HESI LPN
Maternity HESI Practice Questions
1. The _____ is the inner layer of the embryo from which the lungs and digestive system develop.
- A. neural tube
- B. mesoderm
- C. endoderm
- D. umbilical cord
Correct answer: C
Rationale: The endoderm is the correct answer. It is the innermost layer of the embryo that gives rise to organs such as the lungs, digestive system, liver, and pancreas. The neural tube (Choice A) forms the brain and spinal cord, not the lungs or digestive system. Mesoderm (Choice B) develops into structures like muscles, bones, and circulatory system, not the lungs or digestive system. The umbilical cord (Choice D) serves as a connection between the embryo and the placenta, providing nutrients and oxygen, but it is not the layer from which lungs and digestive system develop.
2. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?
- A. “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.”
- B. “The drug keeps your baby from requiring too much sedation.”
- C. “Surfactant is used to reduce episodes of periodic apnea.”
- D. “Your baby needs this medication to fight a possible respiratory tract infection.”
Correct answer: A
Rationale: Artificial surfactant can be administered as an adjunct to oxygen and ventilation therapy for premature infants with respiratory distress syndrome (RDS). It helps improve respiratory compliance by aiding in the exchange of oxygen and carbon dioxide until the infant can produce enough surfactant naturally. The correct explanation to the parents would be that surfactant therapy enhances the baby’s lung function by facilitating the exchange of oxygen and carbon dioxide. Choice B is incorrect because surfactant therapy does not affect sedation needs. Choice C is inaccurate as surfactant is not used to reduce episodes of periodic apnea. Choice D is incorrect as surfactant is not administered to fight respiratory tract infections; it specifically targets improving lung function in RDS.
3. A child has been admitted to the pediatric unit with a severe asthma attack. What type of acid-base imbalance should the nurse expect the child to develop?
- A. metabolic alkalosis due to insufficient production of acid metabolites
- B. respiratory alkalosis due to depressed respirations and retention of carbon dioxide
- C. respiratory acidosis due to impaired respirations and increased formation of carbonic acid
- D. metabolic acidosis due to the kidneys' inability to compensate for decreased carbonic acid formation
Correct answer: C
Rationale: In a severe asthma attack, the child is likely to develop respiratory acidosis. This occurs due to impaired respirations, leading to the retention of carbon dioxide and the formation of carbonic acid. Choice A is incorrect as metabolic alkalosis is not expected in this situation. Choice B is incorrect as respiratory alkalosis does not align with the scenario of impaired respirations in severe asthma attacks. Choice D is also incorrect as it describes metabolic acidosis, which is not typically associated with severe asthma attacks.
4. A nursing assistive personnel (AP) is providing AM care to patients. Which action by the NAP will require the nurse to intervene?
- A. Not offering a backrub to a patient with fractured ribs
- B. Not offering to wash the hair of a patient with neck trauma
- C. Turning off the television while giving a backrub to the patient
- D. Turning the patient's head with neck injury to the side when giving oral care
Correct answer: D
Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.
5. A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?
- A. Reassure the client that pre-surgery anxiety is a normal experience
- B. Explain the surgery in clear terms that the client can understand
- C. Call the surgeon back to clarify the information with the client
- D. Redirect the client’s thoughts by teaching relaxation techniques
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.