HESI LPN
HESI Focus on Maternity Exam
1. The healthcare provider is planning care for a client at 30 weeks gestation who is experiencing preterm labor. Which medication is most important in preventing this fetus from developing respiratory distress syndrome?
- A. Ampicillin 1 gram IV push every 8 hours
- B. Betamethasone 12 mg deep IM
- C. Terbutaline 0.25 mg subcutaneously every 15 minutes for 3 doses
- D. Butorphanol tartrate 1 mg IV push every 2 hours as needed
Correct answer: B
Rationale: Betamethasone is a corticosteroid given to stimulate fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Ampicillin (Choice A) is an antibiotic and does not prevent respiratory distress syndrome. Terbutaline (Choice C) is a tocolytic used to inhibit contractions and does not directly prevent respiratory distress syndrome. Butorphanol tartrate (Choice D) is an opioid analgesic and does not have a role in preventing respiratory distress syndrome in preterm infants.
2. When reviewing the electronic medical record of a postpartum client, which of the following factors places the client at risk for infection?
- A. Meconium-stained amniotic fluid
- B. Placenta previa
- C. Midline episiotomy
- D. Gestational hypertension
Correct answer: C
Rationale: The correct answer is C: Midline episiotomy. An episiotomy is a surgical incision made during childbirth to enlarge the vaginal opening. This procedure increases the risk of infection in the postpartum period due to the incision site being a potential entry point for pathogens. Meconium-stained amniotic fluid (choice A) is a risk factor for fetal distress but does not directly increase the mother's risk of infection. Placenta previa (choice B) is a condition where the placenta partially or completely covers the cervix, leading to potential bleeding issues but not necessarily an increased risk of infection. Gestational hypertension (choice D) is a hypertensive disorder that affects some pregnant women but is not directly associated with an increased risk of infection in the postpartum period.
3. What is the primary rationale for thoroughly drying the infant immediately after birth?
- A. Stimulates crying and lung expansion.
- B. Removes maternal blood from the skin surface.
- C. Reduces heat loss from evaporation.
- D. Increases blood supply to the hands and feet.
Correct answer: C
Rationale: The primary rationale for thoroughly drying the infant immediately after birth is to reduce heat loss from evaporation. This helps maintain the infant's body temperature and prevent hypothermia. Choice A (Stimulates crying and lung expansion) is incorrect because drying the infant is not primarily done to stimulate crying but rather to prevent heat loss. Choice B (Removes maternal blood from the skin surface) is incorrect as the main reason is to prevent heat loss, not to remove maternal blood. Choice D (Increases blood supply to the hands and feet) is also incorrect as drying the infant is not intended to increase blood supply but rather to regulate body temperature.
4. A woman with gestational diabetes has had little or no experience reading and interpreting glucose levels. The client shows the nurse her readings for the past few days. Which reading signals the nurse that the client may require an adjustment of insulin or carbohydrates?
- A. 75 mg/dl before lunch. This is low; better eat now.
- B. 115 mg/dl 1 hour after lunch. This is a little high; maybe eat a little less next time.
- C. 115 mg/dl 2 hours after lunch. This is too high; it is time for insulin.
- D. 50 mg/dl just after waking up from a nap. This is too low; maybe eat a snack before going to sleep.
Correct answer: D
Rationale: 50 mg/dl after waking from a nap is too low. During hours of sleep, glucose levels should not be less than 60 mg/dl. Snacks before sleeping can be helpful. The premeal acceptable range is 60 to 99 mg/dl. The readings 1 hour after a meal should be less than 129 mg/dl. Two hours after eating, the readings should be less than 120 mg/dl.
5. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take?
- A. Assess bowel sounds.
- B. Continue to monitor.
- C. Assist with intubation.
- D. Rub the infant's back.
Correct answer: B
Rationale: Cyanosis of the hands and feet, known as acrocyanosis, is common in newborns shortly after birth and usually resolves on its own. It is not indicative of a need for immediate intervention. Therefore, the appropriate action is to continue monitoring the newborn's condition. Assessing bowel sounds (Choice A) is not relevant to the presenting issue of cyanosis and respiratory rate. Assisting with intubation (Choice C) is an invasive procedure that is not warranted based on the information provided. Rubbing the infant's back (Choice D) is not necessary for acrocyanosis and could potentially disturb the newborn.
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