HESI LPN
Maternity HESI Practice Questions
1. At 31 weeks gestation, a client with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide?
- A. Assessment for congenital anomalies
- B. Recalculation of gestational age
- C. Evaluation of fetal growth
- D. Determination of fetal presentation
Correct answer: C
Rationale: The correct answer is C: 'Evaluation of fetal growth.' A fundal height measurement smaller than expected may indicate intrauterine growth restriction (IUGR), requiring serial ultrasounds to monitor fetal growth. Assessing for congenital anomalies (choice A) is usually done through detailed anatomy scans earlier in pregnancy. Recalculating gestational age (choice B) is typically unnecessary at this stage unless there are concerns about accuracy. Determining fetal presentation (choice D) is usually done closer to term to plan for the mode of delivery.
2. A community health nurse is conducting a home visit to assess a family's health needs. What is the first step in this process?
- A. Develop a care plan
- B. Conduct a physical examination
- C. Establish rapport with the family
- D. Provide health education
Correct answer: C
Rationale: Establishing rapport with the family is crucial in the initial stages of a home visit. It helps build trust, open communication channels, and allows the nurse to gain insight into the family's health needs and concerns. Developing a care plan (Choice A) comes after the assessment phase, where information is gathered. Conducting a physical examination (Choice B) is a part of the assessment but typically follows establishing rapport. Providing health education (Choice D) is important but usually occurs after the assessment and care planning stages.
3. A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?
- A. Hepatitis C (HepC)
- B. Influenza type B (HIB)
- C. Measles, mumps, rubella (MMR)
- D. Diphtheria, tetanus, pertussis (DTaP)
Correct answer: C
Rationale: The correct answer is C: Measles, mumps, rubella (MMR). MMR vaccine is commonly included in precollege physicals to ensure students are protected against these diseases. Choice A, Hepatitis C (HepC), is incorrect as the standard vaccine for hepatitis given in childhood is Hepatitis B. Choice B, Influenza type B (HIB), is not typically administered during precollege physicals but is recommended for younger children. Choice D, Diphtheria, tetanus, pertussis (DTaP), is usually given in early childhood and not typically repeated during precollege physicals.
4. An adult client is undergoing weekly external radiation treatments for breast cancer and reports increasing fatigue. What action should the nurse take?
- A. Notify the healthcare provider or charge nurse immediately
- B. Offer to reschedule the treatment for the following week
- C. Plan to monitor the client's vital signs every 30 minutes
- D. Reinforce the need for extra rest periods and plenty of sleep
Correct answer: D
Rationale: The correct action for the nurse to take when a client undergoing radiation treatment for breast cancer reports increasing fatigue is to reinforce the need for extra rest periods and plenty of sleep. Fatigue is a common side effect of radiation therapy, and adequate rest and sleep can help manage this symptom. Notifying the healthcare provider or charge nurse immediately (choice A) is not necessary for increasing fatigue, as it is expected during radiation therapy. Offering to reschedule the treatment for the following week (choice B) is not the best initial action for managing fatigue. Planning to monitor the client's vital signs every 30 minutes (choice C) is unnecessary and not directly related to managing fatigue caused by radiation therapy.
5. A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?
- A. Increase the sedation as prescribed.
- B. Manually ventilate the client using an ambu bag.
- C. Check the ventilator settings and alarms.
- D. Suction the client’s airway.
Correct answer: C
Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.