HESI LPN
HESI Maternal Newborn
1. A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL, hematocrit 29%, hepatitis surface antigen positive, Group B Streptococcus positive, and rubella non-immune. Which intervention should the nurse implement?
- A. Transfuse 2 units of packed red blood cells.
- B. Give measles, mumps, rubella vaccine 0.5 mL.
- C. Administer ampicillin 2 grams intravenously.
- D. Inject hepatitis B immune globulin 0.5 milliliters.
Correct answer: C
Rationale: The correct intervention in this scenario is to administer ampicillin 2 grams intravenously. This is crucial to prevent Group B Streptococcus infection in the newborn during delivery. Option A, transfusing packed red blood cells, is not indicated based on the hemoglobin and hematocrit levels provided. Option B, giving measles, mumps, rubella vaccine, is not necessary at this time. Option D, injecting hepatitis B immune globulin, is not appropriate for the conditions presented in the question.
2. Which drug was marketed in the 1960s to pregnant women and caused birth defects such as missing or stunted limbs in infants?
- A. Progestin
- B. Estrogen
- C. Thalidomide
- D. Oxytocin
Correct answer: C
Rationale: Thalidomide is the correct answer. Thalidomide was a drug marketed in the 1960s to pregnant women as a sedative and anti-nausea medication but tragically led to severe birth defects, including limb deformities, when taken during pregnancy. Progestin (Choice A) and Estrogen (Choice B) are hormones that are not associated with causing birth defects like Thalidomide. Oxytocin (Choice D) is a hormone that plays a role in labor and breastfeeding and is not known to cause birth defects like Thalidomide.
3. Which of the following statements is true of mutations?
- A. Mutations can only occur by chance.
- B. Mutations produce sperm and ova cells.
- C. Mutations occur through radiation or other environmental influences.
- D. Mutations help adenine combine with guanine to form the single spiral structure of DNA.
Correct answer: C
Rationale: The correct answer is C. Mutations can occur due to environmental influences such as radiation, chemicals, or other external factors, leading to changes in the DNA sequence. Choice A is incorrect because mutations can also occur due to errors in DNA replication, not solely by chance. Choice B is incorrect as mutations affect the DNA sequence itself, not the production of specific cells. Choice D is incorrect because mutations involve changes in the DNA sequence and do not specifically involve the formation of the DNA structure.
4. The _____ is the inner layer of the embryo from which the lungs and digestive system develop.
- A. neural tube
- B. mesoderm
- C. endoderm
- D. umbilical cord
Correct answer: C
Rationale: The endoderm is the correct answer. It is the innermost layer of the embryo that gives rise to organs such as the lungs, digestive system, liver, and pancreas. The neural tube (Choice A) forms the brain and spinal cord, not the lungs or digestive system. Mesoderm (Choice B) develops into structures like muscles, bones, and circulatory system, not the lungs or digestive system. The umbilical cord (Choice D) serves as a connection between the embryo and the placenta, providing nutrients and oxygen, but it is not the layer from which lungs and digestive system develop.
5. A client at 38 weeks of gestation has a prescription for intravaginal misoprostol. Which of the following statements should the nurse make?
- A. “You will need to stay in a side-lying position for 30 minutes after each dose.”
- B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.”
- C. “You will receive a magnesium supplement immediately following therapy.”
- D. “You will need to have a full bladder before the therapy begins.”
Correct answer: A
Rationale: The correct answer is A. Instructing the client to stay in a side-lying position after receiving misoprostol intravaginally is essential. This position helps keep the medication in place, allowing for better absorption. Choice B is incorrect because oxytocin administration is not typically indicated after misoprostol use. Choice C is incorrect as magnesium supplementation is not part of the standard protocol for misoprostol administration. Choice D is incorrect as having a full bladder is not necessary before initiating misoprostol therapy.
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