a 3 hour old male infants hands and feet are cyanotic and he has an axillary temperature of 965f 358c a respiratory rate of 40 breaths per minute and
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Nursing Elites

HESI LPN

HESI Focus on Maternity Exam

1. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?

Correct answer: B

Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.

2. 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?

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.

3. When do mothers usually feel the first fetal movements during pregnancy?

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 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.

5. Which of the following statements is a characteristic of supermales?

Correct answer: A

Rationale: The correct characteristic of supermales, individuals with an XYY chromosome pattern, is that they are somewhat taller than average. Choice B is incorrect as supermales do not exhibit minimal facial hair growth compared to normal males. Choice C is incorrect as gynecomastia, the development of male breasts, is not a characteristic of supermales. Choice D is also incorrect as impotence is not a typical characteristic associated with supermales.

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