HESI LPN
Maternity HESI Test Bank
1. When should the low-risk patient, who is 16 weeks pregnant, be advised to return to the prenatal clinic?
- A. 1 week.
- B. 2 weeks.
- C. 3 weeks.
- D. 4 weeks.
Correct answer: D
Rationale: The correct answer is D: 4 weeks. Low-risk pregnant patients typically have prenatal visits every 4 weeks until 28 weeks of gestation. This frequency allows for adequate monitoring of the pregnancy without being overly burdensome on the patient. Choices A, B, and C are incorrect as they do not align with the standard prenatal care schedule for low-risk pregnancies. Visits that are too frequent may cause unnecessary anxiety for the patient, while visits that are too infrequent may miss important opportunities for monitoring and intervention.
2. When obtaining a health history from a client, a nurse in a woman’s health clinic should identify which of the following findings as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct answer: D
Rationale: Chlamydia infection is a significant risk factor for developing pelvic inflammatory disease (PID). PID is often caused by untreated sexually transmitted infections (STIs) like Chlamydia and Gonorrhea that ascend from the vagina to the upper reproductive organs. Recurrent cystitis (choice A) is more related to urinary tract infections, frequent alcohol use (choice B) is not directly linked to PID, and the use of oral contraceptives (choice C) does not increase the risk of developing PID.
3. A woman has experienced iron deficiency anemia during her pregnancy. She had been taking iron for 3 months before the birth. The client gave birth by cesarean 2 days earlier and has been having problems with constipation. After assisting her back to bed from the bathroom, the nurse notes that the woman’s stools are dark (greenish-black). What should the nurse’s initial action be?
- A. Perform a guaiac test and record the results.
- B. Recognize the finding as abnormal and report it to the primary health care provider.
- C. Recognize the finding as a normal result of iron therapy.
- D. Check the woman’s next stool to validate the observation.
Correct answer: C
Rationale: The nurse should recognize that dark stools are a common side effect in clients who are taking iron replacement therapy. Dark stools are a known, expected result of iron supplementation and are not indicative of a complication unless other symptoms of GI bleeding are present. A guaiac test would be necessary if there were concerns about gastrointestinal bleeding. Recognizing dark stools as a consequence of iron therapy is an essential nursing assessment skill and does not require immediate reporting. Checking the next stool to confirm the observation is unnecessary as the presence of dark stools in this context is already an expected outcome of iron supplementation.
4. A client with hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma reagin
- C. Prothrombin time
- D. Urine culture
Correct answer: A
Rationale: Urine ketones should be anticipated as a laboratory test for a client with hyperemesis gravidarum because it helps assess the severity of dehydration and malnutrition, which are common complications of this condition. Choice B, rapid plasma reagin, is a test for syphilis and is not relevant to hyperemesis gravidarum. Choice C, prothrombin time, is a measure of blood clotting function and is not typically indicated for hyperemesis gravidarum. Choice D, urine culture, is used to identify bacteria in the urine and is not directly related to assessing dehydration and malnutrition in clients with hyperemesis gravidarum.
5. What nursing action should the nurse implement for a 3-hour-old male infant who presents with cyanotic hands and feet, an axillary temperature of 96.5°F (35.8°C), a respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute?
- A. Administer oxygen by mouth at 2L/min
- B. Gradually warm the infant under a radiant heat source
- C. Notify the pediatrician of the infant's vital signs
- D. Perform a heel-stick to maintain blood glucose levels
Correct answer: B
Rationale: The correct nursing action is to gradually warm the infant under a radiant heat source. The infant is presenting with signs of cold stress, indicated by cyanotic extremities and a low body temperature. Gradual warming is crucial to stabilize the infant's temperature and prevent further complications. Administering oxygen, notifying the pediatrician, or performing a heel-stick are not the priority actions in this scenario and may not address the immediate need to raise the infant's body temperature.
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