HESI LPN
HESI Maternal Newborn
1. What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?
- A. Assessing the strength of uterine contractions
- B. Re-evaluating the need for medication
- C. Reminding her to push 3 times with each contraction
- D. Assisting her to maintain control
Correct answer: D
Rationale: During the transitional phase of labor, which is the most intense phase, the primary focus of nursing care for a client who anticipates an unmedicated delivery should be assisting her to maintain control. This is essential to help her manage the intense pain and anxiety associated with this phase without the use of medication. Assessing the strength of uterine contractions (Choice A) is important but not the primary focus during the transitional phase. Re-evaluating the need for medication (Choice B) is not applicable as the client anticipates an unmedicated delivery. Reminding her to push 3 times with each contraction (Choice C) is more related to the pushing stage of labor and not the transitional phase.
2. A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5mm of erythema without induration. Which is the best initial nursing action?
- A. Review the healthcare worker's history for possible exposure to TB.
- B. Instruct the healthcare worker to return for a repeat test in 1 week.
- C. Refer the healthcare worker to a healthcare provider for isoniazid (INH) therapy.
- D. Document negative results in the healthcare worker's medical record.
Correct answer: D
Rationale: A Mantoux tuberculosis skin test without induration is considered negative. In this case, with 5mm of erythema and no induration, the result is negative, indicating no current infection. The best initial nursing action is to document these negative results in the healthcare worker's medical record. Reviewing the history for possible exposure to TB is unnecessary as the test result is negative. Instructing the healthcare worker to return for a repeat test or referring for INH therapy is not warranted when the test is negative.
3. A pre-term baby develops nasal flaring, cyanosis, and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first?
- A. Cardiopulmonary resuscitation
- B. Insertion of a chest tube
- C. Oxygen therapy
- D. Assisted ventilation
Correct answer: B
Rationale: The correct answer is B: Insertion of a chest tube. In a case of spontaneous pneumothorax, the primary intervention is to insert a chest tube. This procedure allows the trapped air to escape from the pleural space, relieving pressure and enabling the lung to re-expand. Choices A, C, and D are not the initial interventions for spontaneous pneumothorax. Cardiopulmonary resuscitation is indicated for cardiac arrest, oxygen therapy may provide supportive care but does not address the underlying issue of trapped air in the pleural space, and assisted ventilation may be needed later but is not the first-line treatment for a pneumothorax.
4. During a well-child check-up, what respiratory assessment finding should the nurse anticipate in a 3-year-old?
- A. A resting respiratory rate of 40 breaths per minute
- B. Bronchovesicular breath sounds in the peripheral lung fields
- C. Retractions in the intercostal spaces with each inspiration
- D. High-pitched whistling sounds over the bronchi
Correct answer: A
Rationale: A resting respiratory rate of 40 breaths per minute is within the expected range for a 3-year-old child. This is considered normal in this age group as their respiratory rate is generally higher compared to adults. Bronchovesicular breath sounds in the peripheral lung fields are not an expected finding in a 3-year-old. Retractions in the intercostal spaces with each inspiration indicate increased work of breathing and are abnormal. High-pitched whistling sounds over the bronchi are characteristic of wheezing, which is not typically expected in a healthy 3-year-old during a routine check-up.
5. The PN administered darbepoetin alfa to a client with chronic kidney disease (CKD). Which serum laboratory value should the PN monitor to assess the effectiveness of this drug?
- A. Calcium
- B. Phosphorus
- C. Hemoglobin
- D. White blood cell count
Correct answer: C
Rationale: Darbepoetin alfa is used to stimulate red blood cell production in clients with CKD. Monitoring hemoglobin levels is essential to assess the effectiveness of the treatment and to adjust the dosage to avoid complications such as hypertension or thrombosis. Monitoring calcium (Choice A), phosphorus (Choice B), or white blood cell count (Choice D) is not directly related to the effectiveness of darbepoetin alfa in treating anemia associated with CKD.