HESI LPN
HESI Maternity 55 Questions
1. Genotypes are solely based on genetic information.
- A. TRUE
- B. FALSE
- C. Sometimes
- D. Never
Correct answer: B
Rationale: The correct answer is B - FALSE. Genotypes are solely based on genetic information and do not reflect environmental influences. Phenotypes, on the other hand, result from the interaction of genetic and environmental factors. Choices A, C, and D are incorrect because genotypes are not influenced by environmental factors, and they are determined by an individual's genetic makeup.
2. 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.
3. A client who is 24 weeks gestation arrives at the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next?
- A. Review the client's previous blood pressures in the chart.
- B. Obtain the client's blood pressure.
- C. Observe and time the client's contractions.
- D. Examine the client for pedal edema.
Correct answer: B
Rationale: Swollen hands and rapid weight gain could be signs of preeclampsia, so the next step is to check the client's blood pressure. Elevated blood pressure is a key indicator in assessing for preeclampsia in pregnancy. Reviewing the client's previous blood pressures may provide additional context but obtaining the current blood pressure is crucial for immediate assessment. Observing and timing contractions are not relevant in this scenario as the client is not presenting with signs of active labor. Examining for pedal edema is important in assessing for fluid retention, but obtaining the blood pressure takes precedence in this case due to the potential seriousness of preeclampsia.
4. A newborn is being assessed by a nurse who was born post-term. Which of the following findings should the nurse expect?
- A. Nails extending over tips of fingers
- B. Large deposits of subcutaneous fat
- C. Pale, translucent skin
- D. Thin covering of fine hair on shoulders and back
Correct answer: A
Rationale: Post-term newborns often have longer nails that extend over the tips of their fingers due to the extended gestation period. This occurs because the baby continues to grow in utero past the typical 40 weeks of gestation. Choices B, C, and D are incorrect as large deposits of subcutaneous fat, pale translucent skin, and a thin covering of fine hair on shoulders and back are not typically associated with post-term newborns. Longer nails are a common finding in post-term newborns due to the prolonged time spent in the womb, allowing for more nail growth compared to infants born at term.
5. At 12 hours after the birth of a healthy infant, the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia. Which action should the nurse take?
- A. Check the suprapubic area for distention
- B. Inform the client to take a warm sitz bath
- C. Inspect the client's perineal and rectal areas
- D. Apply a fresh pad and check in 1 hour
Correct answer: C
Rationale: In this situation, the mother's complaint of constant vaginal pressure along with a firm fundus and moderate rubra lochia indicates a potential perineal injury or hematoma. The correct action for the nurse to take is to inspect the client's perineal and rectal areas to assess for any signs of trauma or hematoma. Checking the suprapubic area for distention (Choice A) is not the priority here since the symptoms suggest a perineal issue. Advising a warm sitz bath (Choice B) may not address the underlying issue and could potentially worsen any existing trauma. Applying a fresh pad and checking in 1 hour (Choice D) does not address the need for immediate assessment of the perineal and rectal areas in response to the reported symptoms.
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