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

HESI LPN

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?

A. Jaundice evident at 26 hours
B. Hematocrit of 55%
C. Serum bilirubin of 12 mg/dL
D. Positive Coombs test

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 patients should the home care nurse assess first?

A. A 65-year-old male with known COPD and difficulty breathing after climbing a flight of stairs.
B. A 78-year-old with CHF who has gained 4 lbs according to her tele-monitoring.
C. A 50-year-old with bilateral leg swelling and difficulty walking.
D. A 60-year-old with lower back pain.

Correct answer: A

Rationale: The correct answer is A. A patient with known COPD and difficulty breathing after physical exertion like climbing stairs requires immediate assessment by the nurse. This could indicate a potential exacerbation of COPD, which needs prompt intervention to prevent respiratory distress. Choices B, C, and D describe important patient situations that also require attention, but the urgency is higher with a COPD patient experiencing difficulty breathing.

3. Which of the following is not classified as an essential health service?

A. Provision of eye glasses and dentures for the elderly
B. Maternal and child care
C. Basic sanitation and prevention and control of locally endemic diseases
D. Promotion of proper nutrition, adequate supply of safe water, and health education

Correct answer: A

Rationale: The provision of eyeglasses and dentures for the elderly is not classified as an essential health service. Essential health services typically focus on preventive, promotive, curative, and rehabilitative care that address the primary healthcare needs of individuals and communities. Choices B, C, and D are examples of essential health services as they directly contribute to improving and maintaining the health of populations. Maternal and child care, basic sanitation, disease prevention, nutrition promotion, safe water supply, and health education are essential components of public health initiatives.

4. The healthcare professional enters the room as a 3-year-old is having a generalized seizure. Which intervention should the healthcare professional do first?

A. Clear the area of any hazards
B. Place the child on the side
C. Restrain the child
D. Give the prescribed anticonvulsant

Correct answer: B

Rationale: Placing the child on the side is the priority intervention during a generalized seizure as it helps maintain an open airway and prevents aspiration. Clearing the area of any hazards is important but should come after ensuring the child's safety. Restraining the child is not recommended during a seizure as it can lead to injury. Giving the prescribed anticonvulsant is important but should not be the first action during an ongoing seizure.

5. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the Center for Disease Control (CDC)?

A. 13 to 18 years of age.
B. 11 to 12 years of age.
C. 18 to 24 months of age.
D. 4 to 6 years of age.

Correct answer: D

Rationale: The correct answer is D: 4 to 6 years of age. The CDC recommends the MMR booster for children in this age group. Choice A (13 to 18 years of age) is incorrect as it is not the recommended age range for the MMR booster. Choice B (11 to 12 years of age) is also incorrect as it does not align with the CDC guidelines for the MMR booster. Choice C (18 to 24 months of age) is not the correct age range for the MMR booster according to CDC recommendations.