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. What maternal factor should the nurse identify as having the greatest impact on the development of spina bifida occulta in a newborn?
- A. Short interval between pregnancies
- B. Folic acid deficiency
- C. Preeclampsia
- D. Tobacco use
Correct answer: B
Rationale: Folic acid deficiency during pregnancy is a well-known risk factor for neural tube defects, including spina bifida occulta, making supplementation critical in prenatal care. Folic acid plays a crucial role in neural tube formation during early pregnancy. Short intervals between pregnancies do not directly impact the development of spina bifida occulta. Preeclampsia is a hypertensive disorder of pregnancy and is not directly linked to spina bifida occulta. While tobacco use during pregnancy has various adverse effects, it is not the primary factor influencing the development of spina bifida occulta in newborns.
3. The nurse is caring for a multiparous client who is 8 centimeters dilated, 100% effaced, and the fetal head is at 0 station. The client is shivering and states extreme discomfort with the urge to bear down. Which intervention should the nurse implement?
- A. Administer IV pain medication
- B. Perform a vaginal exam
- C. Reposition to side-lying
- D. Encourage pushing with each contraction
Correct answer: C
Rationale: Repositioning the client to a side-lying position is the most appropriate intervention in this scenario. This position can help relieve pressure on the cervix and reduce the urge to push prematurely, allowing the cervix to continue dilating. Administering IV pain medication may not address the underlying cause of the discomfort, and pushing prematurely can lead to cervical trauma. Performing a vaginal exam is not necessary at this point as the client is already 8 centimeters dilated, and the fetal head is at 0 station.
4. The _________ is the hollow organ within females in which the embryo and fetus develop.
- A. placenta
- B. ovum
- C. uterus
- D. amniotic sac
Correct answer: C
Rationale: The correct answer is C: uterus. The uterus is the organ where the embryo implants and the fetus develops during pregnancy. The placenta (choice A) is an organ that develops during pregnancy and provides nutrients and oxygen to the fetus, but it is not the organ where the embryo and fetus physically develop. The ovum (choice B) is the female reproductive cell or egg that is fertilized by the sperm to form an embryo, but it is not the organ where the embryo and fetus develop. The amniotic sac (choice D) is a membrane filled with amniotic fluid that surrounds and protects the fetus, but it is not the organ where the embryo and fetus physically develop.
5. What is the typical sex chromosome pattern for females?
- A. XX
- B. XYY
- C. XY
- D. XXY
Correct answer: A
Rationale: The typical sex chromosome pattern for females is XX. Females have two X chromosomes, which is represented as XX. Choice B (XYY) is incorrect as it represents the sex chromosome pattern for males with an extra Y chromosome. Choice C (XY) is the sex chromosome pattern for males. Choice D (XXY) represents a genetic disorder known as Klinefelter syndrome, where males have an extra X chromosome.
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