HESI LPN
Maternity HESI Practice Questions
1. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7-pound, 10-ounce (3220-gram) infant. Which information should the nurse provide to the client about these findings?
- A. The uterus should be firm to prevent an intrauterine infection.
- B. Both the lower uterine segment and the fundus must be massaged.
- C. A firm uterus prevents the endometrial lining from being sloughed.
- D. Clots may form inside a boggy uterus and need to be expelled.
Correct answer: D
Rationale: After childbirth, a boggy uterus indicates poor uterine tone, which can lead to the formation of clots. Massaging the fundus helps the uterus contract and expel clots, reducing the risk of postpartum hemorrhage. Choices A, B, and C are incorrect because the main concern with a boggy uterus is the risk of clot formation and postpartum hemorrhage, not solely preventing intrauterine infection, massaging the lower uterine segment, or preventing the endometrial lining from sloughing.
2. The nurse is caring for a multiparous client who is 8 centimeters dilated, 100% effaced, and the fetal head is at 0 station. The client is shivering and states extreme discomfort with the urge to bear down. Which intervention should the nurse implement?
- A. Administer IV pain medication
- B. Perform a vaginal exam
- C. Reposition to side-lying
- D. Encourage pushing with each contraction
Correct answer: C
Rationale: Repositioning the client to a side-lying position is the most appropriate intervention in this scenario. This position can help relieve pressure on the cervix and reduce the urge to push prematurely, allowing the cervix to continue dilating. Administering IV pain medication may not address the underlying cause of the discomfort, and pushing prematurely can lead to cervical trauma. Performing a vaginal exam is not necessary at this point as the client is already 8 centimeters dilated, and the fetal head is at 0 station.
3. A newborn assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?
- A. Tobacco use.
- B. Folic acid deficiency.
- C. Short interval between pregnancies.
- D. Preeclampsia.
Correct answer: B
Rationale: Folic acid deficiency during pregnancy is strongly associated with neural tube defects like spina bifida occulta. Adequate folic acid intake before and during early pregnancy significantly reduces the risk of such complications. Tobacco use (Choice A) is linked to other adverse outcomes but not specifically spina bifida occulta. Short intervals between pregnancies (Choice C) can increase the risk of preterm birth and low birth weight but are not directly linked to spina bifida occulta. Preeclampsia (Choice D) is a hypertensive disorder that poses risks to both the mother and baby but is not the primary factor contributing to spina bifida occulta development.
4. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?
- A. Assess the blood pressure for hypertension.
- B. Gently massage fundus every four hours.
- C. Observe for signs of uterine hemorrhage.
- D. Encourage direct contact with the infant.
Correct answer: C
Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.
5. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?
- A. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.â€
- B. “The drug keeps your baby from requiring too much sedation.â€
- C. “Surfactant is used to reduce episodes of periodic apnea.â€
- D. “Your baby needs this medication to fight a possible respiratory tract infection.â€
Correct answer: A
Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby’s lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.
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