HESI RN
HESI Maternity Test Bank
1. What action should be implemented when preparing to measure the fundal height of a pregnant client?
- A. Have the client empty her bladder.
- B. Request the client lie on her left side.
- C. Perform Leopold's maneuvers first.
- D. Give the client some cold juice to drink.
Correct answer: A
Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.
2. What is the triangular space lying between the vaginal and rectal canals?
- A. Pelvic floor
- B. Perineum
- C. Vestibule
- D. Perineal body
Correct answer: B
Rationale: The correct answer is B: Perineum. The perineum is the triangular space located between the vaginal and rectal canals. It is a region containing various muscles, nerves, and blood vessels that support the pelvic floor. Choice A, Pelvic floor, refers to the structure supporting the organs in the pelvic cavity, not the space between the vaginal and rectal canals. Choice C, Vestibule, is the space within the labia minora containing the openings of the urethra and vagina, not the area between the vaginal and rectal canals. Choice D, Perineal body, is a fibromuscular mass in the perineum area but not the space between the vaginal and rectal canals.
3. Community health nurses are particularly concerned with the source of communicable diseases such as hepatitis A. Which group of individuals have a higher risk of contracting that type of hepatitis?
- A. IV drug users who share needles
- B. low-income families living in cramped quarters
- C. those who have recently received a blood transfusion
- D. sexually active persons with multiple partners
Correct answer: B
Rationale: The correct answer is B. Hepatitis A is often spread through close personal contact and poor sanitary conditions, which are more common in low-income, cramped living situations. IV drug users sharing needles are at higher risk of hepatitis B and C due to bloodborne transmission. Those who have recently received a blood transfusion are at risk of hepatitis C or other bloodborne infections. Sexually active persons with multiple partners are at risk of hepatitis B, which can be transmitted through sexual contact.
4. An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?
- A. Encourage high levels of physical activity.
- B. Provide a quiet and structured environment.
- C. Engage the client in creative arts activities.
- D. Allow the client to make decisions about their schedule.
Correct answer: B
Rationale: During a manic episode, individuals with bipolar disorder may experience heightened energy levels, decreased need for sleep, and racing thoughts. Providing a quiet and structured environment is crucial in managing these symptoms as it helps reduce external stimuli, prevent overstimulation, and promote a sense of calmness. Encouraging high levels of physical activity may exacerbate the manic symptoms by further increasing stimulation and excitement. Engaging the client in creative arts activities might be beneficial during stable periods but may not be the most appropriate intervention during a manic episode. Allowing the client to make decisions about their schedule could potentially lead to impulsivity and poor judgment, which are common characteristics of mania.
5. An adolescent with intellectual disability is admitted for refusing to complete oral hygiene. A behavior modification program is recommended. Which reinforcement is best?
- A. Unit tasks for each omitted teeth brushing.
- B. Candy for each successfully completed hygiene task.
- C. Privilege restriction for refusing hygiene tasks.
- D. Preferred activities or tokens for compliance.
Correct answer: D
Rationale: The best reinforcement strategy in this scenario is providing preferred activities or tokens for compliance. Positive reinforcement is effective in behavior modification programs for individuals with intellectual disabilities. Offering preferred activities or tokens serves as a reward for completing the desired behavior, in this case, oral hygiene tasks. Choices A, B, and C do not focus on reinforcing the desired behavior with positive incentives. Choice A does not provide a positive reinforcement for compliance but rather focuses on the omission of a task. Choice B uses candy, which may not be ideal for oral hygiene. Choice C involves punishment rather than positive reinforcement.