the mother has active herpes (HSV II) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery?
- A. Document the newborn's temperature on the flow sheet.
- B. Place the newborn in the isolation area of the nursery.
- C. Obtain a blood specimen for a serum glucose level.
- D. Administer the vitamin K injection.
Correct answer: B
Rationale: Newborns exposed to active herpes lesions are at high risk for neonatal herpes, which can be severe. Placing the newborn in isolation is crucial as it helps prevent the spread of the virus and allows for close monitoring. Documenting the newborn's temperature, obtaining a blood specimen for a serum glucose level, and administering the vitamin K injection are important interventions but are not the priority when dealing with a potential infectious risk like neonatal herpes.
5. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?
- A. Uterine atony.
- B. Uterine inversion.
- C. Vaginal hematoma.
- D. Vaginal laceration.
Correct answer: A
Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.
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