HESI LPN
HESI Focus on Maternity Exam
1. The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right. She tells the nurse, "Now my daughter is not getting enough to eat." Which response would be best for the nurse to make?
- A. Feed your baby hourly until you feel confident that your child is receiving enough milk.
- B. Don't worry, soon your milk will come in, and you will feel how full your breasts are.
- C. Since you are so concerned, you should probably supplement breastfeeding with formula.
- D. If your baby's urine is straw-colored, she's getting enough milk.
Correct answer: D
Rationale: Reassuring the mother that the baby's urine color can be an indicator of adequate hydration can help her feel more confident in her breastfeeding.
2. When caring for a pregnant woman with cardiac problems, the nurse must be alert for the signs and symptoms of cardiac decompensation. Which critical findings would the nurse find on assessment of the client experiencing this condition?
- A. Regular heart rate and hypertension.
- B. Increased urinary output, tachycardia, and dry cough.
- C. Shortness of breath, bradycardia, and hypertension.
- D. Dyspnea, crackles, and an irregular, weak pulse.
Correct answer: D
Rationale: In pregnant women with cardiac problems, signs of cardiac decompensation include dyspnea, crackles, an irregular, weak, and rapid pulse, rapid respirations, a moist and frequent cough, generalized edema, increasing fatigue, and cyanosis of the lips and nailbeds. Choice A is incorrect as a regular heart rate and hypertension are not typically associated with cardiac decompensation. Choice B is incorrect as increased urinary output and dry cough are not indicative of cardiac decompensation, only tachycardia is. Choice C is incorrect as bradycardia and hypertension are not typically seen in cardiac decompensation; dyspnea is a critical sign instead.
3. A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. What is the nurse’s highest priority in this situation?
- A. Prepare the woman for imminent birth.
- B. Notify the woman’s primary healthcare provider.
- C. Document the characteristics of the fluid.
- D. Assess the fetal heart rate (FHR) and pattern.
Correct answer: D
Rationale: The correct answer is to assess the fetal heart rate (FHR) and pattern (Choice D). When a multiparous woman's membranes rupture after 8 hours of labor, the nurse's priority is to assess the fetal well-being. Rupture of membranes can lead to potential complications such as umbilical cord prolapse. Monitoring the fetal heart rate and pattern immediately after the rupture of membranes is crucial to ensure the fetus is not in distress. This assessment helps in determining the need for immediate interventions to safeguard the fetus. Documenting the characteristics of the fluid (Choice C) may be necessary but is of lower priority compared to assessing fetal well-being. While preparing the woman for imminent birth (Choice A) is important, assessing the fetal heart rate takes precedence to ensure the fetus is not compromised. Notifying the woman's primary healthcare provider (Choice B) is also important but not the highest priority at this moment.
4. Daisy was always unusually short for her age. She was unable to conceive a child after marriage, and upon visiting a doctor, she was prescribed estrogen replacement therapy. Daisy is most likely suffering from:
- A. Phenylketonuria (PKU).
- B. Cystic fibrosis.
- C. Turner syndrome.
- D. Huntington’s disease (HD).
Correct answer: C
Rationale: Daisy's symptoms of short stature and infertility, along with the prescription of estrogen replacement therapy, are indicative of Turner syndrome. Turner syndrome is a genetic condition in which a female is partially or completely missing one X chromosome. This results in short stature, infertility, and other physical characteristics. Phenylketonuria (PKU) is a metabolic disorder caused by a mutation in the gene responsible for the breakdown of the amino acid phenylalanine. Cystic fibrosis is a genetic disorder affecting the respiratory and digestive systems. Huntington's disease (HD) is a neurodegenerative disorder that affects muscle coordination and leads to cognitive decline.
5. Why is a client with gestational diabetes being scheduled for an amniocentesis when the fetus has an estimated weight of eight pounds (3629 grams) at 36 weeks gestation? What information is the amniocentesis seeking to obtain?
- A. Presence of a neural tube defect.
- B. Chromosomal abnormalities.
- C. Gender of the fetus.
- D. Fetal lung maturity.
Correct answer: D
Rationale: An amniocentesis in this scenario is most likely being performed to assess fetal lung maturity. This is necessary when considering early delivery due to macrosomia (large fetal size), which is a common concern in gestational diabetes. Evaluating fetal lung maturity is crucial to determine if the fetus's lungs are developed enough to support breathing independently outside the womb. The presence of a neural tube defect and chromosomal abnormalities are not typically assessed through amniocentesis in this situation, and determining the gender of the fetus is not the primary purpose of the procedure here.
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