HESI LPN
HESI Maternity 55 Questions
1. A primigravida arrives at the observation unit of the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time?
- A. Membranes are intact.
- B. 2+ pitting edema in lower extremities.
- C. Contractions decrease with walking.
- D. Cervical dilation is 1 centimeter.
Correct answer: C
Rationale: The correct answer is C. Contractions that decrease with walking are typically indicative of false labor, as true labor contractions tend to intensify with activity. Choices A, B, and D are incorrect. A) Intact membranes are a normal finding and do not confirm the absence of labor. B) 2+ pitting edema in lower extremities is a sign of fluid retention and not directly related to labor status. D) Cervical dilation of 1 centimeter indicates some cervical changes, but it alone does not confirm active labor.
2. A client with a diagnosis of schizophrenia is prescribed quetiapine. The nurse should monitor the client for which potential side effect?
- A. Weight gain
- B. Dry mouth
- C. Nausea
- D. Headache
Correct answer: A
Rationale: Quetiapine is known to cause weight gain as a common side effect. Monitoring the client's weight is crucial to identify any significant changes that may occur due to the medication.
3. What is the most important intervention for a nurse to implement for a child with sickle cell anemia admitted to the hospital during a vaso-occlusive crisis?
- A. Administering oxygen
- B. Ensuring adequate hydration
- C. Monitoring vital signs
- D. Administering pain medication
Correct answer: B
Rationale: Ensuring adequate hydration is crucial during a vaso-occlusive crisis in sickle cell anemia as it helps to reduce the viscosity of the blood and prevent further sickling of the cells. While administering oxygen may be necessary in some cases, ensuring hydration takes precedence as it directly impacts the underlying pathophysiology of the crisis. Monitoring vital signs is important for ongoing assessment but does not directly address the crisis as hydration does. Administering pain medication is important for pain relief but does not address the primary issue of vaso-occlusion and is not the most crucial intervention in this scenario.
4. A perinatal nurse is caring for a woman in the immediate postpartum period. Assessment reveals that the client is experiencing profuse bleeding. What is the most likely cause of this bleeding?
- A. Uterine atony.
- B. Uterine inversion.
- C. Vaginal hematoma.
- D. Vaginal laceration.
Correct answer: A
Rationale: Uterine atony is significant hypotonia of the uterus and is the leading cause of postpartum hemorrhage. It results in the inability of the uterus to contract effectively after delivery, leading to excessive bleeding. Uterine inversion is a rare but serious complication that involves the turning inside out of the uterus, leading to hemorrhage, but it is not the most likely cause of profuse bleeding in this scenario. Vaginal hematoma may cause bleeding but is typically associated with pain as a primary symptom rather than profuse bleeding. Vaginal lacerations can cause bleeding, but in the presence of a firm, contracted uterine fundus, uterine atony is a more likely cause of ongoing profuse bleeding in the postpartum period.
5. A client has bacterial vaginosis. Which of the following medications should the nurse expect to administer?
- A. Metronidazole
- B. Fluconazole
- C. Acyclovir
- D. Clindamycin
Correct answer: A
Rationale: Metronidazole is the correct choice for treating bacterial vaginosis as it is the first-line medication recommended for this condition. Metronidazole works by disrupting the DNA structure of bacteria, making it an effective treatment. Choice B, Fluconazole, is an antifungal medication primarily used for treating fungal infections, not bacterial vaginosis. Choice C, Acyclovir, is an antiviral medication used to treat viral infections, not bacterial vaginosis. Choice D, Clindamycin, is also used to treat bacterial infections but is not the first-line treatment for bacterial vaginosis, making it an incorrect choice in this scenario.