HESI LPN
HESI Maternity 55 Questions
1. A client at 38 weeks gestation is admitted to labor and delivery with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What should the nurse do first?
- A. Push the call light for help
- B. Inspect the client's perineum
- C. Notify a healthcare provider
- D. Turn on the infant warmer
Correct answer: B
Rationale: Inspecting the client's perineum immediately is necessary to assess if the baby is being delivered, which would require urgent action. Pushing the call light for help (Choice A) may delay the assessment and immediate action needed. Notifying a healthcare provider (Choice C) might cause further delays, as the situation requires urgent attention. Turning on the infant warmer (Choice D) is not the priority; ensuring safe delivery and assessment of the baby's condition come first.
2. A child with acute lymphoblastic leukemia (ALL) is hospitalized for treatment. What is the priority nursing intervention?
- A. Administering antibiotics
- B. Preventing infection
- C. Providing nutritional support
- D. Managing pain
Correct answer: B
Rationale: The priority nursing intervention for a child hospitalized for acute lymphoblastic leukemia (ALL) is preventing infection. Children with ALL have compromised immune systems, making them highly vulnerable to infections. Preventing infections through strict aseptic techniques, isolation precautions, and proper hygiene is crucial to safeguard the child's health. Administering antibiotics (choice A) may be necessary if an infection occurs, but the primary focus should be on infection prevention. While providing nutritional support (choice C) is important, preventing infection takes precedence due to its direct impact on the child's survival. Managing pain (choice D) is essential for the child's comfort but is not the priority over preventing life-threatening infections in this scenario.
3. How should a child with a newly diagnosed seizure disorder be managed?
- A. Avoid all physical activity
- B. Monitor for triggers and ensure safety
- C. Increase dietary sodium intake
- D. Restrict all forms of social interaction
Correct answer: B
Rationale: When managing a child with a newly diagnosed seizure disorder, it is essential to monitor for triggers and ensure safety. By identifying triggers such as lack of sleep, stress, or specific foods, healthcare professionals can help prevent seizures. Ensuring safety involves creating a safe environment to prevent injuries during a seizure. Choices A, C, and D are incorrect. Avoiding all physical activity can be detrimental as appropriate exercise is essential for overall health. Increasing dietary sodium intake is not a standard recommendation for managing seizures. Restricting all forms of social interaction is unnecessary and can have negative effects on the child's emotional well-being.
4. What is an early sign of congestive heart failure that the nurse should recognize?
- A. tachypnea
- B. bradycardia
- C. inability to sweat
- D. increased urinary output
Correct answer: A
Rationale: Tachypnea is an early sign of congestive heart failure that nurses should recognize. Tachypnea refers to rapid breathing, which can be an indication of the body's attempt to compensate for decreased cardiac output in congestive heart failure. Bradycardia (choice B) is a slow heart rate and is not typically associated with congestive heart failure. Inability to sweat (choice C) and increased urinary output (choice D) are not specific early signs of congestive heart failure and are not typically recognized as such.
5. When admitting a client with Parkinson's disease to the home healthcare service, which nursing diagnosis should have priority in planning care?
- A. Impaired physical mobility related to muscle rigidity and weakness.
- B. Ineffective coping related to depression and dysfunction due to disease progression.
- C. Ineffective breathing pattern related to respiratory muscle weakness.
- D. Fear related to constant possibility of experiencing seizures.
Correct answer: A
Rationale: The correct answer is A: 'Impaired physical mobility related to muscle rigidity and weakness.' For a client with Parkinson's disease, impaired physical mobility is a priority nursing diagnosis because of the characteristic motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Addressing impaired physical mobility is crucial to enhance the client's quality of life. Choices B, C, and D are not the priority nursing diagnoses for a client with Parkinson's disease. Ineffective coping (Choice B) and fear of seizures (Choice D) may be concerns but are not the priority. Ineffective breathing pattern (Choice C) is not typically associated with Parkinson's disease.