HESI Maternity (Maternal And Child Health Nursing) Exam

1. A 36-year-old male client loses all function from his waist down after sustaining a spinal cord injury after falling off the roof of his house. The nurse asks the client how this injury will affect the different aspects of his life. The client replies, "It won't." This reaction exemplifies that the client is at what stage of the grieving process?

Clients usually responds to the loss by following the stages of the grieving process. The paralyzed condition of the client is his loss. The client is denying that this loss will affect him or his life.

Explanation

Clients usually responds to the loss by following the stages of the grieving process. The paralyzed condition of the client is his loss. The client is denying that this loss will affect him or his life.

Submit

2. During a prenatal visit, the nurse checks the fetal heart rate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted?

80 beats per minute

100 beats per minute

150 beats per minute

180 beats per minute

During the third trimester of pregnancy, a normal fetal heart rate (FHR) is typically between 120 and 160 beats per minute. This range indicates that the baby's heart is functioning properly and receiving adequate oxygen and nutrients. Therefore, the correct answer is 150 beats per minute, as it falls within the normal range for FHR during the third trimester.

Explanation

During the third trimester of pregnancy, a normal fetal heart rate (FHR) is typically between 120 and 160 beats per minute. This range indicates that the baby's heart is functioning properly and receiving adequate oxygen and nutrients. Therefore, the correct answer is 150 beats per minute, as it falls within the normal range for FHR during the third trimester.

3. During a prenatal visit, the nurse checks the fetal heart rate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which of the following heart rates is noted?

80 beats per minute

100 beats per minute

150 beats per minute

180 beats per minute

During the third trimester of pregnancy, a normal fetal heart rate (FHR) is typically around 120-160 beats per minute. A heart rate of 150 beats per minute falls within this range, indicating a normal FHR. Higher or lower heart rates may be a cause for concern and may require further evaluation.

Explanation

During the third trimester of pregnancy, a normal fetal heart rate (FHR) is typically around 120-160 beats per minute. A heart rate of 150 beats per minute falls within this range, indicating a normal FHR. Higher or lower heart rates may be a cause for concern and may require further evaluation.

4. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?

Dysuria

Frequency

Incontinence

Burning urination

Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.

Explanation

Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.

5. A client LMP began July 5. Her EDD should be which of the following?

January 2

March 28

April 12

October 12

To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.

Explanation

To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.

6. A 25-year-old client with diabetes type I visits the clinic to discuss her and her husband's desire to start a family. This diabetic client

Should be discouraged from becoming pregnant

Has a greater risk of complications during pregnancy

Should be informed about treatment for infertility

Will be able to carry out a completely normal pregnancy

Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.

Explanation

Clients with DM are at greater risk for developing maternal and fetal complications during pregnancy.

7. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:

“Nausea and vomiting can be decreased if I eat a few crackers before arising”

“If I start to leak colostrum, I should cleanse my nipples with soap and water”

“If I have a vaginal discharge, I should wear nylon underwear”

“Leg cramps can be alleviated if I put an ice pack on the area”

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

Explanation

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

8. A client suspects that she is pregnant and visits the clinic. Of the following changes caused by pregnancy, which is the only positive sign that the client is pregnant?

Enlarge abdomen

Positive pregnancy test

Detection of fetal heartbeat

Uterine contraction

Positive signs of pregnancy are detected changes that provide objective, conclusive proof of pregnancy. 1. detection of fetal heartbeat 2. fetal movement palpated by a professional 3. visualization of the fetus by sonography The other choices are considered PROBABLE signs of pregnancy.

Explanation

Positive signs of pregnancy are detected changes that provide objective, conclusive proof of pregnancy. 1. detection of fetal heartbeat 2. fetal movement palpated by a professional 3. visualization of the fetus by sonography The other choices are considered PROBABLE signs of pregnancy.

9. Family centered nursing care for women and newborn focuses on which of the following?

Assisting individuals and families achieve their optimal health

Diagnosing and treating problems promptly

Preventing further complications from developing

Conducting nursing research to evaluate clinical skills

Family centered nursing care for women and newborn focuses on assisting individuals and families achieve their optimal health. This approach recognizes the importance of involving the entire family in the care and decision-making process. It aims to promote the well-being of both the mother and the newborn by providing support, education, and resources to help them achieve and maintain their best possible health outcomes. This approach also emphasizes the importance of preventive care and early intervention to prevent further complications from developing. By focusing on assisting individuals and families in achieving optimal health, family centered nursing care aims to promote holistic and comprehensive care for women and newborns.

