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. According to a study in 2013 by van Gameren-Oosterom, individuals with Down syndrome:
- A. are unlikely to die from cardiovascular problems by middle age.
- B. have no specific characteristic features.
- C. show deficits in cognitive development.
- D. are likely to have only 46 chromosomes.
Correct answer: C
Rationale: The correct answer is C. According to a study in 2013 by van Gameren-Oosterom, individuals with Down syndrome often exhibit deficits in cognitive development. This is a common characteristic of Down syndrome, along with other health challenges. Choice A is incorrect because individuals with Down syndrome are at a higher risk of cardiovascular problems, contrary to being unlikely to die from them. Choice B is incorrect as Down syndrome is associated with specific characteristic features such as distinctive facial characteristics, making the statement that they have no specific features incorrect. Choice D is incorrect as individuals with Down syndrome have an extra copy of chromosome 21, resulting in a total of 47 chromosomes, not 46.
3. As women reach the end of their childbearing years, does ovulation become more regular?
- A. TRUE
- B. FALSE
- C. Rarely
- D. Always
Correct answer: B
Rationale: The correct answer is B: FALSE. As women age and reach the end of their childbearing years, ovulation becomes less regular due to hormonal changes associated with menopause. This can result in irregular ovulation patterns or even the cessation of ovulation entirely. Choice A is incorrect because ovulation does not become more regular with age. Choices C and D are also incorrect as they do not accurately reflect the changes in ovulation patterns that occur as women approach the end of their childbearing years.
4. A healthcare provider is reviewing laboratory results for a client who is pregnant. The healthcare provider should expect which of the following laboratory values to increase?
- A. RBC count
- B. Bilirubin
- C. Fasting blood glucose
- D. BUN
Correct answer: A
Rationale: During pregnancy, the body increases the production of red blood cells (RBCs) to meet the increased oxygen demands. This physiological response is known as physiological anemia of pregnancy. Therefore, the RBC count is expected to increase during pregnancy. Bilirubin levels may remain relatively stable, fasting blood glucose levels might fluctuate due to gestational diabetes, and blood urea nitrogen (BUN) levels are not typically affected by pregnancy, making them less likely to increase in this scenario. The correct answer is A because an increase in RBC count is a normal physiological adaptation to pregnancy to support the increased oxygen needs of the mother and the growing fetus. Bilirubin, a product of red blood cell breakdown, is more related to liver function and not expected to increase during pregnancy. Fasting blood glucose levels may vary due to gestational diabetes, but it is not a consistent finding in all pregnant individuals. BUN levels are related to kidney function and are not typically impacted by pregnancy, making it an unlikely choice for an expected increase in laboratory values during pregnancy.
5. 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.
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