HESI LPN
HESI Maternal Newborn
1. The actual sets of traits that people exhibit are called their genotypes.
- A. TRUE
- B. FALSE
- C. Possibly
- D. Always
Correct answer: B
Rationale: The actual sets of traits that people exhibit are called phenotypes, not genotypes. Genotypes refer to the genetic makeup of an individual.
2. Does a blastocyst gain mass only when it receives nourishment from outside?
- A. TRUE
- B. FALSE
- C. Sometimes
- D. Always
Correct answer: A
Rationale: A blastocyst does indeed require external nourishment from the mother's body to continue developing and gaining mass. Without this external nourishment, the blastocyst would not be able to grow and develop properly. Therefore, the statement that a blastocyst gains mass only when it receives nourishment from outside is true. Choices B, C, and D are incorrect because they do not accurately reflect the dependency of a blastocyst on external nourishment for its development and growth.
3. The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?
- A. Caput succedaneum
- B. Hydrocephalus
- C. Cephalhematoma
- D. Microcephaly
Correct answer: C
Rationale: The correct answer is Cephalhematoma. Cephalhematoma is a collection of blood between the skull bone and periosteum that does not cross the suture line. It often occurs due to birth trauma, such as forceps delivery, leading to localized swelling. Caput succedaneum (Choice A) is diffuse swelling of the scalp that may cross suture lines and is typically present at birth. Hydrocephalus (Choice B) is an abnormal accumulation of cerebrospinal fluid within the brain's ventricles. Microcephaly (Choice D) is a condition characterized by a smaller than average head size and may be present at birth or develop later in infancy.
4. A client is receiving oxytocin by continuous IV infusion for labor induction. Which of the following interventions should the nurse include in the plan?
- A. Increase the infusion rate every 30 to 60 minutes.
- B. Maintain the client in a supine position.
- C. Titrate the infusion rate by 4 milliunits/min.
- D. Limit IV intake to 4 L per 24 hours.
Correct answer: A
Rationale: The correct answer is to increase the infusion rate every 30 to 60 minutes. This approach allows for the careful monitoring and adjustment of oxytocin administration during labor induction. Choice B is incorrect because maintaining the client in a supine position can decrease blood flow to the placenta and compromise fetal oxygenation. Choice C is incorrect as titrating the infusion rate by 4 milliunits/min is not a standard practice for oxytocin administration. Choice D is incorrect as limiting IV intake to 4 L per 24 hours is not specifically related to the administration of oxytocin for labor induction.
5. What is the highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy?
- A. Assessing FHR and maternal vital signs.
- B. Performing a venipuncture for hemoglobin and hematocrit levels.
- C. Placing clean disposable pads to collect any drainage.
- D. Monitoring uterine contractions.
Correct answer: A
Rationale: The highest priority nursing intervention when admitting a pregnant woman who has experienced a bleeding episode in late pregnancy is to assess the fetal heart rate (FHR) and maternal vital signs. This assessment is crucial in determining the extent of blood loss and its impact on both the mother and the fetus. Ensuring the well-being of both the mother and the fetus is the top priority in this situation. While obtaining hemoglobin and hematocrit levels is important, it can be done after the initial assessment. Placing clean disposable pads is necessary for managing any drainage but does not take precedence over assessing vital signs. Monitoring uterine contractions is important but is not the highest priority when compared to assessing the FHR and maternal vital signs.
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