Explanation

Family centered nursing care for women and newborn focuses on assisting individuals and families achieve their optimal health. This approach recognizes the importance of involving the entire family in the care and decision-making process. It aims to promote the well-being of both the mother and the newborn by providing support, education, and resources to help them achieve and maintain their best possible health outcomes. This approach also emphasizes the importance of preventive care and early intervention to prevent further complications from developing. By focusing on assisting individuals and families in achieving optimal health, family centered nursing care aims to promote holistic and comprehensive care for women and newborns.

10. The fetal heart is carefully monitored throughout pregnancy and during labor to assess fetal well being. Which of the following represents an appropriate fetal heart rate?

108

127

170

185

The appropriate range of fetal heart rate is 120-160 beats per minute.

Explanation

The appropriate range of fetal heart rate is 120-160 beats per minute.

11. This is a dark streak down the midline of the abdomen that may appear as the uterus is enlarging. The LPN correctly describes this to the pregnant woman as?

The LPN correctly describes the dark streak down the midline of the abdomen as "linea nigra." This is a common occurrence during pregnancy as the uterus enlarges. The darkening of the skin is caused by hormonal changes and increased pigmentation. The LPN is providing accurate information to the pregnant woman about this normal phenomenon.

Explanation

The LPN correctly describes the dark streak down the midline of the abdomen as "linea nigra." This is a common occurrence during pregnancy as the uterus enlarges. The darkening of the skin is caused by hormonal changes and increased pigmentation. The LPN is providing accurate information to the pregnant woman about this normal phenomenon.

Submit

12. According to Diane, her LMP is November 15, 2002, using the Naegle's rule what is her EDC?

August 23, 2003

August 18, 2003

July 22, 2003

February 22, 2003

not-available-via-ai

Explanation

not-available-via-ai

13. Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?

Introversion, egocentrism, narcissism

Awkwardness, clumsiness, and unattractiveness

Anxiety, passivity, extroversion

Ambivalence, fear, fantasies

During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well- being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.

Explanation

During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well- being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.

14. A nurse is collecting data during the admission asessment of a client who is pregnant with twins. The client also has 5 year old child. The nurse would document which gravida and para status on this client?

G1P1

G2P1

G2P2

G3P2

The client is pregnant with twins, which means this is her second pregnancy (G2). She already has one child, so her para status is 1. Therefore, the nurse would document G2P1 to indicate that this is the client's second pregnancy and she has one living child.

Explanation

The client is pregnant with twins, which means this is her second pregnancy (G2). She already has one child, so her para status is 1. Therefore, the nurse would document G2P1 to indicate that this is the client's second pregnancy and she has one living child.

15. Which of the following represents the average amount of weight gained during pregnancy?

12 to 2 lbs

15 to 25 lbs

25 to 35 lbs

25 to 40 lbs

The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.

Explanation

The average amount of weight gained during pregnancy is 25 to 35 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.

16. During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?

Post partum phase

First trimester

Second trimester

Third trimester

First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

Explanation

First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

17. The LPN has initiated the administration of vancomycin via IV piggyback. In which of the following situations should the nurse recognize that the client may be experiencing a fatal reaction to this medication?

The client start coughing

The client complains of pain at the intravenous catheter insertion site

The nurse hears the client snoring from the hall

The nurse notices the client's neck and chest is bright red

While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.

Explanation

While administering vancomycin the LPN should know to monitor the client carefully for the development of Red Man Syndrome or anaphylactic shock. The common side effects of this medicine are pruritus, flushing and erythema to the head, neck, and upper body.

18. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs would the nurse Mica expect to administer if the client develops complications related to heparin therapy?

Calcium gluconate

Protamine sulfate

Methylegonovine

Nitrofurantoin

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications cause by heparin overdose.

Explanation

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications cause by heparin overdose.

19. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The LPN should tell the patient that she can expect to feel the fetus move at which time?

Between 10 and 12 weeks’ gestation

Between 16 and 20 weeks’ gestation

Between 21 and 23 weeks’ gestation

Between 24 and 26 weeks’ gestation

A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

Explanation

A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

20. Which of the following fundal heights indicates less than 12 weeks' gestation when the date of the LMP is unknown?

Uterus in the pelvis

Uterus at the xiphoid process

Uterus in the abdomen

Uterus in the umbilicus

When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.

