HESI RN
Maternity HESI Quizlet
1. In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The LPN/LVN bases the explanation on knowledge that for the normal newborn, the
- A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week.
- B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week.
- C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month.
- D. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
Correct answer: D
Rationale: The anterior fontanel typically closes between 12 to 18 months, while the posterior fontanel usually closes by the end of the second month. It is important for parents to know these timeframes as it helps in monitoring the normal growth and development of their newborn. Delayed closure of fontanels may indicate potential health issues, and early closure may also warrant further evaluation by healthcare providers.
2. What is the most common cause of coronary artery disease?
- A. Atherosclerosis.
- B. Hyperlipidemia.
- C. Diabetes.
- D. Smoking.
Correct answer: A
Rationale: The correct answer is Atherosclerosis. It is the primary cause of coronary artery disease, as it involves the buildup of plaque in the arteries, restricting blood flow to the heart. Hyperlipidemia (choice B) contributes to atherosclerosis by increasing cholesterol levels in the blood but is not the direct cause of coronary artery disease. Diabetes (choice C) can accelerate atherosclerosis due to high blood sugar levels, but it is not the most common cause. Smoking (choice D) is a significant risk factor for developing coronary artery disease but is not the primary cause.
3. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
- A. Risk for imbalanced body temperature
- B. Excess fluid volume
- C. Fatigue
- D. Ineffective Tissue Perfusion
Correct answer: D
Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.
4. The nurse is caring for a client with chronic renal failure who is receiving peritoneal dialysis. Which of the following findings should be reported immediately to the physician?
- A. Clear dialysate outflow.
- B. Increased blood pressure.
- C. Cloudy dialysate outflow.
- D. Decreased urine output.
Correct answer: C
Rationale: Cloudy dialysate outflow should be reported immediately to the physician. It is indicative of peritonitis, a severe infection of the peritoneal cavity and a serious complication of peritoneal dialysis. Prompt medical attention is crucial to prevent further complications or systemic infection. Clear dialysate outflow (Choice A) is a normal finding in peritoneal dialysis. Increased blood pressure (Choice B) and decreased urine output (Choice D) are common in clients with chronic renal failure and may not require immediate reporting unless they are significantly abnormal or accompanied by other concerning symptoms.
5. A nurse at a provider's office is reinforcing teaching with a client who is being treated with chemotherapy and is losing weight. Which of the following instructions should the nurse give to increase the client's caloric intake? (Select one that doesn't apply).
- A. Top yogurt with granola.
- B. Use honey on toast.
- C. Use milk instead of water in recipes.
- D. Increase fluids during meals.
Correct answer: D
Rationale: Increasing fluids during meals does not directly contribute to increasing caloric intake. Topping yogurt with granola, using honey on toast, and using milk instead of water in recipes are effective ways to boost caloric intake. While adequate fluid intake is important for hydration and overall health, it does not address the specific need to increase caloric intake in this scenario.