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. Genotypes are solely based on genetic information.
- A. TRUE
- B. FALSE
- C. Sometimes
- D. Never
Correct answer: B
Rationale: The correct answer is B - FALSE. Genotypes are solely based on genetic information and do not reflect environmental influences. Phenotypes, on the other hand, result from the interaction of genetic and environmental factors. Choices A, C, and D are incorrect because genotypes are not influenced by environmental factors, and they are determined by an individual's genetic makeup.
3. 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.
4. Twenty-year-old Jack is extremely tall and has very thick facial hair. Most of his male secondary sex characteristics are also more pronounced than men of his age. In this scenario, Jack is most likely:
- A. an XYY male.
- B. diagnosed with Klinefelter syndrome.
- C. an XXY male.
- D. diagnosed with Down syndrome.
Correct answer: A
Rationale: The correct answer is A: an XYY male. Individuals with XYY syndrome often exhibit increased height and more pronounced secondary male characteristics, such as thick facial hair. Choice B, Klinefelter syndrome (XXY), typically presents with less prominent male secondary sex characteristics due to the presence of an extra X chromosome. Choice C, XXY male, refers to Klinefelter syndrome, which does not align with the description of Jack having more pronounced male secondary sex characteristics. Choice D, Down syndrome, is caused by a trisomy of chromosome 21 and is not associated with the physical characteristics described in the scenario.
5. A nurse is reviewing laboratory results for a term newborn who is 24 hours old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct answer: D
Rationale: A glucose level of 20 mg/dL is critically low for a newborn and requires immediate intervention. Hypoglycemia in a newborn can lead to serious complications such as neurologic deficits. The normal range for glucose levels in a newborn is typically 40-60 mg/dL. Choices A, B, and C represent normal or acceptable values for a term newborn and do not require immediate intervention. A WBC count of 10,000/mm3, platelets of 180,000/mm3, and hemoglobin of 20g/dL are all within normal ranges for a term newborn and do not raise immediate concerns.
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