HESI RN
HESI Maternity 55 Questions Quizlet
1. Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
- A. a cephalhematoma, caused by birth trauma and may last up to 8 weeks.
- B. a subarachnoid hematoma, which requires immediate drainage to prevent further complications.
- C. molding, caused by pressure during labor and will disappear within 2 to 3 days.
- D. a subdural hematoma, which can result in lifelong damage.
Correct answer: A
Rationale: Cephalhematoma is the accumulation of blood between the periosteum and skull, often due to birth trauma, and typically resolves within weeks. It is a common finding in newborns and is not usually a cause for concern as it gradually resolves without specific treatment. Subarachnoid hematoma and subdural hematoma are different conditions that present with distinct characteristics and require different management strategies. Therefore, the correct answer is A. Subarachnoid hematoma is typically found in the subarachnoid space and requires immediate intervention, not just observation like cephalhematoma. Molding refers to the shaping of the fetal head during passage through the birth canal and is a temporary change, not a collection of blood like in cephalhematoma. Subdural hematoma is located beneath the dura mater and is associated with significant complications, unlike the self-limiting nature of cephalhematoma.
2. A homeless client with alcohol dependency will be dismissed from the emergency department in 24 hours. The nurse notes that a tuberculin skin test was prescribed by the healthcare provider. What intervention is most important for the nurse to implement prior to discharge?
- A. Identify how the client will follow-up to have the results read
- B. Give the client written information about the tuberculosis test
- C. Determine if the client understands the purpose of the tuberculin test
- D. Explain to the client results should be read between 48 and 72 hours
Correct answer: A
Rationale: The most important intervention for the nurse to implement prior to the discharge of a homeless client with alcohol dependency who had a tuberculin skin test prescribed is to identify how the client will follow-up to have the results read. This is crucial to ensure proper diagnosis and treatment. Providing written information (Choice B) is helpful but not as critical as ensuring the follow-up plan. Determining if the client understands the purpose of the test (Choice C) is important but not as immediate as ensuring the follow-up plan. Explaining when the results should be read (Choice D) is important, but the priority is to make sure the client has a plan in place for follow-up.
3. Which of the following methods is used for permanent contraception in males?
- A. Vasectomy
- B. Tubal ligation
- C. Condoms
- D. Coitus interruptus
Correct answer: A
Rationale: The correct answer is A: Vasectomy. Vasectomy is a surgical procedure for permanent contraception in males by cutting or blocking the vas deferens. Choice B, Tubal ligation, is a method for permanent contraception in females by blocking or sealing the fallopian tubes. Choice C, Condoms, provide a barrier method of contraception but are not permanent. Choice D, Coitus interruptus, involves withdrawing the penis before ejaculation and is not a reliable method of contraception.
4. The parents of a child on phenytoin (Dilantin) have received discharge instructions from the nurse. Which of the following statements suggests that the teaching was effective?
- A. We will call the healthcare provider if the child develops acne.
- B. Our child should brush and floss carefully after every meal.
- C. We will skip the next dose if vomiting or fever occurs.
- D. When our child is seizure-free for 6 months, we can stop the medication.
Correct answer: B
Rationale: The correct answer is B. Proper oral hygiene, including brushing and flossing carefully after every meal, is essential for children on phenytoin to prevent gingival hyperplasia, a common side effect. Choice A is incorrect because acne is not a common side effect of phenytoin and does not require immediate healthcare provider notification. Choice C is incorrect because vomiting or fever should not prompt skipping a dose without consulting the healthcare provider first. Choice D is incorrect because discontinuing phenytoin should never be done abruptly or without healthcare provider guidance, even if the child is seizure-free for 6 months.
5. The nurse is assessing a 4-month-old infant who has just received routine immunizations. The mother reports that the baby has been fussy and has a low-grade fever since the immunizations. What is the best response by the nurse?
- A. These are common side effects and should resolve within a few days
- B. Your baby may be having an allergic reaction to the immunizations
- C. You should bring your baby to the clinic immediately for evaluation
- D. You should give your baby aspirin to help with the fever
Correct answer: A
Rationale: The correct response by the nurse is to reassure the mother that fussiness and low-grade fever are common side effects of immunizations in infants and should resolve within a few days. It is essential to educate the mother about these expected reactions to alleviate her concerns. Choice B is incorrect because allergic reactions to immunizations usually present with more severe symptoms such as difficulty breathing or swelling. Choice C is not warranted unless there are concerning symptoms present. Choice D is inappropriate as aspirin is contraindicated in infants due to the risk of Reye's syndrome.