HESI LPN
HESI Maternity 55 Questions
1. Which of the following processes happen during mitosis?
- A. Strands of deoxyribonucleic acid (DNA) break apart.
- B. Adenine combines with its appropriate partner, cytosine.
- C. Sperm and ova cells are created.
- D. Twenty-three chromosomes are created.
Correct answer: A
Rationale: The correct process that happens during mitosis is the breaking apart, replication, and division of DNA strands into two new cells, each with the same number of chromosomes as the original cell. Choice B is incorrect because it describes base pairing in DNA, not a process specific to mitosis. Choice C is incorrect as the creation of sperm and ova cells is related to meiosis, not mitosis. Choice D is incorrect because chromosomes are not created during mitosis; they are replicated and divided equally between the daughter cells.
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. A client in labor requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
- A. Assisting the client into a squatting position
- B. Having the client lie in a supine position
- C. Applying fundal pressure during contractions
- D. Encouraging the client to void every 6 hours
Correct answer: A
Rationale: Assisting the client into a squatting position promotes comfort during labor. This position can help relieve pain by utilizing gravity, allowing the pelvic outlet to widen, and potentially facilitating the progress of labor. Lying in a supine position (Choice B) can hinder labor progression and increase discomfort. Applying fundal pressure (Choice C) can be inappropriate and may cause harm as it is not routinely recommended during labor. Encouraging the client to void every 6 hours (Choice D) is important for bladder management but does not directly address pain relief during labor.
4. A newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn's admission. What action should the nurse take to ensure adequate installation of the ointment?
- A. Instill a thin ribbon into each lower conjunctival sac
- B. Occlude the inner canthus after retracting the eyelids
- C. Mummy wrap the infant before instilling the ointment
- D. Stabilize the instilling hand on the neonate's head
Correct answer: A
Rationale: To ensure adequate installation of the ophthalmic erythromycin 5% ointment in a newborn, the nurse should instill a thin ribbon into each lower conjunctival sac. This method helps to ensure proper distribution and effectiveness of the medication to prevent neonatal conjunctivitis. Choices B, C, and D are incorrect. Occluding the inner canthus after retracting the eyelids, mummy wrapping the infant, or stabilizing the instilling hand on the neonate's head are not appropriate actions for ensuring the proper installation of the ointment.
5. A client is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 minutes on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct answer: B
Rationale: Ensuring the newborn's mouth is wide open before latching is crucial for achieving a proper latch, which can help reduce nipple soreness. Placing a snug dressing on the nipple when not breastfeeding (choice A) can lead to further irritation and hinder healing. Encouraging the client to limit the newborn’s feeding to 10 minutes on each breast (choice C) may not be adequate for effective feeding as infants should feed until they are satisfied. Instructing the client to begin feeding with the most tender nipple (choice D) can worsen the soreness as it may not allow the baby to feed effectively.
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