a 16 year old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia shes not presently convulsing which interve
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HESI Maternal Newborn

1. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?

Correct answer: B

Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.

2. A prenatal educator is teaching a class about false labor. Which of the following information should the educator include?

Correct answer: D

Rationale: The correct answer is D. False labor contractions, also known as Braxton Hicks contractions, are typically irregular and do not lead to cervical dilation or effacement. They are often described as sporadic and temporary, becoming temporarily regular. Choices A, B, and C are incorrect because false labor contractions do not intensify with activity, do not cause cervical changes like dilation and effacement, and are not associated with the presence of a bloody show.

3. Monozygotic (MZ) twins are known as fraternal twins.

Correct answer: B

Rationale: The correct answer is B: 'FALSE.' Monozygotic (MZ) twins are identical twins, not fraternal. Fraternal twins are dizygotic (DZ). The statement in the question is incorrect as MZ twins are genetically identical, while fraternal twins actually refer to dizygotic twins who develop from two separate fertilized eggs. Therefore, monozygotic twins are not known as fraternal twins, making option B the correct choice. Options A, C, and D are incorrect as they do not accurately describe the relationship between monozygotic and fraternal twins.

4. After meiosis, each new cell nucleus contains _____ chromosomes.

Correct answer: C

Rationale: After meiosis, each resulting cell contains 23 chromosomes. Meiosis is a process that involves two sequential divisions resulting in four daughter cells, each with half the number of chromosomes as the parent cell. In humans, the parent cell has 46 chromosomes (diploid), and after meiosis, the resulting cells (sperm or ova) have 23 chromosomes (haploid). Choice A (46 chromosomes) is incorrect because this is the number of chromosomes in a human diploid cell before meiosis. Choices B (35 chromosomes) and D (12 chromosomes) are incorrect as they do not represent the correct number of chromosomes after meiosis in human cells.

5. A client at 26 weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Correct answer: B

Rationale: An elevated AFP level during pregnancy can indicate potential fetal anomalies. Further evaluation is necessary to confirm the findings and assess the need for additional interventions. Scheduling a sonogram is the appropriate next step as it can provide more definitive results and help identify any underlying issues. Choice A is incorrect because dismissing the elevated AFP level as a false reading without further investigation can lead to missing important information about the baby's health. Choice C is not the best immediate action, as scheduling a sonogram would provide more detailed information than just repeating the AFP test. Choice D is incorrect as discussing intrauterine surgical correction is premature at this stage and not typically indicated based solely on an elevated AFP level.

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