Explanation

When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.

21. The LPN is preparing to administer Solu-Medrol 40 mg mixed in 150 mL of sodium chloride via intravenous piggyback. The medication is to be administered over 30 minutes. Using the tubing with a drop factor of 15 ggts/mL, what would the LPN calculate the rate to be in drops per minute?

40

50

75

150

The LPN would calculate the rate to be 75 drops per minute by using the formula: (Volume in mL / Time in minutes) x Drop factor. In this case, the volume is 150 mL, the time is 30 minutes, and the drop factor is 15 ggts/mL. Plugging these values into the formula, we get (150 / 30) x 15 = 75 drops per minute.

Explanation

The LPN would calculate the rate to be 75 drops per minute by using the formula: (Volume in mL / Time in minutes) x Drop factor. In this case, the volume is 150 mL, the time is 30 minutes, and the drop factor is 15 ggts/mL. Plugging these values into the formula, we get (150 / 30) x 15 = 75 drops per minute.

22. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should the nurse respond?

“Yes, it produces no adverse effect.”

“No, it can initiate premature uterine contractions.”

“No, it can promote sodium retention.”

“No, it can lead to increased absorption of fat-soluble vitamins.”

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.

Explanation

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if intestinal motility is increased.

23. On which of the following areas would the nurse expect to observe chloasma?

Breast, areola, and nipples

Chest, neck, arms, and legs

Abdomen, breast, and thighs

Cheeks, forehead, and nose

Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.

Explanation

Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.

24. During the prenatal visit, the client states that she has been experiencing heartburn frequently. The LPN provides instruction on the cause and prevention of heartburn. When she ask to verbalize understanding of the information, which of the following statements by the client indicates further instruction may be necessary?

"The sphincter that normally prevents stomach contents from going back up into the esophagus is relaxed."

"I should try to avoid drinking fluids while I'm eating."

"Eating six or seven small meals a day may help my symptoms."

"I'll eat enough to ensure that I am full at every meal."

It suggests that the instruction might need to be reinforced on preventing stomach distention.

Explanation

It suggests that the instruction might need to be reinforced on preventing stomach distention.

25. Which of the following would the nurse identify as a presumptive sign of pregnancy?

Hegar sign

Nausea and vomiting

Skin pigmentation changes

Positive serum pregnancy test

resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

Explanation

resumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign, skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.

26. She complained of leg cramps, which usually occurs at night. To provide relief, the nurse tells Diane to:

Dorsiflex the foot while extending the knee when the cramps occur

Dorsiflex the foot while flexing the knee when the cramps occurs

Plantar flex the foot while flexing the knee when the cramps occur

Plantar flex the foot while extending the knee when the cramp occur

The correct answer is to dorsiflex the foot while extending the knee when the cramps occur. Dorsiflexion refers to pulling the toes towards the shin, while plantar flexion refers to pointing the toes away from the shin. Extending the knee means straightening the leg, while flexing the knee means bending the leg. By dorsiflexing the foot and extending the knee, the muscles in the leg are stretched and relaxed, which can help relieve the leg cramps.

Explanation

The correct answer is to dorsiflex the foot while extending the knee when the cramps occur. Dorsiflexion refers to pulling the toes towards the shin, while plantar flexion refers to pointing the toes away from the shin. Extending the knee means straightening the leg, while flexing the knee means bending the leg. By dorsiflexing the foot and extending the knee, the muscles in the leg are stretched and relaxed, which can help relieve the leg cramps.

27. Cervical softening and uterine souffle are classified as which of the following?

Diagnostic signs

Presumptive signs

Probable signs

Positive signs

Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

Explanation

Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.

28. A primigravida client at 25 weeks' gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:

Tailor sitting

Leg lifting

Shoulder circling

Squatting exercises

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

Explanation

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

29. When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?

Thrombophlebitis

Pregnancy induced hypertension

Pressure on blood vessels from the enlarging uterus

The force of gravity pulling down on the uterus

Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.

Explanation

Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.

