HESI LPN
HESI Maternity 55 Questions
1. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 minutes.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hours.
Correct answer: A
Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.
2. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?
- A. Encourage the client to stop hurting themselves.
- B. Discuss what the client was feeling before self-harming.
- C. Inform the client that the behavior will be reported to their doctor.
- D. Ask the client why they hurt themselves.
Correct answer: B
Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.
3. A child has been diagnosed with gastroesophageal reflux disease (GERD). What position should the nurse recommend the child be placed in after eating?
- A. Supine
- B. Prone
- C. Semi-Fowler's
- D. Trendelenburg
Correct answer: C
Rationale: After eating, it is beneficial to place a child with GERD in a semi-Fowler's position. This position helps prevent reflux by keeping the child's head elevated above the stomach, reducing the chances of gastric contents flowing back into the esophagus. Placing the child supine (lying flat on their back) can worsen reflux symptoms by allowing gravity to work against the natural flow of gastric contents. Prone position (lying on the stomach) is not recommended due to the increased risk of aspiration. Trendelenburg position (feet elevated above head) is also inappropriate as it can lead to increased pressure on the abdomen, potentially worsening reflux symptoms.
4. A parent asks the nurse what to do when their toddler has temper tantrums. What play materials should the nurse suggest to offer the child as another way of expressing anger?
- A. Ball and bat
- B. Wad of clay
- C. Punching bag
- D. Pegs and pounding board
Correct answer: D
Rationale: Pegs and pounding boards are recommended as play materials for toddlers to express their anger in a constructive manner. These tools provide a safe and effective outlet for the child's emotions through physical activity. Options A, B, and C do not offer the same interactive and expressive qualities that pegs and pounding boards provide. A ball and bat may encourage aggressive behavior, a wad of clay is more suitable for creative expression rather than anger management, and a punching bag may promote violent behavior which is not appropriate for toddlers.
5. A client with a diagnosis of chronic heart failure is receiving digoxin. What is the most important instruction the nurse should provide?
- A. Take the medication with a high-fiber meal
- B. Monitor pulse rate daily before taking the medication
- C. Avoid dairy products while on this medication
- D. Discontinue the medication if blurred vision is experienced
Correct answer: B
Rationale: The most important instruction the nurse should provide is to monitor pulse rate daily before taking the medication. Digoxin can lead to bradycardia, so it is crucial to assess the pulse rate before administering the medication. This practice helps ensure that the heart rate is not too low for the safe use of digoxin. Choice A is incorrect as there is no specific requirement to take digoxin with a high-fiber meal. Choice C is also incorrect because there is no need to avoid dairy products while on digoxin. Choice D is incorrect since blurred vision is not a common side effect of digoxin; hence, it is not the most critical instruction to provide.