HESI LPN
Maternity HESI Test Bank
1. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?
- A. Page the pediatrician STAT
- B. Continue resuscitative efforts
- C. Repeat the Apgar assessment in 5 minutes
- D. Inform the parents of the infant's condition
Correct answer: B
Rationale: In a situation where an infant receives a low Apgar score of 3 following a traumatic delivery, the most crucial intervention for the nurse to implement is to continue resuscitative efforts. A low Apgar score indicates that the newborn is in distress and requires immediate medical attention to support breathing, heart rate, muscle tone, reflex irritability, and color. Continuing resuscitative efforts is essential to provide life-saving interventions promptly. Paging the pediatrician may cause a delay in crucial interventions, repeating the Apgar assessment in 5 minutes is not appropriate as immediate action is needed to stabilize the infant, and informing parents should not take precedence over providing immediate medical care to the newborn.
2. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?
- A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
- B. Risk for altered gas exchange.
- C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
- D. Risk for increased cardiac output, related to the use of antihypertensive drugs.
Correct answer: A
Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.
3. Does the probability of having a child with Down’s syndrome increase with the age of the parents?
- A. TRUE
- B. FALSE
- C. Sometimes
- D. Never
Correct answer: A
Rationale: The correct answer is A: TRUE. Advanced parental age, particularly maternal age, is associated with an increased risk of Down's syndrome in offspring. As parents get older, the likelihood of having a child with Down's syndrome increases. Choices B, C, and D are incorrect because the risk of Down's syndrome is known to rise with parental age, especially maternal age, due to the increased likelihood of chromosomal abnormalities during egg formation.
4. What is a procedure for using ultrasonic sound waves to create a picture of an embryo or fetus?
- A. Phenotype
- B. Sonogram
- C. Genotype
- D. Alpha-fetoprotein (AFP) assay
Correct answer: B
Rationale: A sonogram, also known as an ultrasound, is a procedure that utilizes sound waves to generate images of a developing embryo or fetus. This imaging technique is commonly used in prenatal care to monitor fetal development and identify any potential abnormalities. Choices A, C, and D are incorrect because a phenotype refers to an individual's observable traits resulting from genetic and environmental influences, a genotype is an individual's genetic makeup, and an alpha-fetoprotein (AFP) assay is a blood test used to screen for certain birth defects.
5. Do sebaceous glands cause a developing organism to grow arms or wings, skin, or scales?
- A. True
- B. False
- C. Possibly
- D. Never
Correct answer: B
Rationale: The correct answer is B: False. Sebaceous glands are associated with the skin's oil production and have no role in the development of limbs or body coverings. Sebaceous glands primarily produce sebum, an oily substance that lubricates and waterproofs the skin and hair. Choices A, C, and D are incorrect because sebaceous glands do not influence the growth of arms, wings, skin, or scales in a developing organism.
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