HESI LPN
HESI Maternal Newborn
1. A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage.
- B. Apply counterpressure to the client's sacrum.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct answer: B
Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.
2. The embryo and fetus develop within a protective _______ in the uterus.
- A. amniotic sac
- B. umbilical cord
- C. neural tube
- D. embryonic disk
Correct answer: A
Rationale: The correct answer is A, the amniotic sac. The amniotic sac is a fluid-filled structure that surrounds and protects the developing embryo and fetus in the uterus. It provides a cushion against external pressure, allows for movement and growth, and helps maintain a stable environment for the developing fetus. Choices B, C, and D are incorrect. The umbilical cord connects the fetus to the placenta and serves as a conduit for nutrients and waste; the neural tube is a structure that forms the central nervous system in early embryonic development; and the embryonic disk is a structure that forms during gastrulation, one of the early stages of embryonic development.
3. According to a study conducted in 2013 by Fellman, what affects the chances of having twins?
- A. Increase when a woman conceives at a younger age.
- B. Increase with parental age.
- C. Decrease with the frequency of intercourse before conception.
- D. Decrease with the use of fertility drugs.
Correct answer: B
Rationale: The correct answer is B. According to the study by Fellman in 2013, the chances of having twins actually increase with parental age. Choice A is incorrect as the study does not specify a younger age for conceiving to increase the chances of twins. Choice C is incorrect as the frequency of intercourse before conception is not a highlighted factor in the study. Choice D is also incorrect as the study does not discuss the impact of fertility drugs on the likelihood of having twins.
4. Which of the following statements is true of mutations?
- A. Mutations can only occur by chance.
- B. Mutations produce sperm and ova cells.
- C. Mutations occur through radiation or other environmental influences.
- D. Mutations help adenine combine with guanine to form the single spiral structure of DNA.
Correct answer: C
Rationale: The correct answer is C. Mutations can occur due to environmental influences such as radiation, chemicals, or other external factors, leading to changes in the DNA sequence. Choice A is incorrect because mutations can also occur due to errors in DNA replication, not solely by chance. Choice B is incorrect as mutations affect the DNA sequence itself, not the production of specific cells. Choice D is incorrect because mutations involve changes in the DNA sequence and do not specifically involve the formation of the DNA structure.
5. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?
- A. Page the pediatrician STAT
- B. Continue resuscitative efforts
- C. Repeat the Apgar assessment in 5 minutes
- D. Inform the parents of the infant's condition
Correct answer: B
Rationale: In a situation where an infant receives a low Apgar score of 3 following a traumatic delivery, the most crucial intervention for the nurse to implement is to continue resuscitative efforts. A low Apgar score indicates that the newborn is in distress and requires immediate medical attention to support breathing, heart rate, muscle tone, reflex irritability, and color. Continuing resuscitative efforts is essential to provide life-saving interventions promptly. Paging the pediatrician may cause a delay in crucial interventions, repeating the Apgar assessment in 5 minutes is not appropriate as immediate action is needed to stabilize the infant, and informing parents should not take precedence over providing immediate medical care to the newborn.
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