HESI LPN
HESI Maternal Newborn
1. In the context of an average ejaculation, which of the following statements is true about sperm?
- A. The average count of sperm in the ejaculate is 2.5 billion.
- B. Sperm in the ejaculate find the ovum by following the current of the fluid coming from the cervix.
- C. Only 1 in 1,000 sperm in the ejaculate will ever approach an ovum.
- D. Most of the sperm in the ejaculate move about in a random pattern in the vagina.
Correct answer: C
Rationale: Out of millions of sperm released during ejaculation, only a small fraction, about 1 in 1,000, will approach the ovum. This statement is true as sperm face many obstacles and challenges on their journey to reach and fertilize an ovum. Choice A is incorrect because the average count of sperm in an ejaculate is typically in the millions, not billions. Choice B is incorrect as sperm do not find the ovum by following the current of fluid; they navigate using other mechanisms. Choice D is incorrect because while some sperm may move randomly in the vagina, the ones that approach the ovum do so through a more purposeful and directed movement.
2. A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client?
- A. Assess the blood pressure for hypertension.
- B. Gently massage fundus every four hours.
- C. Observe for signs of uterine hemorrhage.
- D. Encourage direct contact with the infant.
Correct answer: C
Rationale: After a prolonged labor and delivery of a large infant, the client is at an increased risk for uterine atony and postpartum hemorrhage, making observation for signs of bleeding a priority. Assessing the blood pressure for hypertension (Choice A) is not the priority in this situation as the immediate concern is postpartum hemorrhage. Gently massaging the fundus every four hours (Choice B) is a routine postpartum care activity but is not the priority in this scenario. Encouraging direct contact with the infant (Choice D) is important for bonding but does not address the immediate risk of uterine hemorrhage after delivery.
3. Following an amniocentesis, a nurse is caring for a client. The nurse should observe the client for which of the following complications?
- A. Hyperemesis
- B. Proteinuria
- C. Hypoxia
- D. Hemorrhage
Correct answer: D
Rationale: After an amniocentesis, the nurse should monitor the client for potential complications, with hemorrhage being a significant concern due to the invasive nature of the procedure. Hyperemesis (severe vomiting), proteinuria (excessive protein in the urine), and hypoxia (low oxygen levels) are not typically associated with amniocentesis and are less likely to occur compared to hemorrhage, which is a more common complication that requires prompt recognition and intervention.
4. A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a calm environment
- B. Monitor blood glucose levels every hour
- C. Initiate seizure precautions
- D. Place the infant on their back with legs extended
Correct answer: C
Rationale: Initiating seizure precautions is crucial when caring for an infant with neonatal abstinence syndrome due to the increased risk of seizures. Providing a calm environment (Choice A) is important to reduce stimulation as these infants may be irritable. Monitoring blood glucose levels (Choice B) is not typically a priority in neonatal abstinence syndrome unless specific signs or symptoms suggest the need for this assessment. Placing the infant on their back with legs extended (Choice D) does not directly address the potential complications associated with neonatal abstinence syndrome, such as seizures.
5. A newborn is 1 hour old with a respiratory rate of 50/min, a heart rate of 130/min, and an axillary temperature of 36.1°C (97°F). Which of the following actions should be taken?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn's head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level.
Correct answer: B
Rationale: Applying a cap to the newborn's head is the correct action in this scenario. Newborns are at risk of heat loss due to their high surface area to volume ratio, and maintaining their body temperature is crucial to prevent hypothermia. Giving a warm bath can further increase heat loss and is not recommended. Repositioning the newborn may not address the primary concern of temperature regulation. While monitoring oxygen saturation is important, addressing thermal regulation takes precedence in this situation.
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