which statement by the client will assist the nurse in determining whether she is in true labor as opposed to false labor
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HESI LPN

HESI Focus on Maternity Exam

1. Which statement by the client will assist the healthcare provider in determining whether she is in true labor as opposed to false labor?

Correct answer: C

Rationale: The correct answer is C. Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Choice A indicates the passing of the mucus plug, which is a sign of early labor but not definitive for true labor. Choice B, the breaking of the bag of waters, is a sign of labor but does not confirm whether it is true or false labor. Choice D, the baby dropping and increased urination frequency, suggests lightening, a sign that labor may be approaching, but it does not confirm true labor.

2. Dizygotic (DZ) twins share _________ percent of their genes.

Correct answer: C

Rationale: Dizygotic (DZ) twins share approximately 50% of their genes. This is because dizygotic twins, also known as fraternal twins, originate from two separate fertilized eggs and share similar genetic similarity to regular siblings. Choice A (100%) is incorrect because if twins shared 100% of their genes, they would be identical twins (monozygotic). Choice B (75%) is incorrect as it is not the typical genetic similarity seen in dizygotic twins. Choice D (25%) is incorrect as it represents a significantly lower genetic similarity than what is observed in dizygotic twins.

3. How many chromosomes are typically found in human cells, organized into pairs?

Correct answer: B

Rationale: Human cells typically contain 46 chromosomes organized into 23 pairs. This is the correct number for a normal human cell. Choices A, C, and D are incorrect because they do not represent the typical chromosome count in human cells.

4. A newborn is 24 hours old, and a healthcare provider is caring for them. Which of the following laboratory findings should the healthcare provider report to the provider?

Correct answer: D

Rationale: The correct answer is D: WBC count 32,000/mm3. A WBC count of 32,000/mm3 is significantly elevated in a newborn and could indicate an infection, which needs immediate attention and intervention. High white blood cell counts in newborns can be concerning as they may suggest an ongoing infection or other underlying issues that require prompt medical evaluation and treatment. Choices A, B, and C are within normal ranges for a newborn and would not typically warrant immediate reporting to the provider. Hgb levels of 20 g/dL (Choice A) are high for newborns, but this is not as concerning as a significantly elevated WBC count. Bilirubin levels of 2 mg/dL (Choice B) are within normal limits for a newborn and do not indicate immediate issues. Platelet count of 200,000/mm3 (Choice C) is also within the normal range for a newborn and would not require immediate reporting.

5. 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?

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.

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