a nurse is planning care for a full term newborn who is receiving phototherapy which of the following actions should the nurse include in the plan of
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HESI Maternity 55 Questions

1. A healthcare professional is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the healthcare professional include in the plan of care?

Correct answer: B

Rationale: When a newborn is receiving phototherapy, it is important to avoid using lotions or ointments on their skin as these products can lead to skin irritation and burns under the phototherapy lights. Dressing the newborn in lightweight clothing helps ensure proper exposure to the phototherapy lights. Keeping the newborn supine during treatment helps maximize exposure to the light. However, the key consideration in this scenario is to prevent skin irritation and burns by avoiding lotions or ointments.

2. A newborn who was born post-term is being assessed by a nurse. Which of the following findings should the nurse expect?

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.

3. A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes. The nurse observes several shallow small vesicles on her pubis, labia, and perineum. The nurse should recognize the client is exhibiting symptoms of which condition?

Correct answer: C

Rationale: The correct answer is C: Herpes Simplex Virus (HSV). HSV can present with small vesicles on the genital area, and it is a concern during labor due to the risk of transmission to the newborn. Genital warts (Choice A) are caused by the human papillomavirus (HPV) and typically present as flesh-colored growths, not vesicles. Syphilis (Choice B) manifests as painless sores and can have systemic effects but does not typically present with vesicles. German measles (Choice D), also known as Rubella, is a viral illness characterized by a red rash, fever, and lymphadenopathy, not vesicles.

4. Which of the following statements is true of sickle-cell anemia?

Correct answer: C

Rationale: The correct answer is C. Sickle-cell anemia results from a mutation in the beta-globin gene, causing red blood cells to become sickle-shaped. These misshapen cells can obstruct small blood vessels, leading to reduced oxygen delivery to tissues. Choices A, B, and D are incorrect because sickle-cell anemia is typically managed with treatments such as pain relief medications, hydration, and in severe cases, blood transfusions. It is caused by a specific mutation in the beta-globin gene, not by the inability to metabolize phenylalanine. Additionally, sickle-cell anemia is more prevalent in individuals of African, Mediterranean, Middle Eastern, and Indian descent, not exclusive to any specific gender.

5. Which of the following pairs of bases is present in the rungs of the ladder-like structure of deoxyribonucleic acid (DNA)?

Correct answer: A

Rationale: The correct answer is A: Cytosine with guanine. In the DNA double helix, cytosine always pairs with guanine forming a base pair, and adenine pairs with thymine. These complementary base pairs form the rungs of the ladder-like structure of DNA. Choice B, Rhodamine with biotin, is incorrect as they are not base pairs found in DNA. Choice D, Serine with tyrosine, is incorrect as they are amino acids, not DNA bases. Choice C, Diaminopurine with ribozyme, is also incorrect as ribozyme is an enzyme, not a base, and diaminopurine is not one of the standard bases found in DNA.

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