HESI LPN
HESI Focus on Maternity Exam
1. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?
- A. Administer oxygen by mouth at 2L/min
- B. Gradually warm the infant under a radiant heat source
- C. Notify the pediatrician of the infant's vital signs
- D. Perform a heel-stick to maintain blood glucose levels
Correct answer: B
Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.
2. Which of the following pairs share 100% of their genes?
- A. Biovular twins
- B. Fraternal twins
- C. Dizygotic (DZ) twins
- D. Monozygotic (MZ) twins
Correct answer: D
Rationale: The correct answer is Monozygotic (MZ) twins. Monozygotic twins, also known as identical twins, share 100% of their genes because they originate from the same fertilized egg that splits into two. Fraternal twins (choice B), also known as dizygotic (DZ) twins (choice C), result from two separate fertilized eggs and share approximately 50% of their genes. Biovular twins (choice A) is not a term used in genetics and does not describe a type of twinning.
3. Do neural tube defects cause an elevation in the alpha-fetoprotein (AFP) level in the mother’s blood?
- A. Yes
- B. No
- C. Possibly
- D. Never
Correct answer: A
Rationale: Yes, neural tube defects can cause an elevation in AFP levels in the mother’s blood. AFP levels are often used as a screening marker during pregnancy to detect neural tube defects. Choice B is incorrect because an elevation in AFP levels can indeed occur in the presence of neural tube defects. Choice C is not the best option as it leaves room for uncertainty when the relationship between neural tube defects and AFP elevation is well-established. Choice D is incorrect as neural tube defects are known to influence AFP levels in the maternal blood.
4. Polygenic traits are those that are:
- A. developed during adolescence.
- B. transmitted by the mother.
- C. uncommon in humans.
- D. determined by several pairs of genes.
Correct answer: D
Rationale: Polygenic traits, such as height and skin color, are determined by several pairs of genes working together. These traits are influenced by the combined effects of multiple genes across the genome, rather than being controlled by a single gene pair. Choices A, B, and C are incorrect because polygenic traits are not specifically developed during adolescence, transmitted by the mother, or uncommon in humans. Understanding polygenic traits is essential in genetics as they demonstrate the complexity of genetic inheritance and the influence of multiple genes on a single trait.
5. Which of the following statements about Rh incompatibility is true?
- A. Rh incompatibility occurs most commonly during a woman’s first pregnancy.
- B. Rh incompatibility is an untreatable condition that leaves a woman infertile for the rest of her life.
- C. Rh incompatibility is an abnormality that is transmitted from generation to generation and carried by a sex chromosome.
- D. Rh incompatibility occurs due to antibodies transmitted to a fetus during subsequent deliveries causing brain damage or death.
Correct answer: D
Rationale: Rh incompatibility occurs when the mother's antibodies attack the fetus's red blood cells, leading to serious complications, usually in subsequent pregnancies. Choice A is incorrect because Rh incompatibility often occurs in subsequent pregnancies, not necessarily the first one. Choice B is incorrect as Rh incompatibility does not render a woman infertile but can lead to complications during pregnancies. Choice C is incorrect as Rh incompatibility is not carried by a sex chromosome but involves the Rh factor on red blood cells.
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