HESI LPN

1. At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. The woman states that her contractions are occurring every 4 to 5 minutes and lasting approximately 30 seconds each. Which of the following questions would be most appropriate to ask at this point?

• A. Has your bag of waters broken yet?
• B. Have you had regular prenatal care?
• C. At how many weeks gestation are you?
• D. How many other children do you have?

Correct Answer: C

Rationale: In this scenario, asking about the gestational age is crucial as it helps determine the stage of labor and potential complications. Knowing the number of weeks of gestation can guide the healthcare provider in assessing the progress of labor and making decisions about the care of both the mother and the baby. Choices A, B, and D are not as relevant in this urgent situation. While knowing if the bag of waters has broken is important for assessing the progress of labor, determining gestational age is more critical at this point. Asking about regular prenatal care or the number of other children does not provide immediate information necessary for managing the current situation.

2. What is the first action to take before administering tube feeding to an infant?

• A. Irrigate the tube with water.
• B. Offer a pacifier to the infant.
• C. Slowly instill 10 mL of formula.
• D. Place the infant in the Trendelenburg position.

Correct Answer: B

Rationale: The correct first action before administering tube feeding to an infant is to offer a pacifier. Providing a pacifier stimulates the sucking reflex, aiding in digestion and providing comfort to the infant. Irrigating the tube with water (Choice A) is not typically the initial step and could potentially introduce unnecessary fluid into the infant's system. Slowly instilling formula (Choice C) should only be done after ensuring the tube is appropriately placed. Placing the infant in the Trendelenburg position (Choice D) is not necessary for tube feeding and could pose risks such as aspiration.

3. A 7-month-old girl is to be catheterized to obtain a sterile urine specimen. One of the infant’s parents expresses fear that this procedure may traumatize the baby psychologically. How should the nurse provide reassurance?

• A. The fear is justified and the nurse should obtain a “clean catch” specimen.
• B. Parents have a right to refuse the catheterization and the concerns are realistic.
• C. Although the concern is appropriate, the need for a sterile specimen is the priority.
• D. The procedure is uncomfortable, but there should not be a damaging long-term effect.

Correct Answer: D

Rationale: While catheterization can be uncomfortable, it does not typically result in long-term psychological harm, and obtaining a sterile specimen is important for accurate diagnosis.

4. When you attempt to assess a 22-year-old woman who has been sexually assaulted, and she orders you not to touch her, your most appropriate initial action should be to

• A. ask the patient to sign a release form
• B. ask a female EMT-B to attempt to assess the patient
• C. explain to the patient that she must be examined
• D. transport the patient without performing an assessment

Correct Answer: B

Rationale: In this scenario, the patient has requested not to be touched, indicating a need for sensitivity and understanding. Asking a female EMT-B to attempt to assess the patient is the most appropriate initial action as it respects the patient's need for privacy, comfort, and potentially reduces re-traumatization. Asking the patient to sign a release form (Choice A) is not suitable as it disregards the patient's immediate concerns. Explaining to the patient that she must be examined (Choice C) may further distress her and violate her autonomy. Transporting the patient without performing an assessment (Choice D) ignores the patient's expressed wishes and may lead to inadequate care.

5. Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include

• A. Oxygen, uterine massage, and transport
• B. Oxygen, placement on the left side, and transport
• C. Oxygen, treatment for shock, and uterine massage during transport
• D. Oxygen, internal vaginal pads, and treatment for shock during transport

Correct Answer: C

Rationale: In this scenario, the 21-year-old mother is showing signs of hemorrhagic shock with increased heart rate, diaphoresis, and vaginal bleeding. The appropriate management includes providing oxygen to support tissue perfusion, treating for shock to restore adequate circulation, and performing uterine massage to help control bleeding during transport. Options A, B, and D do not address the comprehensive management needed for postpartum hemorrhage in this situation.