30. A client at 36 weeks' gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?

The ultrasound will help to locate the placenta

The ultrasound identifies blood flow through the umbilical cord

The test will determine where to insert the needle

The ultrasound locates a pool of amniotic fluid

Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

Explanation

Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

31. Mrs. Puente is visiting the clinic for a prenatal assessment. This is the client's fourth pregnancy. She lost one pregnancy during the ninth week of gestation. One pregnancy resulted in the birth of a stillborn infant at full term, and she has one living child who was born the 35th week of gestation. Which of the following best describes the client?

G5P2111

G4P1111

G4P1211

G5P1112

Gravida represents the total number of pregnancies that the client has had. Para describes the results of the pregnancies. Para is made up of four parts: the number of infants born at term or after 37 weeks; the number of infants born preterm or after 20 weeks but before 37 weeks; the number of spontaneous or therapeutic abortions or pregnancies that ended up prior to 20 weeks; and the number of living children. Mrs. Puente has had 4 pregnancies, meaning she is a gravid four. She gave birth to a stillborn infant at term, gave birth to a preterm infant who is also her living child, lost one pregnancy during the ninth week of gestation. Mrs. Puente is G4P1111, the answer is B.

Explanation

Gravida represents the total number of pregnancies that the client has had. Para describes the results of the pregnancies. Para is made up of four parts: the number of infants born at term or after 37 weeks; the number of infants born preterm or after 20 weeks but before 37 weeks; the number of spontaneous or therapeutic abortions or pregnancies that ended up prior to 20 weeks; and the number of living children. Mrs. Puente has had 4 pregnancies, meaning she is a gravid four. She gave birth to a stillborn infant at term, gave birth to a preterm infant who is also her living child, lost one pregnancy during the ninth week of gestation. Mrs. Puente is G4P1111, the answer is B.

32. A client is pregnant with her third child. Medical history of the client indicates a previous precipitate labor and birth. Which of the following interventions would NOT be expected during labor of the present pregnancy?

Use of magnesium sulfate

Close monitoring of the fetus for hypoxia

The nurse stays at the bedside constantly or as much as possible

Amnioinfusion will be performed

Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.

Explanation

Amnioinfusion is instillation of fluid into the amniotic sac within the uterus to treat oligohydraminios. This is not done to prevent precipitate labor and birth.

33. During a lecture on reproduction, a student nurse asks the instructor what determines the sex of a fetus. Accurate information in response to this question would be:

"The sex of the fetus is not determined until the eighth week of gestation."

"The fertilization of the zygote is the point at which sex is determined."

"Males have one less pair of chromosomes than females."

"Sex is determined by the chromosomes contributed by the ovum."

The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.

Explanation

The sex of the fetus is determined at the point that the sperm fertilizes the ovum to form the zygote. Sex is ultimately determined by the chromosome contributed by the sperm.

34. A patient in her 14^th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient

Knowledge deficit

Fluid volume deficit

Anticipatory grieving

Pain

If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

Explanation

If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count should be instituted. Although the other diagnoses are applicable to this patient, they are not the primary diagnosis.

35. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, "We know several friends in our age group and all of them have their own child already, Why can't we have one?". Which of the following would be the most pertinent nursing diagnosis for this couple?

Fear related to the unknown

Pain related to numerous procedures.

Ineffective family coping related to infertility.

Self-esteem disturbance related to infertility.

Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.

Explanation

Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.

36. The physcician orders epinephrine 0.1 mg SQ x 1 now. The constitution of epinephrine according to the vial is 1;1000, or 1 g of epinephrine per 1,000 mL of solution. How much solution should be drawn into the syringe by the LPN?

0.01 mL

0.1 mL

1.0 mL

10 mL

1000mg/1000mL = 0.1mg/x mL

1000x=100

x= 100/1000

x=0.1 mL

Explanation

1000mg/1000mL = 0.1mg/x mL

1000x=100

x= 100/1000

x=0.1 mL

37. When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?

Sperm count

Sperm motility

Sperm maturity

Sperm volume

Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.

Explanation

Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.

38. The hormone responsible for the development of the ovum during the menstrual cycle is?

Estrogen

Progesterone

Follicle stimulating hormone

Leutenizing hormone

Follicle stimulating hormone (FSH) is responsible for the development of the ovum during the menstrual cycle. FSH stimulates the growth and maturation of ovarian follicles, which contain the developing egg. This hormone is released by the pituitary gland and plays a crucial role in the regulation of the menstrual cycle. It helps to stimulate the growth of the follicles, which eventually leads to the release of a mature egg during ovulation.

