HESI LPN
HESI Maternal Newborn
1. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Allow liberal family visitation
- B. Keep an airway at the bedside
- C. Assess temperature every hour
- D. Monitor blood pressure, pulse, and respiration every 4 hours
Correct answer: B
Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.
2. A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?
- A. Administering intravenous fluids
- B. Monitoring for signs of infection
- C. Monitoring for signs of dehydration
- D. Monitoring for signs of pain
Correct answer: C
Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis involves the obstruction of the pyloric sphincter, leading to projectile vomiting, which can result in dehydration and electrolyte imbalances. Monitoring for signs of dehydration is crucial to assess the child's fluid status and prevent complications. Administering intravenous fluids, although important in managing dehydration, is not typically a preoperative intervention but rather a treatment during or after surgery. Monitoring for signs of infection and pain may also be important but are not the priority preoperative interventions in a child with pyloric stenosis.
3. During a tonic-clonic seizure, what is the nurse's priority intervention?
- A. Insert an oral airway
- B. Administer oxygen via nasal cannula
- C. Restrain the client's arms and legs
- D. Protect the client's head from injury
Correct answer: D
Rationale: During a tonic-clonic seizure, the nurse's priority intervention is to protect the client's head from injury. This is crucial to prevent trauma, as head injuries can be severe during a seizure. Inserting an oral airway may cause injury or obstruction during the seizure and is not recommended. Administering oxygen via nasal cannula can be done after ensuring the client's safety. Restraining the client's arms and legs is also not recommended as it can lead to further injury or harm.
4. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- A. Wear cotton clothing to avoid static electricity.
- B. Avoid using any electrical appliances.
- C. Keep the oxygen tank away from heat sources.
- D. Use only a specific type of nasal cannula.
Correct answer: A
Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.
5. The nurse is evaluating the effectiveness of a community health program aimed at reducing teen pregnancy rates. Which outcome indicates the program was successful?
- A. increased attendance at health education classes
- B. decreased number of repeat pregnancies among teens
- C. higher number of teens seeking prenatal care
- D. greater use of contraception among teens
Correct answer: D
Rationale: The correct answer is D: greater use of contraception among teens. This outcome indicates successful prevention of pregnancies by demonstrating that teens are taking proactive steps to avoid unintended pregnancies. Increased attendance at health education classes (choice A) may show improved knowledge but does not directly measure the prevention of pregnancies. While a decreased number of repeat pregnancies among teens (choice B) is positive, it does not necessarily indicate prevention of initial pregnancies. A higher number of teens seeking prenatal care (choice C) is important for maternal and fetal health but does not directly reflect the prevention of teen pregnancies.