HESI LPN
Maternity HESI Test Bank
1. A nurse is planning to teach a group of clients who are breastfeeding after returning to work. Which of the following instructions should the nurse include in the teaching?
- A. “Thawed breast milk can be refrigerated for up to 24 hours.”
- B. “Breast milk can be stored in a deep freezer for 12 months.”
- C. “Breast milk can be stored at room temperature for up to 4 hours.”
- D. “Thawed breast milk that is unused cannot be refrozen.”
Correct answer: B
Rationale: The correct answer is B: “Breast milk can be stored in a deep freezer for 12 months.” This instruction is important for mothers returning to work to ensure a long-term storage option for breast milk. Choice A is incorrect because thawed breast milk should be used within 24 hours if stored in the refrigerator. Choice C is incorrect as breast milk can be kept at room temperature for only up to 4 hours. Choice D is incorrect as thawed breast milk that is unused should not be refrozen due to safety concerns.
2. Tim, a 27-year-old man, has unusually narrow shoulders, low muscle mass, and has no facial and body hair. His doctor recently prescribed testosterone replacement therapy to him. Tim is most likely suffering from:
- A. Phenylketonuria (PKU).
- B. Cystic fibrosis.
- C. Klinefelter syndrome.
- D. Huntington’s disease (HD).
Correct answer: C
Rationale: Tim's physical characteristics, such as narrow shoulders, low muscle mass, and lack of facial and body hair, are typical signs of Klinefelter syndrome, a genetic condition where males have an extra X chromosome (XXY). This leads to underdeveloped testes and reduced testosterone production, resulting in features like gynecomastia, sparse facial and body hair, and reduced muscle mass. Testosterone replacement therapy is commonly used to address the hormonal imbalance in individuals with Klinefelter syndrome. Phenylketonuria (PKU) is a metabolic disorder unrelated to the symptoms described in Tim's case. Cystic fibrosis is a genetic respiratory condition that does not present with the physical characteristics mentioned. Huntington’s disease (HD) is a neurodegenerative disorder primarily affecting motor function and cognition, not physical appearance and muscle mass.
3. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
- A. A client with a urinary output of 300 ml in 8 hours
- B. A client reporting abdominal cramping during breastfeeding
- C. A client receiving magnesium sulfate with absent deep tendon reflexes
- D. A client reporting lochia rubra requiring changing perineal pads every 3 hours
Correct answer: C
Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.
4. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?
- A. Page the pediatrician STAT
- B. Continue resuscitative efforts
- C. Repeat the Apgar assessment in 5 minutes
- D. Inform the parents of the infant's condition
Correct answer: B
Rationale: In a situation where an infant receives a low Apgar score of 3 following a traumatic delivery, the most crucial intervention for the nurse to implement is to continue resuscitative efforts. A low Apgar score indicates that the newborn is in distress and requires immediate medical attention to support breathing, heart rate, muscle tone, reflex irritability, and color. Continuing resuscitative efforts is essential to provide life-saving interventions promptly. Paging the pediatrician may cause a delay in crucial interventions, repeating the Apgar assessment in 5 minutes is not appropriate as immediate action is needed to stabilize the infant, and informing parents should not take precedence over providing immediate medical care to the newborn.
5. A 38-week primigravida is admitted to labor and delivery after a non-reactive result on a non-stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the healthcare provider?
- A. A pattern of fetal late decelerations.
- B. Fetal heart rate accelerations with fetal movement.
- C. Absence of uterine contractions within 20 minutes.
- D. Spontaneous rupture of membranes.
Correct answer: A
Rationale: The correct answer is A: A pattern of fetal late decelerations. Late decelerations during a contraction stress test are concerning as they indicate uteroplacental insufficiency, which can pose a risk to fetal well-being. Reporting this finding to the healthcare provider is crucial for prompt intervention. Choice B, fetal heart rate accelerations with fetal movement, is a reassuring sign of fetal well-being and does not raise immediate concerns. Choice C, absence of uterine contractions within 20 minutes, may require further assessment but is not as critical as late decelerations. Choice D, spontaneous rupture of membranes, is important but not the most immediate concern during a contraction stress test.
Similar Questions
Access More Features
HESI LPN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI LPN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99