HESI LPN
HESI Maternal Newborn
1. A client has experienced a fetal demise following a vaginal delivery at term. What should the nurse advise the client?
- A. “You can bathe and dress your baby if you’d like to.â€
- B. “If you don’t hold the baby, it will make letting go much harder.â€
- C. “You should name the baby so he/she can have an identity.â€
- D. “I’m sure you will be able to have another baby when you’re ready.â€
Correct answer: A
Rationale: After a fetal demise, allowing the parents to bathe and dress their baby can offer them a sense of closure and help them in their grieving process. This act can provide a tangible way for the parents to bond with their baby and create lasting memories. Option B is incorrect because each individual may have different emotional needs and holding the baby may not be appropriate or helpful for everyone. Option C, while well-intentioned, may not be suitable for all parents as naming the baby could be emotionally challenging. Option D is insensitive as it overlooks the grieving process of losing a baby by suggesting a replacement.
2. A newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn's admission. What action should the nurse take to ensure adequate installation of the ointment?
- A. Instill a thin ribbon into each lower conjunctival sac
- B. Occlude the inner canthus after retracting the eyelids
- C. Mummy wrap the infant before instilling the ointment
- D. Stabilize the instilling hand on the neonate's head
Correct answer: A
Rationale: To ensure adequate installation of the ophthalmic erythromycin 5% ointment in a newborn, the nurse should instill a thin ribbon into each lower conjunctival sac. This method helps to ensure proper distribution and effectiveness of the medication to prevent neonatal conjunctivitis. Choices B, C, and D are incorrect. Occluding the inner canthus after retracting the eyelids, mummy wrapping the infant, or stabilizing the instilling hand on the neonate's head are not appropriate actions for ensuring the proper installation of the ointment.
3. A client is in the second stage of labor. Which of the following manifestations should the nurse expect?
- A. The client expels the placenta
- B. The client experiences gradual dilation of the cervix
- C. The client begins having regular contractions
- D. The client delivers the newborn
Correct answer: D
Rationale: During the second stage of labor, the cervix is fully dilated, and the client delivers the newborn. The expulsion of the placenta occurs during the third stage of labor, not the second stage. Regular contractions typically begin in the first stage of labor, not the second. Gradual dilation of the cervix occurs during the first stage of labor, specifically during the active phase.
4. What causes cystic fibrosis?
- A. Sex-linked abnormality.
- B. Abnormality in the 21st pair of chromosomes.
- C. Recessive gene.
- D. Single segment found only on the Y chromosome.
Correct answer: C
Rationale: Cystic fibrosis is a genetic disorder caused by inheriting two copies of a recessive gene, one from each parent. This means that both parents must carry at least one copy of the faulty gene for a child to inherit the condition. Choice A is incorrect because cystic fibrosis is not linked to the sex chromosomes. Choice B is incorrect as cystic fibrosis is not caused by an abnormality in the 21st pair of chromosomes but by a specific gene mutation. Choice D is also incorrect as cystic fibrosis is not related to the Y chromosome, which is specific to males.
5. What is the typical sex chromosome pattern for females?
- A. XX
- B. XYY
- C. XY
- D. XXY
Correct answer: A
Rationale: The typical sex chromosome pattern for females is XX. Females have two X chromosomes, which is represented as XX. Choice B (XYY) is incorrect as it represents the sex chromosome pattern for males with an extra Y chromosome. Choice C (XY) is the sex chromosome pattern for males. Choice D (XXY) represents a genetic disorder known as Klinefelter syndrome, where males have an extra X chromosome.
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