HESI LPN
HESI Focus on Maternity Exam
1. A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take?
- A. Assess bowel sounds.
- B. Continue to monitor.
- C. Assist with intubation.
- D. Rub the infant's back.
Correct answer: B
Rationale: Cyanosis of the hands and feet, known as acrocyanosis, is common in newborns shortly after birth and usually resolves on its own. It is not indicative of a need for immediate intervention. Therefore, the appropriate action is to continue monitoring the newborn's condition. Assessing bowel sounds (Choice A) is not relevant to the presenting issue of cyanosis and respiratory rate. Assisting with intubation (Choice C) is an invasive procedure that is not warranted based on the information provided. Rubbing the infant's back (Choice D) is not necessary for acrocyanosis and could potentially disturb the newborn.
2. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?
- A. Alcohol
- B. Mineral oil
- C. Calamine
- D. A&D ointment
Correct answer: B
Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (Choice A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (Choice C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (Choice D) is typically used for diaper rash and minor skin irritations, not for cradle cap.
3. A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What should the nurse include in the accident prevention teaching plan?
- A. Remove small objects from the floor.
- B. Cover electric outlets with safety plugs.
- C. Remove toxic substances from low areas.
- D. Test the temperature of water before bathing.
Correct answer: D
Rationale: The correct answer is to test the temperature of water before bathing. This is crucial in preventing burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can be easily burned by water that is too hot. Removing small objects from the floor (Choice A) is important to prevent choking hazards but not directly related to burns. Covering electric outlets with safety plugs (Choice B) is essential to prevent electrocution but does not address the risk of burns specifically. Removing toxic substances from low areas (Choice C) is necessary to prevent poisoning but is not directly related to burns. Therefore, the priority in this scenario is to prevent burns by ensuring the water temperature is safe for the infant.
4. A client has been sitting in a chair for 1 hour. Which of the following complications poses the greatest risk to the client?
- A. Decreased subcutaneous fat
- B. Muscle atrophy
- C. Pressure injury
- D. Fecal impaction
Correct answer: C
Rationale: The correct answer is C: Pressure injury. Prolonged sitting can lead to pressure injuries due to continuous pressure on certain body areas, reducing blood flow and causing tissue damage. While decreased subcutaneous fat, muscle atrophy, and fecal impaction are potential concerns, pressure injuries pose the greatest immediate risk as they can lead to serious complications such as tissue necrosis and infection if not addressed promptly. Decreased subcutaneous fat and muscle atrophy may develop over time with prolonged immobility but are not as acutely dangerous as a pressure injury. Fecal impaction, while uncomfortable and potentially serious, does not pose an immediate life-threatening risk compared to the development of a pressure injury.
5. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:
- A. On an empty stomach
- B. At the same time each evening
- C. Evenly spaced around the clock
- D. As needed when the client complains of depression
Correct answer: B
Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.