HESI RN
HESI Maternity Test Bank
1. What maternal behavior is typically observed when a new mother first receives her infant?
- A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
- B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
- C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
- D. She eagerly reaches for the infant and then holds the infant close to her own body.
Correct answer: B
Rationale: When a new mother first receives her infant, a typical maternal behavior is to use her arms and hands to receive the infant and then trace the infant's profile with her fingertips. This action is a gentle way of bonding with the newborn and aids in recognizing the infant's features. Choices A, C, and D are incorrect as they do not accurately describe the common behavior of tracing the infant's profile, which is a significant part of the initial interaction between a mother and her newborn.
2. A full-term infant is transferred to the nursery from labor and delivery. Which information is most important for the LPN/LVN to receive when planning immediate care for the newborn?
- A. Length of labor and method of delivery.
- B. Infant's condition at birth and treatment received.
- C. Feeding method chosen by the parents.
- D. History of drugs given to the mother during labor.
Correct answer: B
Rationale: When a full-term infant is transferred to the nursery, the most crucial information for the LPN/LVN to receive for immediate care planning is the infant's condition at birth and any treatments received. This data helps in determining the initial care needs and monitoring requirements for the newborn. Choices A, C, and D are not as critical as the infant's condition at birth and treatment received. The length of labor and method of delivery may provide background information but may not be as essential for immediate care planning. The feeding method chosen by the parents and the history of drugs given to the mother during labor are important but do not take precedence over knowing the infant's condition and treatment received.
3. A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
- A. Inform her that a decreased need for insulin occurs while breastfeeding.
- B. Counsel her to increase her caloric intake.
- C. Advise the client to breastfeed more frequently.
- D. Schedule an appointment for the client with the diabetic nurse educator.
Correct answer: A
Rationale: The correct answer is A. During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. Choice B is incorrect as increasing caloric intake is not directly related to the decrease in insulin needs during breastfeeding. Choice C is incorrect as advising the client to breastfeed more frequently does not address the issue of decreased insulin needs. Choice D is incorrect as scheduling an appointment with the diabetic nurse educator is not necessary at this point since the decreased need for insulin is a common physiological response to breastfeeding.
4. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
- A. Turn the client to her left side
- B. Contact the healthcare provider
- C. Assess the fetal heart rate
- D. Check the cervical dilation
Correct answer: C
Rationale: The correct answer is to assess the fetal heart rate. When amniotic fluid is greenish-brown, it may indicate the presence of meconium, which can be concerning as it may lead to fetal distress. Assessing the fetal heart rate will help determine the well-being of the fetus and guide further actions to ensure the safety of both the mother and the baby.
5. The parents of a 3-year-old boy with Duchenne muscular dystrophy (DMD) ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The lack of the protein dystrophin in the mother can impact the XXX muscle groups of males.
- D. Spinal cord damage due to birth trauma during a breech vaginal birth weakens the muscles.
Correct answer: A
Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder, meaning the gene mutation causing DMD is located on the X chromosome. Males have one X chromosome and one Y chromosome, so if the X chromosome they inherit from their mother carries the mutated gene, they will develop DMD. Females have two X chromosomes, so they are carriers of the gene but are usually not affected by the disease. Therefore, the nurse should explain to the parents that DMD is an inherited X-linked recessive disorder that primarily affects male children in the family.
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