HESI LPN
Maternity HESI Test Bank
1. 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.
2. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?
- A. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
- B. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
- C. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
- D. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.
Correct answer: B
Rationale: The correct interpretation of the assessment provided is that the cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines. In the given assessment, the measurements are ordered as dilation, effacement, and station. Choice A is incorrect as it wrongly places the presenting part below the ischial spines. Choice C is incorrect because it places the presenting part below the ischial spines. Choice D is also incorrect as it incorrectly states that the presenting part is below the ischial spines, even though it correctly mentions the dilation and effacement of the cervix.
3. A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Allow liberal family visitation
- B. Keep an airway at the bedside
- C. Assess temperature every hour
- D. Monitor blood pressure, pulse, and respiration every 4 hours
Correct answer: B
Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.
4. A client who is at 24 weeks of gestation is receiving teaching about expected changes during pregnancy. Which of the following information should the nurse include?
- A. Your stomach will empty rapidly
- B. You should expect your uterus to double in size
- C. You should anticipate nasal stuffiness
- D. Your nipples will become lighter in color
Correct answer: C
Rationale: Nasal stuffiness is a common symptom during pregnancy due to increased blood flow and hormonal changes. This symptom is caused by the increased blood volume and hormonal changes that lead to swelling of the nasal passages. Choices A, B, and D are incorrect. Stomach emptying rate does not significantly change during pregnancy; the uterus does not double in size at 24 weeks but rather grows steadily, and nipples typically darken in color due to increased pigmentation.
5. What determines a child’s sex?
- A. Presence of teratogens at the time of conception.
- B. Sex chromosome received from the mother.
- C. Presence of teratogens at the time of ovulation.
- D. Sex chromosome received from the father.
Correct answer: D
Rationale: The correct answer is the sex chromosome received from the father. The father contributes either an X or Y chromosome, which determines the child's sex. This occurs at the moment of fertilization when the sperm carrying either an X (resulting in a female) or Y (resulting in a male) chromosome fertilizes the egg. Choices A, B, and C are incorrect because the presence of teratogens at the time of conception or ovulation does not determine the child's sex. While the sex chromosome received from the mother is important, it is the father's contribution that ultimately determines the child's sex.
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