Explanation

Follicle stimulating hormone (FSH) is responsible for the development of the ovum during the menstrual cycle. FSH stimulates the growth and maturation of ovarian follicles, which contain the developing egg. This hormone is released by the pituitary gland and plays a crucial role in the regulation of the menstrual cycle. It helps to stimulate the growth of the follicles, which eventually leads to the release of a mature egg during ovulation.

39. Ativan 0.5 mg IM every 1 hour as needed is prescribed for a client experiencing delirium tremens. The medication vial reads 2mg/mL of solution. How many mL should the LPN draw into the syringe for single-dose administration?

2mg/mL= 0.5mg/xmL

2x=0.5

x=0.5/2

x=0.25 mL

Explanation

2mg/mL= 0.5mg/xmL

2x=0.5

x=0.5/2

x=0.25 mL

Submit

40. Which of the following prenatal laboratory test values would the nurse consider as significant?

Hematocrit 33.5%

Rubella titer less than 1:8

White blood cells 8,000/mm3

One hour glucose challenge test 110 g/dL

A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.

Explanation

A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.

41. The nurse identifies substance abuse behaviors exhibited by a pregnant client during an initial prenatal screening. While promoting a therapeutic and accepting environment, the care managment by the nurse would be MOST appropriate if focused on which of the following?

Discouraging substance use during pregnancy

Termination of the pregnancy at an early stage

Eliminating substance use during pregnancy

Setting boundaries with the client in regards to substance use

Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.

Explanation

Use of substances during pregnancy can lead to severe fetal or neonatal abnormalities, complications, and death. The primary goal of nursing care should be prevention or elimination of substance use during pregnancy.

42. What is the recommended drug for the prevention of maternal-fetal HIV transmission; it is usually administered orally beginning after 14 weeks' gestation, intravenously during labor, and in the form of syrup to the neonate after birth for 6 weeks?

Zidovudine is the recommended drug for the prevention of maternal-fetal HIV transmission. It is typically administered orally starting after 14 weeks of gestation, intravenously during labor, and in the form of syrup to the neonate after birth for 6 weeks. Zidovudine is an antiretroviral medication that helps reduce the risk of HIV transmission from mother to child during pregnancy, labor, and breastfeeding. By taking zidovudine as prescribed, the chances of vertical transmission of HIV can be significantly reduced.

Explanation

Zidovudine is the recommended drug for the prevention of maternal-fetal HIV transmission. It is typically administered orally starting after 14 weeks of gestation, intravenously during labor, and in the form of syrup to the neonate after birth for 6 weeks. Zidovudine is an antiretroviral medication that helps reduce the risk of HIV transmission from mother to child during pregnancy, labor, and breastfeeding. By taking zidovudine as prescribed, the chances of vertical transmission of HIV can be significantly reduced.

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43. Which of the following would cause a false-positive result on a pregnancy test?

The test was performed less than 10 days after anabortion

The test was performed too early or too late in thepregnancy

The urine sample was stored too long at roomtemperature

A spontaneous abortion or a missed abortion isimpending

A false-positive reaction can occur if the
pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.

Explanation

A false-positive reaction can occur if the
pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false- negative results.

44. Pediazole is a suspension medication that contains 200 mg erythromycin and 600 mg sulfisoxazole per 5 mL. The physician orders Pediazole 4 mL PO every 12 hours. How many mg of sulfisoxazole is this client receiving in a 24-hour period?

160 mg

320 mg

480 mg

960 mg

600 mg/ 5 mL = x mg/ 4 mL

2400 = 5x

x= 2400/5

x= 480 mg per dose x 2 = 960 mg in 24 hours.

Explanation

600 mg/ 5 mL = x mg/ 4 mL

2400 = 5x

x= 2400/5

x= 480 mg per dose x 2 = 960 mg in 24 hours.

45. The nurse is educating a primigravida patient who is 12 weeks pregnant about the danger signs of pregnancy. The information provided is clearly understood by the expectant mother if the client states the following danger signs of pregnancy: Slect all that apply.

Gush of vaginal discharge

Vaginal bleeding

Persistent vomiting

Constipation

Urinary frequency

Epigastric or abdominal pain

Fetal heart rate of 120

The correct answer is gush of vaginal discharge, vaginal bleeding, persistent vomiting, and epigastric or abdominal pain. These are all potential danger signs of pregnancy that the nurse is educating the patient about. Constipation and urinary frequency are not typically considered danger signs of pregnancy. Fetal heart rate of 120 is within the normal range and not a danger sign.

