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

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. Which procedure is used to detect neural tube defects such as spina bifida and certain chromosomal abnormalities?

A. Artificial insemination
B. Amniocentesis
C. Endometriosis
D. Alpha-fetoprotein (AFP) assay

Correct answer: D

Rationale: The correct answer is the Alpha-fetoprotein (AFP) assay. This blood test measures the level of AFP in a pregnant woman's blood, aiding in the detection of neural tube defects and certain chromosomal abnormalities in the fetus. Choice A, artificial insemination, is a method used to facilitate fertilization and is not related to detecting fetal abnormalities. Choice B, amniocentesis, involves collecting amniotic fluid for genetic testing, not directly measuring AFP levels. Choice C, endometriosis, is a medical condition involving abnormal tissue growth and is not a procedure for detecting fetal abnormalities. Therefore, the Alpha-fetoprotein (AFP) assay is the most appropriate option for detecting neural tube defects such as spina bifida and certain chromosomal abnormalities.

3. A newborn is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?

A. Apply a thin layer of lotion to the newborn's skin every 8 hours.
B. Give the newborn 1 oz of glucose water every 4 hours.
C. Ensure the newborn's eyes are closed beneath the shield.
D. Dress the newborn in a thin layer of clothing during therapy.

Correct answer: C

Rationale: During phototherapy using a lamp, it is crucial to protect the newborn's eyes from the light to prevent damage. Closing the newborn's eyes beneath the shield is essential for this purpose. Applying lotion to the skin (Choice A) is not recommended as it can intensify the effects of the phototherapy. Giving glucose water (Choice B) is unrelated to the phototherapy process and is not indicated. Dressing the newborn in clothing (Choice D) may hinder the effectiveness of the phototherapy by blocking the light exposure to the skin.

4. Which of the following statements is true about Tay-Sachs disease?

A. It is most commonly found among children in Jewish families of Eastern European background.
B. Children who have this disease suffer from excessive production of mucus in the lungs and pancreas.
C. It is most commonly found among children in Asian American families.
D. Children who have this disease suffer from muscular dystrophy characterized by a weakening of the muscles.

Correct answer: A

Rationale: The correct answer is A. Tay-Sachs disease is most commonly found among Jewish families of Eastern European descent. It is a fatal genetic disorder that affects the nervous system. Choice B is incorrect because Tay-Sachs disease does not involve excessive mucus production in the lungs and pancreas. Choice C is incorrect as it states that Tay-Sachs disease is most commonly found among Asian American families, which is inaccurate. Choice D is also incorrect because Tay-Sachs disease does not cause muscular dystrophy characterized by weakening of the muscles.

5. Monozygotic (MZ) twins are known as fraternal twins.

A. TRUE
B. FALSE
C. Possibly
D. Never

Correct answer: B

Rationale: The correct answer is B: 'FALSE.' Monozygotic (MZ) twins are identical twins, not fraternal. Fraternal twins are dizygotic (DZ). The statement in the question is incorrect as MZ twins are genetically identical, while fraternal twins actually refer to dizygotic twins who develop from two separate fertilized eggs. Therefore, monozygotic twins are not known as fraternal twins, making option B the correct choice. Options A, C, and D are incorrect as they do not accurately describe the relationship between monozygotic and fraternal twins.