HESI LPN
Maternity HESI Test Bank
1. Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement?
- A. Page the pediatrician STAT
- B. Continue resuscitative efforts
- C. Repeat the Apgar assessment in 5 minutes
- D. Inform the parents of the infant's condition
Correct answer: B
Rationale: In a situation where an infant receives a low Apgar score of 3 following a traumatic delivery, the most crucial intervention for the nurse to implement is to continue resuscitative efforts. A low Apgar score indicates that the newborn is in distress and requires immediate medical attention to support breathing, heart rate, muscle tone, reflex irritability, and color. Continuing resuscitative efforts is essential to provide life-saving interventions promptly. Paging the pediatrician may cause a delay in crucial interventions, repeating the Apgar assessment in 5 minutes is not appropriate as immediate action is needed to stabilize the infant, and informing parents should not take precedence over providing immediate medical care to the newborn.
2. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?
- A. Assessing FHR and maternal vital signs.
- B. Performing a venipuncture for hemoglobin and hematocrit levels.
- C. Placing clean disposable pads to collect any drainage.
- D. Monitoring uterine contractions.
Correct answer: A
Rationale: The highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to assess the fetal heart rate (FHR) and maternal vital signs. This assessment is crucial in determining the extent of blood loss and its impact on both the mother and the fetus. Ensuring the well-being of both the mother and the fetus is the top priority in this situation. While obtaining hemoglobin and hematocrit levels is important, it can be done after the initial assessment. Placing clean disposable pads is necessary for managing any drainage but does not take precedence over assessing vital signs. Monitoring uterine contractions is important but is not the highest priority when compared to assessing the FHR and maternal vital signs.
3. In contrast to placenta previa, what is the most prevalent clinical manifestation of abruptio placentae?
- A. Bleeding.
- B. Intense abdominal pain.
- C. Uterine activity.
- D. Cramping.
Correct answer: B
Rationale: The correct answer is B: Intense abdominal pain. Pain is absent with placenta previa but can be agonizing with abruptio placentae. While bleeding may be present in varying degrees for both placental conditions, intense abdominal pain is a distinguishing feature of abruptio placentae. Uterine activity and cramping may be present with both placental conditions, but they are not the most prevalent clinical manifestation of abruptio placentae.
4. _____ is a type of estrogen, prescribed in the 1940s and 1950s to pregnant women, that is said to have caused testicular, vaginal, and cervical cancer in some offspring.
- A. Androsterone
- B. Adiponectin
- C. Progestin
- D. Diethylstilbestrol
Correct answer: D
Rationale: Diethylstilbestrol (DES) is a synthetic estrogen that was prescribed to pregnant women in the 1940s and 1950s to prevent miscarriages. However, it was later discovered that DES exposure in utero could lead to health issues in offspring, including an increased risk of testicular, vaginal, and cervical cancer. Choice A, Androsterone, is a steroid hormone produced in small amounts in humans and unlikely to be associated with the adverse effects described. Choice B, Adiponectin, is a protein hormone that plays a role in regulating glucose levels and fatty acid breakdown, not related to the adverse effects mentioned. Choice C, Progestin, is a synthetic form of progesterone used in birth control and hormone therapy, not linked to the specific health concerns associated with DES exposure.
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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