Explanation

The correct answer is gush of vaginal discharge, vaginal bleeding, persistent vomiting, and epigastric or abdominal pain. These are all potential danger signs of pregnancy that the nurse is educating the patient about. Constipation and urinary frequency are not typically considered danger signs of pregnancy. Fetal heart rate of 120 is within the normal range and not a danger sign.

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46. A pregnant client states that she "waddles" when she walks. The nurse's explanation is based on which of the following as the cause?

The large size of the newborn

Pressure on the pelvic brim

Relaxation of the pelvic joints

Excessive weight gain

During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.

Explanation

During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.

47. A nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse checks the client for which classic signs of preeclampsia? Select all that apply.

Proteinuria

Hypertension

Low grade fever

Generalized edema

Increase pulse rate

Increase respiratory rate

The three classic signs of preeclampsia are hypertension, generalized edna, and proteinuria.

Explanation

The three classic signs of preeclampsia are hypertension, generalized edna, and proteinuria.

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48.

Reddish purple strech marks that usually occur on the abdomen, breasts, thighs, and upper arm. As a nurse, you would document this correctly in the client's chart by using what medical terminology?

The correct medical terminology to document reddish purple stretch marks that occur on the abdomen, breasts, thighs, and upper arm is "striae gravidarum." This term specifically refers to stretch marks that occur during pregnancy.

Explanation

The correct medical terminology to document reddish purple stretch marks that occur on the abdomen, breasts, thighs, and upper arm is "striae gravidarum." This term specifically refers to stretch marks that occur during pregnancy.

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49. During which of the following phase of the menstrual cycle is it ideal for implantation of a fertilized egg to occur?

Ischemic phase

Mentrual phase

Proliferative phase

Secretory phase

The secretory phase is the phase of the menstrual cycle when the endometrium becomes thick and rich in blood vessels, making it an ideal environment for implantation of a fertilized egg. During this phase, the hormone progesterone is released, which helps prepare the uterus for pregnancy. If fertilization occurs, the fertilized egg can implant itself into the thickened endometrium and begin to develop. Therefore, the secretory phase is the ideal time for implantation to occur.

Explanation

The secretory phase is the phase of the menstrual cycle when the endometrium becomes thick and rich in blood vessels, making it an ideal environment for implantation of a fertilized egg. During this phase, the hormone progesterone is released, which helps prepare the uterus for pregnancy. If fertilization occurs, the fertilized egg can implant itself into the thickened endometrium and begin to develop. Therefore, the secretory phase is the ideal time for implantation to occur.

50. The nurse knows that there are psychological maternal changes that occurs during pregnancy in a primigravida patient. Select all the normal psychological maternal changes that happens throughout pregnancy.

Ambivalence

Breast tenderness

Emotional lability

Body image changes

Bonding or relationship with the fetus

Nausea and vomiting

Syncope

Urinary frequency

During pregnancy, it is normal for a primigravida patient to experience psychological maternal changes such as ambivalence, emotional lability, body image changes, and bonding or relationship with the fetus. These changes are a result of hormonal fluctuations and the anticipation of becoming a mother. Breast tenderness, nausea and vomiting, syncope, and urinary frequency are physiological changes that occur during pregnancy but are not specifically related to psychological maternal changes.

Explanation

During pregnancy, it is normal for a primigravida patient to experience psychological maternal changes such as ambivalence, emotional lability, body image changes, and bonding or relationship with the fetus. These changes are a result of hormonal fluctuations and the anticipation of becoming a mother. Breast tenderness, nausea and vomiting, syncope, and urinary frequency are physiological changes that occur during pregnancy but are not specifically related to psychological maternal changes.

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51. After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

Decreased peristalsis

Increase heart rate

Dry mucous membranes

Nausea and Vomiting

Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

Explanation

Bethanechol will increase GI motility, which may cause nausea, belching, vomiting, intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may gently increase.

52. FHR can be auscultated with a fetoscope as early as which of the following?

5 weeks gestation

10 weeks gestation

13 weeks gestation

20 weeks gestation

The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.

Explanation

The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.

