the mother of a breastfeeding 24 hour old infant is very concerned about the techniques involved in breastfeeding she calls the nurse with each feedin

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. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman’s vital signs, which finding would be of greatest concern to the nurse?

A. Temperature 37.9°C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg.
B. Temperature 37.4°C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg.
C. Temperature 38°C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg.
D. Temperature 36.8°C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg.

Correct answer: A

Rationale: An estimated blood loss (EBL) of 1500 ml following a vaginal birth is significant and can lead to hypovolemia. The vital signs provided in option A (Temperature 37.9°C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg) indicate tachycardia and hypotension, which are concerning signs of hypovolemia due to excessive blood loss. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, and hypotension indicates inadequate perfusion. Options B, C, and D do not exhibit the same level of concern for hypovolemia. Option B shows tachypnea, which can be a result of pain or anxiety postpartum. Option C and D have vital signs within normal limits, which are not indicative of the body's response to significant blood loss.

3. Twins that derive from a single zygote that has split into two are called:

A. monozygotic (MZ) twins.
B. fraternal twins.
C. non-identical twins.
D. dizygotic (DZ) twins.

Correct answer: A

Rationale: The correct answer is A: monozygotic (MZ) twins. Monozygotic twins, also known as identical twins, occur when a single zygote splits into two embryos, leading to two genetically identical individuals. Choice B, fraternal twins, are twins that develop from two separate eggs fertilized by two different sperm cells, resulting in non-identical siblings. Choice C, non-identical twins, is not a common term used to describe this type of twinning. Choice D, dizygotic (DZ) twins, refer to twins that develop from two separate eggs fertilized by two different sperm cells, leading to non-identical twins.

4. Humans begin life as a single cell that divides repeatedly. This cell is known as a(n):

A. zygote.
B. gonadotrope.
C. embryo.
D. chromaffin.

Correct answer: A

Rationale: A zygote is the correct answer. It is the initial cell formed when a sperm cell fertilizes an egg cell, marking the beginning of human development. Choice B, gonadotrope, is incorrect as it refers to a type of hormone-secreting cell in the pituitary gland. Choice C, embryo, is incorrect as it is the stage of development after the zygote has implanted into the uterine wall and undergone initial cell divisions. Choice D, chromaffin, is incorrect as it refers to cells found in the adrenal medulla that produce and store catecholamines.

5. A client is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?

A. Hypotension
B. Polyuria
C. Bilateral crackles
D. Hyperglycemia

Correct answer: C

Rationale: The correct answer is C: Bilateral crackles. Bilateral crackles indicate respiratory complications, which can occur as an adverse effect of an epidural block with opioid analgesics. Hypotension (Choice A) is a common side effect of epidural opioids but is not typically monitored via crackles. Polyuria (Choice B) is excessive urination and is not directly associated with epidural blocks. Hyperglycemia (Choice D) is high blood sugar levels and is not a typical adverse effect of epidural opioids.