HESI LPN
HESI Focus on Maternity Exam
1. A client who delivered a healthy newborn an hour ago asked the nurse when she can go home. Which information is most important for the nurse to provide the client?
- A. After the baby no longer demonstrates acrocyanosis
- B. After the baby receives the vitamin K injection
- C. When ambulating to avoid causing dizziness
- D. When there is no significant vaginal bleeding
Correct answer: D
Rationale: The most critical information for the nurse to provide the client is ensuring that there is no significant vaginal bleeding before discharge. This is vital to prevent complications such as postpartum hemorrhage. Options A, B, and C are important aspects of postpartum care, but assessing and managing vaginal bleeding takes precedence due to its potential seriousness.
2. 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.
3. A client with hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma reagin
- C. Prothrombin time
- D. Urine culture
Correct answer: A
Rationale: Urine ketones should be anticipated as a laboratory test for a client with hyperemesis gravidarum because it helps assess the severity of dehydration and malnutrition, which are common complications of this condition. Choice B, rapid plasma reagin, is a test for syphilis and is not relevant to hyperemesis gravidarum. Choice C, prothrombin time, is a measure of blood clotting function and is not typically indicated for hyperemesis gravidarum. Choice D, urine culture, is used to identify bacteria in the urine and is not directly related to assessing dehydration and malnutrition in clients with hyperemesis gravidarum.
4. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
- A. A client with a urinary output of 300 ml in 8 hours
- B. A client reporting abdominal cramping during breastfeeding
- C. A client receiving magnesium sulfate with absent deep tendon reflexes
- D. A client reporting lochia rubra requiring changing perineal pads every 3 hours
Correct answer: C
Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.
5. Individuals with Klinefelter syndrome produce:
- A. less estrogen than normal males.
- B. less testosterone than normal males.
- C. less adenine than normal males.
- D. less thymine than normal males.
Correct answer: B
Rationale: Individuals with Klinefelter syndrome have an extra X chromosome (XXY), leading to reduced production of testosterone, the primary male sex hormone. This deficiency can result in various physical and developmental characteristics associated with the syndrome. Estrogen levels may actually be relatively elevated due to the imbalance between testosterone and estrogen. Choices C and D are incorrect as adenine and thymine are nucleotide bases found in DNA and are not related to hormone production.
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