53. A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly by stating that which of the following are functions of amniotic fluid? Select all that apply.

Allows for fetal movement

Is a measure of kidney function

Surrounds, cushions, and protects the fetus

Maintains the body temperature of the fetus

Prevents large particles such as bacteria from passing to the fetus

Provides an exchange of nutrients and waste products between the mother and the fetus

Amniotic fluid serves multiple functions during pregnancy. It allows for fetal movement, providing the necessary space for the fetus to move and develop. It also acts as a measure of kidney function, as the fetus excretes waste products into the amniotic fluid. Additionally, amniotic fluid surrounds, cushions, and protects the fetus, acting as a protective barrier against external pressures and impacts. It helps maintain the body temperature of the fetus, providing a stable and optimal environment for growth. Lastly, amniotic fluid facilitates the exchange of nutrients and waste products between the mother and the fetus, supporting the fetal development and ensuring proper nourishment.

Explanation

Amniotic fluid serves multiple functions during pregnancy. It allows for fetal movement, providing the necessary space for the fetus to move and develop. It also acts as a measure of kidney function, as the fetus excretes waste products into the amniotic fluid. Additionally, amniotic fluid surrounds, cushions, and protects the fetus, acting as a protective barrier against external pressures and impacts. It helps maintain the body temperature of the fetus, providing a stable and optimal environment for growth. Lastly, amniotic fluid facilitates the exchange of nutrients and waste products between the mother and the fetus, supporting the fetal development and ensuring proper nourishment.

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54. Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?

Increased plasma HCG levels

Decreased intestinal motility

Decrease gastric acidity

Elevated estrogen levels

During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.

Explanation

During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.

55. A nurse is collecting data from a client who suspects that she is pregnant. The nurse is checking the client for probable signs of pregnancy. Select all that apply.

Ballottement

Chadwick's sign

Uterine enlargement

Braxton Hicks contractions

Outline of fetus via radiography or ultrasound

Fetal heart rate detected by a non electronic device

Hegar's sign

Goodle's sign

Ballottement or rebound of the fetus against the examiner's fingers on palpation; Chadwick's sign or the bluish coloration of the mucus membrane of the cervix, Uterine enlargement, Goodle's sign or the softening of the cervix; Braxton Hicks contraction, and Hegar's sign the softening and thinning of the lower uterine segment are ALL PROBABLE SIGNS OF PREGNANCY.

Explanation

Ballottement or rebound of the fetus against the examiner's fingers on palpation; Chadwick's sign or the bluish coloration of the mucus membrane of the cervix, Uterine enlargement, Goodle's sign or the softening of the cervix; Braxton Hicks contraction, and Hegar's sign the softening and thinning of the lower uterine segment are ALL PROBABLE SIGNS OF PREGNANCY.

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56. A nurse is monitoring for the Physiological Maternal Changes relating to pregnancy for a primigravida patient. What are the normal changes that happens during pregnancy? Select all that apply.

Circulating blood volume increases

Sodium and water retention may occur, which can lead to weight gain

Shortness of breath may be experienced

Breast size atrophies

There is a decrease in vaginal secretions

Frequency of urination occurs during second trimester

Chloasma occurs

During pregnancy, the circulating blood volume increases to support the growing fetus and provide adequate oxygen and nutrients. Sodium and water retention may occur, leading to weight gain. Shortness of breath may be experienced due to the increased demand for oxygen by the mother and the fetus. Chloasma, also known as the "mask of pregnancy," is a condition characterized by the darkening of the skin on the face. Breast size typically increases during pregnancy, rather than atrophying. Vaginal secretions may increase, rather than decrease. Frequency of urination commonly occurs during the first trimester, not the second.

Explanation

During pregnancy, the circulating blood volume increases to support the growing fetus and provide adequate oxygen and nutrients. Sodium and water retention may occur, leading to weight gain. Shortness of breath may be experienced due to the increased demand for oxygen by the mother and the fetus. Chloasma, also known as the "mask of pregnancy," is a condition characterized by the darkening of the skin on the face. Breast size typically increases during pregnancy, rather than atrophying. Vaginal secretions may increase, rather than decrease. Frequency of urination commonly occurs during the first trimester, not the second.

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57. Variation on the length of menstrual cycle is due to variations in the number of days in which of the following phase?

