a newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet what action shoul
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Nursing Elites

HESI LPN

HESI Focus on Maternity Exam

1. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take?

Correct answer: B

Rationale: Cyanosis of the hands and feet, known as acrocyanosis, is common in newborns shortly after birth and usually resolves on its own. It is not indicative of a need for immediate intervention. Therefore, the appropriate action is to continue monitoring the newborn's condition. Assessing bowel sounds (Choice A) is not relevant to the presenting issue of cyanosis and respiratory rate. Assisting with intubation (Choice C) is an invasive procedure that is not warranted based on the information provided. Rubbing the infant's back (Choice D) is not necessary for acrocyanosis and could potentially disturb the newborn.

2. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?

Correct answer: D

Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.

3. The actual sets of traits that people exhibit are called their genotypes.

Correct answer: B

Rationale: The actual sets of traits that people exhibit are called phenotypes, not genotypes. Genotypes refer to the genetic makeup of an individual.

4. How many chromosomes are typically found in human cells, organized into pairs?

Correct answer: B

Rationale: Human cells typically contain 46 chromosomes organized into 23 pairs. This is the correct number for a normal human cell. Choices A, C, and D are incorrect because they do not represent the typical chromosome count in human cells.

5. Genotypes are solely based on genetic information.

Correct answer: B

Rationale: The correct answer is B - FALSE. Genotypes are solely based on genetic information and do not reflect environmental influences. Phenotypes, on the other hand, result from the interaction of genetic and environmental factors. Choices A, C, and D are incorrect because genotypes are not influenced by environmental factors, and they are determined by an individual's genetic makeup.

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