HESI LPN
HESI Maternity 55 Questions
1. A client who is 5 days postpartum is being taught about signs of effective breastfeeding. Which information should the nurse include in the teaching?
- A. Feeling a tugging sensation when the baby is sucking
- B. Expecting the baby to have two to three wet diapers in a 24-hour period
- C. The baby’s urine should appear dark and concentrated
- D. The breast should stay firm after the baby breastfeeds
Correct answer: A
Rationale: Feeling a tugging sensation while the baby is sucking indicates an effective latch and milk transfer during breastfeeding. This sensation means that the baby is effectively drawing milk from the breast. Choice B is incorrect because infants should ideally have six to eight wet diapers in a 24-hour period to show adequate hydration. Choice C is incorrect as a dark and concentrated urine may indicate dehydration, which is not a sign of effective breastfeeding. Choice D is incorrect as the breast should soften after the baby breastfeeds, indicating that the baby has effectively emptied the breast of milk.
2. According to a study in 2014 by Skakkebaek et al., who among the following is most likely to have gynecomastia?
- A. Jennifer, a dancer, who has Down syndrome
- B. Frank, a teacher, who is diagnosed with XYY syndrome
- C. Peter, a fashion designer, who has Klinefelter syndrome
- D. Ria, a gym instructor, who is diagnosed with Turner syndrome
Correct answer: C
Rationale: Individuals with Klinefelter syndrome have an extra X chromosome (XXY) and typically have reduced testosterone levels, which can lead to gynecomastia (enlarged breasts). This condition is not usually associated with Down syndrome (choice A), XYY syndrome (choice B), or Turner syndrome (choice D), making them less likely to have gynecomastia.
3. A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 cm). The nurse notes that this infant has no molding, and it was a breech presentation delivered by cesarean section. What action should the nurse take based on this data?
- A. No action needs to be taken, it is normal for an infant born by cesarean section to have a small head circumference.
- B. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus.
- C. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
- D. Record the findings on the chart. They are within normal limits.
Correct answer: D
Rationale: Head and chest circumference measurements are within normal limits for a newborn, especially for those delivered by cesarean section, so no immediate action is required beyond documentation.
4. What information should the nurse include when teaching a client at 41 weeks of gestation about a non-stress test?
- A. This test will confirm fetal lung maturity.
- B. This test will determine the adequacy of placental perfusion.
- C. This test will detect fetal infection.
- D. This test will predict maternal readiness for labor.
Correct answer: B
Rationale: The correct answer is B: 'This test will determine the adequacy of placental perfusion.' The non-stress test is used to assess fetal well-being by monitoring the fetal heart rate in response to its own movements. It helps determine if the fetus is receiving enough oxygen and nutrients through placental perfusion. Choice A is incorrect because confirming fetal lung maturity is typically determined through tests like amniocentesis, not the non-stress test. Choice C is incorrect because detecting fetal infection is not the primary purpose of a non-stress test. Choice D is incorrect because predicting maternal readiness for labor is not the purpose of the non-stress test; it focuses on fetal well-being.
5. Most victims of _____ die of respiratory infections in their 20s.
- A. Tay-Sachs disease
- B. cystic fibrosis
- C. Turner syndrome
- D. Klinefelter syndrome
Correct answer: B
Rationale: Individuals with cystic fibrosis have a genetic disorder that causes mucus to be thick and sticky, leading to blockages in the lungs and digestive system. This mucus buildup makes them more susceptible to severe respiratory infections, which can ultimately result in premature death in their 20s. Tay-Sachs disease (Choice A) is a genetic disorder that affects the nervous system, not typically causing respiratory infections. Turner syndrome (Choice C) and Klinefelter syndrome (Choice D) are chromosomal disorders that do not directly lead to the respiratory issues observed in cystic fibrosis.
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