HESI LPN
HESI Maternal Newborn
1. What causes Down's syndrome?
- A. Alcohol abuse by the mother at the time of conception.
- B. Sex-linked chromosomal abnormalities.
- C. An extra chromosome on the 21st pair.
- D. Drug abuse by the mother during pregnancy.
Correct answer: C
Rationale: Down's syndrome, also known as trisomy 21, is caused by the presence of an extra chromosome on the 21st pair. Choice A is incorrect as alcohol abuse is not the cause of Down's syndrome. Choice B is incorrect because Down's syndrome is not related to sex-linked chromosomal abnormalities. Choice D is also incorrect as drug abuse by the mother during pregnancy is not the cause of Down's syndrome.
2. What nursing diagnosis is the most appropriate for a woman experiencing severe preeclampsia?
- A. Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.
- B. Risk for altered gas exchange.
- C. Risk for deficient fluid volume, related to increased sodium retention secondary to the administration of magnesium sulfate.
- D. Risk for increased cardiac output, related to the use of antihypertensive drugs.
Correct answer: A
Rationale: The most appropriate nursing diagnosis for a woman experiencing severe preeclampsia is 'Risk for injury to mother and fetus, related to central nervous system (CNS) irritability.' Severe preeclampsia poses a significant risk of injury to both the mother and the fetus due to complications such as seizures, stroke, and placental abruption. 'Risk for altered gas exchange' is not the priority diagnosis as pulmonary edema is more common in severe preeclampsia. 'Risk for deficient fluid volume' is incorrect as sodium retention in severe preeclampsia often leads to fluid overload. 'Risk for increased cardiac output' is also incorrect as antihypertensive drugs are used to reduce cardiac output in this condition.
3. A client is experiencing preterm labor and has a prescription for 4 doses of dexamethasone 6 mg IM every 12 hours. The available concentration is dexamethasone 10 mg/mL. How many mL of dexamethasone should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use trailing zero.)
- A. 0.6 mL
- B. ---
- C. ---
- D. ---
Correct answer: A
Rationale: Calculation: (6 mg/dose) / (10 mg/mL) = 0.6 mL per dose. The correct answer is 0.6 mL. This calculation is obtained by dividing the dose needed (6 mg) by the concentration available (10 mg/mL). The resulting value is 0.6 mL per dose. Choices B, C, and D are not applicable as the correct answer has been calculated accurately.
4. When discussing risk factors for gestational diabetes mellitus (GDM) with a group of pregnant clients, which ethnicity should the nurse identify as having the lowest incidence of GDM?
- A. Asian
- B. Non-Hispanic White American
- C. Hispanic
- D. African American
Correct answer: B
Rationale: Non-Hispanic White Americans have the lowest incidence of gestational diabetes mellitus (GDM) compared to other ethnicities. This is because GDM is more prevalent among certain ethnic groups, such as Asian, Hispanic, and African American populations. Asian individuals have an increased risk of developing GDM due to genetic factors, while Hispanic and African American populations have higher incidences of GDM due to lifestyle and genetic predispositions. Therefore, the correct answer is B, as Non-Hispanic White Americans generally have a lower risk of developing GDM.
5. A client in labor requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
- A. Assisting the client into a squatting position
- B. Having the client lie in a supine position
- C. Applying fundal pressure during contractions
- D. Encouraging the client to void every 6 hours
Correct answer: A
Rationale: Assisting the client into a squatting position promotes comfort during labor. This position can help relieve pain by utilizing gravity, allowing the pelvic outlet to widen, and potentially facilitating the progress of labor. Lying in a supine position (Choice B) can hinder labor progression and increase discomfort. Applying fundal pressure (Choice C) can be inappropriate and may cause harm as it is not routinely recommended during labor. Encouraging the client to void every 6 hours (Choice D) is important for bladder management but does not directly address pain relief during labor.
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