HESI LPN
HESI Focus on Maternity Exam
1. A client who delivered a healthy newborn an hour ago asked the nurse when she can go home. Which information is most important for the nurse to provide the client?
- A. After the baby no longer demonstrates acrocyanosis
- B. After the baby receives the vitamin K injection
- C. When ambulating to avoid causing dizziness
- D. When there is no significant vaginal bleeding
Correct answer: D
Rationale: The most critical information for the nurse to provide the client is ensuring that there is no significant vaginal bleeding before discharge. This is vital to prevent complications such as postpartum hemorrhage. Options A, B, and C are important aspects of postpartum care, but assessing and managing vaginal bleeding takes precedence due to its potential seriousness.
2. A nurse on a labor and delivery unit is providing teaching to a client who plans to use hypnosis to control labor pain. Which of the following information should the nurse include?
- A. Focusing on controlling body functions
- B. Synchronized breathing is often helpful during hypnosis
- C. Hypnosis can be beneficial if practiced during the prenatal period
- D. Hypnosis is ineffective for controlling pain associated with labor
Correct answer: C
Rationale: Hypnosis can be an effective method of pain control during labor, especially if practiced during the prenatal period. Choice A is not specific to hypnosis and may not be directly related. Choice B is not essential for hypnosis and may not always be required. Choice D is incorrect as hypnosis has been shown to be beneficial for managing labor pain when done correctly, making it an inappropriate option to include in the teaching.
3. A client at 20 weeks of gestation has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, White Vaginal Discharge
- B. Urinary Frequency
- C. Vulvar Lesions
- D. Malodorous Discharge
Correct answer: D
Rationale: Malodorous discharge is a common symptom of trichomoniasis caused by the Trichomonas vaginalis parasite. It is typically described as frothy, greenish-yellow, and malodorous. Choices A, B, and C are incorrect findings associated with other conditions. Thick, white vaginal discharge is more characteristic of a yeast infection; urinary frequency may be seen in urinary tract infections; and vulvar lesions are commonly seen in herpes simplex virus infections.
4. A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL, hematocrit 29%, hepatitis surface antigen positive, Group B Streptococcus positive, and rubella non-immune. Which intervention should the nurse implement?
- A. Transfuse 2 units of packed red blood cells.
- B. Give measles, mumps, rubella vaccine 0.5 mL.
- C. Administer ampicillin 2 grams intravenously.
- D. Inject hepatitis B immune globulin 0.5 milliliters.
Correct answer: C
Rationale: The correct intervention in this scenario is to administer ampicillin 2 grams intravenously. This is crucial to prevent Group B Streptococcus infection in the newborn during delivery. Option A, transfusing packed red blood cells, is not indicated based on the hemoglobin and hematocrit levels provided. Option B, giving measles, mumps, rubella vaccine, is not necessary at this time. Option D, injecting hepatitis B immune globulin, is not appropriate for the conditions presented in the question.
5. A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a calm environment
- B. Monitor blood glucose levels every hour
- C. Initiate seizure precautions
- D. Place the infant on their back with legs extended
Correct answer: C
Rationale: Initiating seizure precautions is crucial when caring for an infant with neonatal abstinence syndrome due to the increased risk of seizures. Providing a calm environment (Choice A) is important to reduce stimulation as these infants may be irritable. Monitoring blood glucose levels (Choice B) is not typically a priority in neonatal abstinence syndrome unless specific signs or symptoms suggest the need for this assessment. Placing the infant on their back with legs extended (Choice D) does not directly address the potential complications associated with neonatal abstinence syndrome, such as seizures.
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