HESI LPN
HESI Maternal Newborn
1. A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage.
- B. Apply counterpressure to the client's sacrum.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct answer: B
Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.
2. Daisy was always unusually short for her age. She was unable to conceive a child after marriage, and upon visiting a doctor, she was prescribed estrogen replacement therapy. Daisy is most likely suffering from:
- A. Phenylketonuria (PKU).
- B. Cystic fibrosis.
- C. Turner syndrome.
- D. Huntington’s disease (HD).
Correct answer: C
Rationale: Daisy's symptoms of short stature and infertility, along with the prescription of estrogen replacement therapy, are indicative of Turner syndrome. Turner syndrome is a genetic condition in which a female is partially or completely missing one X chromosome. This results in short stature, infertility, and other physical characteristics. Phenylketonuria (PKU) is a metabolic disorder caused by a mutation in the gene responsible for the breakdown of the amino acid phenylalanine. Cystic fibrosis is a genetic disorder affecting the respiratory and digestive systems. Huntington's disease (HD) is a neurodegenerative disorder that affects muscle coordination and leads to cognitive decline.
3. In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio placentae?
- A. Bleeding.
- B. Intense abdominal pain.
- C. Uterine activity.
- D. Cramping.
Correct answer: B
Rationale: The correct answer is B: Intense abdominal pain. Pain is absent with placenta previa but can be agonizing with abruptio placentae. While bleeding may be present in varying degrees for both placental conditions, intense abdominal pain is a distinguishing feature of abruptio placentae. Uterine activity and cramping may be present with both placental conditions, but they are not the most prevalent clinical manifestation of abruptio placentae.
4. During a prenatal visit, for which of the following clients should the nurse auscultate the fetal heart rate?
- A. A client who has an ultrasound confirming a molar pregnancy
- B. A client who has a crown-rump length corresponding to 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct answer: D
Rationale: The correct answer is D because feeling quickening typically occurs around 18-20 weeks of gestation, indicating fetal movement. This is an appropriate time to auscultate the fetal heart rate. Choice A is incorrect because a molar pregnancy is not a viable pregnancy, and auscultating the fetal heart rate in this case is not applicable. Choice B is incorrect because a crown-rump length of 7 weeks gestation is too early for fetal heart rate auscultation. Choice C is incorrect because a positive urine pregnancy test alone does not indicate the appropriate timing for fetal heart rate auscultation.
5. A client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant?
- A. Morning sickness.
- B. Breast tenderness.
- C. Amenorrhea.
- D. Hegar's sign.
Correct answer: D
Rationale: Hegar's sign, which is a softening of the lower uterine segment, is considered a probable sign of pregnancy as it indicates changes in the cervix and uterus that occur during pregnancy. Amenorrhea, the absence of menstruation, is a common early sign of pregnancy but can also be due to other factors. Morning sickness, nausea and vomiting, can be a sign of early pregnancy but is not as specific as Hegar's sign. Breast tenderness is a common symptom in early pregnancy due to hormonal changes, but it is not as definitive as Hegar's sign in indicating pregnancy.
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