HESI LPN
HESI Focus on Maternity Exam
1. Females with Turner syndrome:
- A. possess more thymine than cytosine.
- B. are taller than average.
- C. produce little estrogen.
- D. are more likely to give birth to twins.
Correct answer: C
Rationale: Turner syndrome is a chromosomal disorder in females characterized by short stature and underdeveloped ovaries, resulting in low estrogen production. This leads to symptoms such as delayed puberty and infertility. Choice A is incorrect because the chromosomal abnormality in Turner syndrome does not affect the thymine-cytosine ratio. Choice B is incorrect as females with Turner syndrome are typically shorter than average. Choice D is incorrect as Turner syndrome does not increase the likelihood of giving birth to twins.
2. A newborn whose mother is HIV positive is admitted to the nursery from labor and delivery. Which action should the nurse implement first?
- A. Initiate treatment with zidovudine (ZDV) syrup at 2 mg per kg
- B. Bathe the infant with dilute chlorhexidine (Hibiclens) or soap
- C. Measure and record the infant's frontal-occipital circumference
- D. Administer vitamin K (AquaMEPHYTON) IM in the vastus lateralis
Correct answer: B
Rationale: The correct first action for a newborn potentially exposed to HIV is to bathe the infant with dilute chlorhexidine or soap. This helps reduce the risk of infection. Initiating treatment with zidovudine would be important but not the first priority. Measuring and recording the infant's frontal-occipital circumference and administering vitamin K are important tasks but are not the priority when dealing with potential HIV exposure. Immediate hygiene measures are crucial to minimize the risk of transmission.
3. When planning care for a newly admitted elderly client who is severely dehydrated, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?
- A. Converse with the client to determine if the mucous membranes are impaired
- B. Report hourly outputs of less than 30 ml/hr
- C. Monitor client's ability to move in the bed
- D. Check skin turgor every 4 hours
Correct answer: B
Rationale: The correct answer is B. Assigning the UAP to report hourly outputs of less than 30 ml/hr is appropriate as it falls within their scope of practice and does not involve making clinical assessments or decisions. Choices A, C, and D involve tasks that require a higher level of clinical judgment and training. Choice A requires assessing mucous membranes, which is beyond the UAP's scope. Choice C involves assessing movement ability, which requires more specialized training. Choice D involves assessing skin turgor, which also requires a higher level of clinical judgment.
4. What is the primary nursing intervention that the practical nurse should perform before administering ampicillin to a client diagnosed with a urinary tract infection?
- A. Obtain a clean-catch urine specimen.
- B. Assess the urine pH for acidity.
- C. Insert an indwelling catheter.
- D. Assess for complaints of dysuria.
Correct answer: A
Rationale: The correct answer is to obtain a clean-catch urine specimen. Before administering ampicillin to a client with a urinary tract infection, it is crucial to collect a urine specimen to determine the causative organism and evaluate the effectiveness of pharmacological therapy. Assessing the urine pH for acidity (choice B) is not the primary intervention needed before administering ampicillin. Inserting an indwelling catheter (choice C) is invasive and not necessary unless indicated for specific reasons. Assessing for complaints of dysuria (choice D) is important but does not take precedence over obtaining a urine specimen for proper diagnosis and treatment.
5. What intervention is recommended for a child with severe dehydration?
- A. Oral rehydration therapy
- B. Intravenous fluid replacement
- C. High-protein diet
- D. Increased physical activity
Correct answer: B
Rationale: Intravenous fluid replacement is the recommended intervention for a child with severe dehydration because it allows for rapid restoration of fluid and electrolyte balance. In severe cases, oral rehydration therapy (Choice A) may not be tolerated due to the child's condition. A high-protein diet (Choice C) is not the primary intervention and does not address the immediate fluid and electrolyte imbalance. Increased physical activity (Choice D) is contraindicated in severe dehydration as it can exacerbate fluid loss, making intravenous fluid replacement the most suitable choice for prompt correction of the severe dehydration.