Fortis - PN Maternity HESI Practice Exam - Questions, Answers and Rationales Which physiological cause(s) for constipation during pregnancy should the
... [Show More] practical nurse (PN) explain to a client in the first trimester? (Select all that apply.) 1. Displacement of the colon. 2. Tightening of the anal sphincter. 3. Change in nutrient absorption. 4. Shifting of liver placement. 5. Decrease in peristalsis. 6. Increase bile production. During pregnancy, the enlarging uterus compresses and displaces the colon (A), which leads to a decrease in peristalsis (E), which contribute to constipation during pregnancy. (B, C, D, and F) do not cause constipation in pregnancy. Which intervention should the practical nurse (PN) provide a neonate during hospitalization? 1. Provide play activities in the hospital room. 2. Offer the neonate a pacifier between feedings. 3. Assign the neonate to a room with other neonates. 4. Request that parents bring security object from home. The neonate needs opportunities for nonnutritive sucking and oral stimulation using a pacifier (B). (A, C and D) are not indicated for a neonate. Which client is a candidate for the administration of human immune globulin (RhoGam) after delivery? 1. The Rh-positive mother who delivers a Rh-positive baby. 2. The Rh-negative mother who delivers a Rh-negative baby. 3. The Rh-positive mother who delivers a Rh-negative baby. 4. The Rh-negative mother who delivers a Rh-positive baby. RhoGam is a human immune globulin that prevents the formation of anti-Rh antibodies in an Rh-negative mother who has given birth to an Rh-positive infant (D). (A, B, or C) are not candidates for RhoGam. A client who took iron supplements during pregnancy delivers an infant by cesarean section. On the second postpartum day, the client reports having a constipated stool that is greenish-black in color. Which action should the practical nurse (PN) implement? 1. Collect a stool sample for guaiac testing. 2. Administer a prescribed rectal suppository. 3. Record color and consistency of the stool. 4. Report the complaints to the charge nurse. Iron supplements cause constipation and contribute to the dark green-black color in stool, which should be documented (C) as an expected finding. (A, B, and D) are not indicated at this time. The mother asks the practical nurse (PN) what her infant may need if the phenylketonuria (PKU) test is positive. What type of treatment should the PN tell the mother will be required? 1. Blood transfusions. 2. Iron-enriched formula. 3. Lifelong dietary management. 4. Medications to prevent infection. PKU is a condition related to the infant's inability to utilize the amino acid, phenylalanine, which must be omitted or strictly minimized in the diet throughout life (C). (A, B, and D) are not indicated. A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as August 5, what expected date of birth (EDB) should the practical nurse (PN) calculate? 1. April 29 2. May 12 3. July 1 4. July 12 Naegele's rule for calculation of EDB is determined by adding 7 days to the first day of the LMP and then subtracting 3 months, so (B) is the correct calculation. (A, C, and D) incorrectly apply Naegele's rule. Which client should the practical nurse (PN) closely monitor for severe afterpains? 1. A mother who had oligohydramnios during the pregnancy. 2. A primiparous client who is bottle feeding. 3. A multigravida who is breastfeeding. 4. A primigravida who delivered a 5 pound 3 ounce infant. After multiple deliveries, the over-distended uterus establishes tonicity during early involution by periodically relaxing and then vigorously contracting, which is also stimulated by breastfeeding which releases oxytocin and causes post-delivery uterine contractions. A multigravida client who is breastfeeding (C) is mostly likely to experience severe afterpains. Oligohydramnios (A) (low amount of amniotic fluid) and bottle feeding (B) do not place the client at risk for experiencing severe afterpains related to multiparity. A low-birth weight infant (D) does not over-distend the uterus during the pregnancy. A primigravida client who is at 39-weeks gestation arrives at the clinic and tells the practical nurse (PN) she is having contractions every 5 minutes. The healthcare provider determines she is dilated 3 cm and in early labor. What action should the practical nurse (PN) implement when the client groans with each contraction? 1. Assist the client to the bathroom to void. 2. Give a prescribed narcotic analgesic. 3. Document the maternal vital signs. 4. Demonstrate simple relaxation measures. The use of relaxation techniques (D) is a recommended and effective method of decreasing the perception of uterine contraction intensity in early labor. Ambulating the client to the bathroom to empty her bladder (A) should allow labor progression, but does not minimize her discomfort. (B) is not indicated at this time. Documentation of vital signs should be made (C), but relaxation techniques provide distraction in early labor and relief of discomfort. The practical nurse (PN) places a newborn who is 4 hours old with an axillary temperature of 97.2 o F under the radiant heat warmer. Which rationale supports the PN's action? 1. Heat loss increases as the newborn stretches from a flexed position. 2. The newborn's thin layer of subcutaneous fat provides poor insulation. 3. The basal metabolic rate is higher in a neonate that an adult. 4. Neonatal body surface area allows for a slower rate of heat loss. Newborns have a large body surface area (BSA) and a relatively thin layer of subcutaneous fat which provides poor insulation (B) and predisposes the newborn to thermoregulation difficulties. (A and C) may contribute to body heat loss, but ineffective thermoregulation in the newborn is due to a lack of subcutaneous fat. The newborn's BSA favors a more rapid heat loss, not (D), than what an adult experiences. Which finding for a 2-week-old infant should the practical nurse (PN) report to the healthcare provider? 1. Yellowish tinge around the eyes. 2. Peeling skin on the trunk. 3. Cool hands compared to body core. 4. Small pink patch on base of neck. A 2-week old infant with a yellow tinged skin around the eyes may indicate jaundice and
should be reported to the healthcare provider (A). (B and D) are expected findings. (C) is likely due to environmental exposure, and the infant should be covered with a blanket. A father expresses concern that his 3-day-old infant looks "yellow." Which information should the practical nurse (PN) provide? 1. This yellow skin condition is the result of hepatic insufficiency. 2. Normal signs of jaundice occur during the first 24 hours of life. 3. Blood incompatibilities between mother and infant blood are common. 4. Physiologic jaundice occurs from a normal reduction in red blood cells. Physiologic jaundice in the newborn is observed when an increase in indirect bilirubin levels peak (maximum serum levels of 5 to 6 mg/dl) between 2 to 4 days of age due to an immature newborn liver. Physiologic jaundice results in newborns due to the rapid lysis of red blood cells (RBCs) after birth (D). (A, B, and C) are inaccurate. A primiparous client asks the practical nurse (PN) how much her newborn baby boy should sleep every day. What information should the PN provide? 1. A primiparous client asks the practical nurse (PN) how much her newborn baby boy should sleep every day. What information should the PN provide? 2. Keep the baby awake during the daytime so he sleeps through the night. 3. A newborn sleeps most of the day and gradually will have increasing periods of wakefulness. 4. Expect your baby to follow your sleep and wake patterns once you establish a pattern at home. The first 6 weeks of life involve a steady decrease in the newborn's sleep time, beginning with approximately 17 hours of sleep a day that progresses to increasing periods of wakefulness (C) as the need for socializing appears. (A, B, and D) are not expectations for the normal sleep patterns of a newborn. A primigravida client asks the practical nurse (PN), "How will I know that I will be going into labor soon?" Which sign should the PN provide that is a common sign? 1. Burst of energy. 2. Urinary retention. 3. Increase in fundal height. 4. Weight gain of 1.5 to 2 kg. Common information that woman often experience with impending labor is a burst of energy (A). Urinary frequency, not (B), and a decrease in fundal height, not (C), occur as the fetus drops into the pelvis with the onset of labor. (D) is not a sign of impending labor. [Show Less]