Proliferative phase

Mentrual phase

Proliferative phase

Secretory phase

The length of the menstrual cycle can vary due to variations in the number of days in the proliferative phase. The proliferative phase is the phase of the menstrual cycle during which the lining of the uterus thickens in preparation for potential implantation of a fertilized egg. The duration of this phase can vary from person to person, which can consequently affect the overall length of the menstrual cycle.

Explanation

The length of the menstrual cycle can vary due to variations in the number of days in the proliferative phase. The proliferative phase is the phase of the menstrual cycle during which the lining of the uterus thickens in preparation for potential implantation of a fertilized egg. The duration of this phase can vary from person to person, which can consequently affect the overall length of the menstrual cycle.

58. A 36 weeks gestation pregnant woman is complaining of urinary urgency and frequency. The nurse explained that the enlarging fetus is pressing the bladder which causes frequent urination. This is normally occuring during the first and third trimesters of pregnancy. The nurse advices the patient to do the following measures to prevent urinary frequency. Select all the necessary measures that the nurse can provide to the patient.

Drink 2 quarts of fluid during the day

Engaging in a regular exercise

Performing Kegel exercises

Soaking in a warm sitz bath

Limiting fluid intake during the evening

During pregnancy, the enlarging fetus can press on the bladder, causing urinary urgency and frequency. To prevent this, the nurse advises the patient to drink 2 quarts of fluid during the day to stay hydrated. Performing Kegel exercises can help strengthen the pelvic floor muscles and improve bladder control. Limiting fluid intake during the evening can reduce the need to urinate at night. Engaging in regular exercise and soaking in a warm sitz bath are not necessary measures to prevent urinary frequency in this situation.

Explanation

During pregnancy, the enlarging fetus can press on the bladder, causing urinary urgency and frequency. To prevent this, the nurse advises the patient to drink 2 quarts of fluid during the day to stay hydrated. Performing Kegel exercises can help strengthen the pelvic floor muscles and improve bladder control. Limiting fluid intake during the evening can reduce the need to urinate at night. Engaging in regular exercise and soaking in a warm sitz bath are not necessary measures to prevent urinary frequency in this situation.

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59. During the third trimester, a pregnant woman reports feeling short of breath when lying flat. Which physiological change is most likely responsible for this symptom?

Increased blood volume

Elevated progesterone levels

The growing uterus compressing the diaphragm

Increased oxygen consumption by the fetus

In the third trimester, the growing uterus can push upward against the diaphragm, reducing lung capacity and making it difficult for the woman to breathe deeply, particularly when lying flat. This is a common physiological change during late pregnancy and is often relieved by changing positions, such as sleeping with the upper body elevated. The other options, while related to pregnancy, are not the primary causes of this specific symptom.

Explanation

In the third trimester, the growing uterus can push upward against the diaphragm, reducing lung capacity and making it difficult for the woman to breathe deeply, particularly when lying flat. This is a common physiological change during late pregnancy and is often relieved by changing positions, such as sleeping with the upper body elevated. The other options, while related to pregnancy, are not the primary causes of this specific symptom.

60. A primigravida patient who is 12 weeks pregnant visits a helath promotion program in the community pertaining to the pregnancy care. A group of nursing student is educating the public about measures to prevent discomfort of pregnancy. The primigravida patient asks one of the student about measures on how to prevent heartburn she is experiencing throughout the day. Select all the necessary measures to prevent the primigravia patient's complaint.

Eating small, frequent meals and avoiding fatty and spicy food

Eating high fiber foods and increase drinking fluids

Drinking milk between milk

Arranging frequent rest periods throughout the day

Sitting upright for 30 minutes after a meal

Engaging in regular exercise

Eating small, frequent meals and avoiding fatty and spicy food can help prevent heartburn during pregnancy by reducing the amount of stomach acid produced and preventing the stomach from becoming too full. Sitting upright for 30 minutes after a meal can also prevent heartburn by allowing gravity to keep stomach acid down. These measures can help alleviate the discomfort of heartburn and provide relief for the primigravida patient.

Explanation

Eating small, frequent meals and avoiding fatty and spicy food can help prevent heartburn during pregnancy by reducing the amount of stomach acid produced and preventing the stomach from becoming too full. Sitting upright for 30 minutes after a meal can also prevent heartburn by allowing gravity to keep stomach acid down. These measures can help alleviate the discomfort of heartburn and provide relief for the primigravida patient.

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