while assessing an rh positive newborn whose mother is rh negative the nurse recognizes the risk for hyperbilirubinemia which of the following should
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Community Health HESI Questions

1. While assessing an Rh-positive newborn whose mother is Rh-negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

Correct answer: C

Rationale: A serum bilirubin level of 12 mg/dL in a newborn is concerning and can indicate a significant risk of hyperbilirubinemia, which requires immediate medical intervention to prevent complications like kernicterus. Jaundice at 26 hours (Choice A) is a symptom, not a laboratory result, and needs monitoring but not an immediate report. Hematocrit of 55% (Choice B) may be elevated but is not indicative of hyperbilirubinemia. A positive Coombs test (Choice D) indicates the presence of antibodies on the newborn's red blood cells but does not directly correlate with the risk of hyperbilirubinemia.

2. Which of the following is designed to help clients reduce the risk of illness and maintain the maximum level of function?

Correct answer: D

Rationale: The correct answer is 'D: health promotion.' Health promotion strategies are aimed at helping individuals reduce the risk of illness and maintain their maximum level of function by emphasizing preventive measures, healthy behaviors, and lifestyle choices. Illness prevention (choice A) focuses on specific actions to avoid illness but may not necessarily address overall function. Crisis intervention (choice B) refers to immediate assistance during emergencies rather than long-term prevention. Rehabilitation (choice C) involves restoring function after illness or injury rather than primarily focusing on preventive measures and maintaining maximum function.

3. A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

Correct answer: A

Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.

4. The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?

Correct answer: C

Rationale: Discussing the rights as a couple allows for open communication and helps ensure that the birthing plan aligns with the couple's preferences and medical advice.

5. The organization of nurses employed in the DOH is the:

Correct answer: A

Rationale: The Philippine Nurses Association is the correct organization for nurses employed in the DOH. The Philippine Nurses Association is a professional organization that represents and serves the interests of Filipino nurses. The National League of Nurses focuses on nursing education and is not specific to nurses employed in the DOH. The Catholic Nurses Guild of the Philippines is a religious organization for Catholic nurses and is not directly linked to nurses employed in the DOH. MCNAP is not a known organization related to nursing in the context provided.

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