HESI LPN
Maternity HESI Test Bank
1. A prenatal educator is teaching a class about false labor. Which of the following information should the educator include?
- A. Contractions will become more intense with walking
- B. There will be dilation and effacement of the cervix
- C. There will be bloody show
- D. Contractions will become temporarily regular
Correct answer: D
Rationale: The correct answer is D. False labor contractions, also known as Braxton Hicks contractions, are typically irregular and do not lead to cervical dilation or effacement. They are often described as sporadic and temporary, becoming temporarily regular. Choices A, B, and C are incorrect because false labor contractions do not intensify with activity, do not cause cervical changes like dilation and effacement, and are not associated with the presence of a bloody show.
2. The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct answer: C
Rationale: Ascites is a common finding in clients with portal hypertension. Portal hypertension results in increased pressure in the portal vein, leading to the development of ascites, which is the accumulation of fluid in the abdominal cavity. Expiratory wheezes (Choice A) are associated with respiratory conditions. Blurred vision (Choice B) is more commonly linked to eye disorders or neurological issues. Dilated pupils (Choice D) can be related to neurological conditions or drug effects, but not specifically to portal hypertension.
3. The urinary drainage of a client with continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement?
- A. Increase the irrigation rate
- B. Lower the head of the bed
- C. Milk the catheter tubing
- D. Evaluate for fluid overload
Correct answer: A
Rationale: Increasing the irrigation rate can help clear any blood clots and reduce the redness in the urinary drainage. This intervention aims to improve the flushing of the bladder and potentially resolve the issue. Lowering the head of the bed would not directly address the red urinary drainage. Milking the catheter tubing is not recommended as it can cause trauma to the catheter or bladder, leading to further complications. While evaluating for fluid overload is an important nursing consideration, it does not directly address the immediate concern of redness in the urinary drainage, which requires a focused intervention to clear any blockages or clots in the system.
4. A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?
- A. Emphasize the importance of active foot flexion
- B. Check the surgical dressing
- C. Complete an incident report
- D. Explain the use of an incentive spirometer every 2 hours
Correct answer: A
Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.
5. What type of vaccine should a child with a history of severe allergic reactions receive?
- A. Live attenuated vaccines
- B. Inactivated vaccines
- C. Subunit vaccines
- D. Recombinant vaccines
Correct answer: B
Rationale: Children with a history of severe allergic reactions should receive inactivated vaccines because they do not contain live pathogens. Live attenuated vaccines (choice A) contain weakened live pathogens and can potentially trigger an allergic reaction in sensitive individuals. Subunit vaccines (choice C) and recombinant vaccines (choice D) may contain components that could still trigger an allergic response in individuals with a history of severe allergies. Inactivated vaccines are the safest choice for individuals with a history of severe allergic reactions as they do not pose a risk of causing an allergic reaction due to the absence of live pathogens.