HESI LPN
HESI Maternal Newborn
1. A client is 4 hours postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct answer: D
Rationale: In hypovolemic shock, there is decreased oxygen delivery to tissues. Administering oxygen at 4L/min via nasal cannula can help improve oxygenation and support tissue perfusion. Indomethacin (Choice A) is a nonsteroidal anti-inflammatory drug and is not indicated in the management of hypovolemic shock. Inserting a second 22-gauge IV catheter (Choice B) may be necessary for fluid resuscitation, but oxygen administration takes precedence. Inserting an indwelling urinary catheter (Choice C) may be considered for monitoring urinary output, but it is not the priority action in managing hypovolemic shock.
2. A nurse on an antepartum unit is reviewing the medical records for four clients. Which of the following clients should the nurse assess first?
- A. A client who has diabetes mellitus and an HbA1c of 5.8%
- B. A client who has preeclampsia and a creatinine level of 1.1 mg/dL
- C. A client who has hyperemesis gravidarum and a sodium level of 110 mEq/L
- D. A client who has placenta previa and a hematocrit of 36%
Correct answer: C
Rationale: A sodium level of 110 mEq/L is critically low and can indicate severe dehydration and electrolyte imbalance, requiring immediate intervention.
3. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?
- A. Caput succedaneum
- B. Hydrocephalus
- C. Cephalhematoma
- D. Microcephaly
Correct answer: C
Rationale: The correct answer is Cephalhematoma. Cephalhematoma is a collection of blood between the skull bone and periosteum that does not cross the suture line. It often occurs due to birth trauma, such as forceps delivery, leading to localized swelling. Caput succedaneum (Choice A) is diffuse swelling of the scalp that may cross suture lines and is typically present at birth. Hydrocephalus (Choice B) is an abnormal accumulation of cerebrospinal fluid within the brain's ventricles. Microcephaly (Choice D) is a condition characterized by a smaller than average head size and may be present at birth or develop later in infancy.
4. Humans begin life as a single cell that divides repeatedly. This cell is known as a(n):
- A. zygote.
- B. gonadotrope.
- C. embryo.
- D. chromaffin.
Correct answer: A
Rationale: A zygote is the correct answer. It is the initial cell formed when a sperm cell fertilizes an egg cell, marking the beginning of human development. Choice B, gonadotrope, is incorrect as it refers to a type of hormone-secreting cell in the pituitary gland. Choice C, embryo, is incorrect as it is the stage of development after the zygote has implanted into the uterine wall and undergone initial cell divisions. Choice D, chromaffin, is incorrect as it refers to cells found in the adrenal medulla that produce and store catecholamines.
5. Which of the following statements is true of a sperm cell?
- A. A sperm cell is significantly larger than an egg cell.
- B. A sperm cell contains two Y chromosomes.
- C. A sperm cell travels randomly inside a woman’s reproductive tract.
- D. A sperm cell is one of the smallest types of cells in the body.
Correct answer: D
Rationale: The correct answer is D. A sperm cell is indeed one of the smallest cells in the human body, much smaller than an egg cell. Choice A is incorrect as sperm cells are much smaller than egg cells. Choice B is incorrect because a sperm cell carries either an X or a Y chromosome, not two Y chromosomes. Choice C is incorrect since sperm cells move in a purposeful manner guided by various factors within a woman's reproductive tract, not randomly.
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