HESI LPN
HESI Maternal Newborn
1. A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct answer: B
Rationale: The correct answer is B: 'The mother is Rh negative, and the father is Rh positive.' Hemolytic disease of the newborn occurs when an Rh-negative mother carries an Rh-positive fetus, leading to Rh incompatibility. In this scenario, the mother produces antibodies against the Rh antigen present in the fetus, which can result in hemolysis of the fetal red blood cells. Choices A, C, and D do not describe the Rh incompatibility that leads to hemolytic disease in newborns. Therefore, they are incorrect.
2. 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.
3. How many pairs of autosomes does a human zygote contain?
- A. 46
- B. 44
- C. 23
- D. 22
Correct answer: D
Rationale: A human zygote contains 22 pairs of autosomes and one pair of sex chromosomes, totaling 46 chromosomes. Therefore, the correct answer is 22. Choices A, B, and C are incorrect because they do not accurately represent the number of autosomes in a human zygote. Option A (46) represents the total number of chromosomes in a human zygote, not the number of autosomes. Option B (44) is incorrect as it does not account for the correct number of autosomes. Option C (23) is inaccurate since it represents the total number of chromosomes in a human gamete, not the number of autosomes in a zygote.
4. A newborn who was born post-term is being assessed by a nurse. Which of the following findings should the nurse expect?
- A. A Rh-negative mother who has an Rh-positive infant
- B. A Rh-positive mother who has an Rh-negative infant
- C. A Rh-positive mother who has an Rh-positive infant
- D. A Rh-negative mother who has an Rh-negative infant
Correct answer: A
Rationale: The correct answer is A: 'A Rh-negative mother who has an Rh-positive infant.' In cases where the newborn is born post-term, the mismatched Rh factor between the mother (Rh-negative) and the infant (Rh-positive) can lead to hemolytic disease of the newborn. This condition occurs when maternal antibodies attack fetal red blood cells, causing hemolysis. This can result in jaundice, anemia, and other serious complications for the infant. Choices B, C, and D are incorrect because they do not reflect the mismatched Rh factor scenario that poses a risk for hemolytic disease of the newborn.
5. A client at 38 weeks of gestation has a prescription for intravaginal misoprostol. Which of the following statements should the nurse make?
- A. “You will need to stay in a side-lying position for 30 minutes after each dose.”
- B. “You will receive an IV infusion of oxytocin 1 hour after your last dose.”
- C. “You will receive a magnesium supplement immediately following therapy.”
- D. “You will need to have a full bladder before the therapy begins.”
Correct answer: A
Rationale: The correct answer is A. Instructing the client to stay in a side-lying position after receiving misoprostol intravaginally is essential. This position helps keep the medication in place, allowing for better absorption. Choice B is incorrect because oxytocin administration is not typically indicated after misoprostol use. Choice C is incorrect as magnesium supplementation is not part of the standard protocol for misoprostol administration. Choice D is incorrect as having a full bladder is not necessary before initiating misoprostol therapy.
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