HESI LPN
HESI Focus on Maternity Exam
1. Humans begin life as a single cell that divides repeatedly. This cell is known as a(n):
- A. zygote.
- B. gonadotrope.
- C. embryo.
- D. chromaffin.
Correct answer: A
Rationale: A zygote is the correct answer. It is the initial cell formed when a sperm cell fertilizes an egg cell, marking the beginning of human development. Choice B, gonadotrope, is incorrect as it refers to a type of hormone-secreting cell in the pituitary gland. Choice C, embryo, is incorrect as it is the stage of development after the zygote has implanted into the uterine wall and undergone initial cell divisions. Choice D, chromaffin, is incorrect as it refers to cells found in the adrenal medulla that produce and store catecholamines.
2. 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.
3. A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse?
- A. Dizziness while standing
- B. Sinus tachycardia
- C. Lower back pain
- D. Absent patellar reflexes
Correct answer: D
Rationale: The correct answer is D: Absent patellar reflexes. Absent patellar reflexes can indicate magnesium toxicity, a serious condition that requires immediate intervention to prevent respiratory depression or cardiac arrest. Dizziness while standing (choice A) is common in pregnancy but does not specifically indicate magnesium toxicity. Sinus tachycardia (choice B) can be a normal response to magnesium sulfate but does not indicate toxicity. Lower back pain (choice C) is common in pregnancy and not specifically associated with magnesium toxicity.
4. Are babies with fetal alcohol syndrome (FAS) often larger than normal, and so are their brains?
- A. TRUE
- B. FALSE
- C. Sometimes
- D. Always
Correct answer: B
Rationale: The correct answer is B: FALSE. Babies with fetal alcohol syndrome (FAS) are typically smaller than normal, with smaller brains and developmental issues. Choice A is incorrect because babies with FAS are not larger than normal. Choice C is incorrect as it does not accurately reflect the typical characteristics of babies with FAS. Choice D is incorrect as babies with FAS are not always larger than normal.
5. A mother spontaneously delivers a newborn infant in the taxicab while on the way to the hospital. The emergency room nurse reported the mother has active herpes (HSV II) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery?
- A. Document the newborn's temperature on the flow sheet.
- B. Place the newborn in the isolation area of the nursery.
- C. Obtain a blood specimen for a serum glucose level.
- D. Administer the vitamin K injection.
Correct answer: B
Rationale: Newborns exposed to active herpes lesions are at high risk for neonatal herpes, which can be severe. Placing the newborn in isolation is crucial as it helps prevent the spread of the virus and allows for close monitoring. Documenting the newborn's temperature, obtaining a blood specimen for a serum glucose level, and administering the vitamin K injection are important interventions but are not the priority when dealing with a potential infectious risk like neonatal herpes.
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