HESI LPN
HESI Maternal Newborn
1. When assessing a woman in the first stage of labor, which clinical finding will alert the nurse that uterine contractions are effective?
- A. Dilation of the cervix.
- B. Descent of the fetus to –2 station.
- C. Rupture of the amniotic membranes.
- D. Increase in bloody show.
Correct answer: A
Rationale: During the first stage of labor, effective uterine contractions lead to cervical dilation. Dilation of the cervix is a key indicator that uterine contractions are progressing labor. Descent of the fetus to -2 station (Choice B) is related to the fetal position in the pelvis and not a direct indicator of uterine contraction effectiveness. Rupture of the amniotic membranes (Choice C) signifies the rupture of the fluid-filled sac surrounding the fetus and does not directly reflect uterine contraction effectiveness. An increase in bloody show (Choice D) can be a sign of impending labor, but it is not a direct indicator of uterine contraction effectiveness.
2. A female client who started chemotherapy three days ago for cancer of the breast calls the clinic reporting that she is so upset she cannot sleep. The client has several PRN medications available. Which drug should the nurse instruct her to take?
- A. Ondansetron 8mgPO no
- B. Lorazepam 2mg PO bedtime
- C. Oxycodone, acetylsalicylic acid one tablet q4 hours PRN
- D. Acetaminophen, diphenhydramine 2 capsules bedtime
Correct answer: D
Rationale: Acetaminophen and diphenhydramine help with sleep without severe side effects.
3. What is an important basis in preparing the family health care plan?
- A. Needs and problems gathered and recognized by the nurse herself
- B. Data gathered from the health center
- C. Needs and problems as seen and accepted by the family
- D. Needs as expected by the midwife assigned in the area where the family resides
Correct answer: C
Rationale: In preparing a family health care plan, it is crucial to consider the needs and problems as perceived and accepted by the family members themselves. This ensures that the plan aligns with the family's beliefs, values, and preferences, leading to better acceptance and adherence. Choices A, B, and D are incorrect because the active involvement and acceptance of the family in recognizing their needs and problems are essential for effective health care planning.
4. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply)
- A. Verify pedal pulses using a doppler pulse device.
- B. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure.
- C. Evaluate the application of the splint to the left leg.
- D.
Correct answer: C
Rationale: It is crucial for the nurse to evaluate the application of the splint to the left leg in a client with diminished distal pulses. This assessment helps ensure that the splint is not causing any compromise to circulation. Verifying pulses and monitoring for leg conditions are important interventions but do not directly address the issue with the splint application in this scenario, making them less relevant.
5. What is a common symptom of congenital heart disease in infants?
- A. Excessive weight gain
- B. Difficulty breathing
- C. High blood pressure
- D. Increased appetite
Correct answer: B
Rationale: Difficulty breathing is a common symptom of congenital heart disease in infants. Infants with congenital heart disease may experience difficulty breathing due to impaired cardiac function, which affects the heart's ability to pump blood effectively. This symptom is often due to issues like heart failure or fluid accumulation in the lungs. Excessive weight gain (Choice A) is not typically associated with congenital heart disease in infants. High blood pressure (Choice C) is less common in infants with congenital heart disease compared to adults. Increased appetite (Choice D) is not a typical symptom of congenital heart disease in infants.