Maternity HESI 2023 Quizlet

Question 1 of 5

When assessing a child with HIV, which system should the nurse assess first?

A. Assess the respiratory system. B. Assess the gastrointestinal system. C. Assess the cardiovascular system. D. Assess the neurological system.

Correct Answer: A

Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.

Question 2 of 5

After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?

A. The new formula is a coconut milk formula used with babies with impaired fat absorption. B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea. C. The new formula is a casein protein source that is low in phenylalanine. D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.

Correct Answer: D

Rationale: The LPN/LVN should inform the mother that Similac® Soy Isomil® Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.

Question 3 of 5

Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse take next?

A. Initiate positive pressure ventilation. B. Intervene after the one-minute Apgar assessment. C. Initiate CPR on the infant. D. Assess the infant's blood glucose level.

Correct Answer: A

Rationale: A heart rate below 100 bpm in a newborn indicates bradycardia and requires intervention. Positive pressure ventilation should be initiated to improve oxygenation and help increase the infant's heart rate. This intervention is crucial to support the newborn's transition to extrauterine life and prevent further complications.

Question 4 of 5

The LPN/LVN identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?

A. Elicit a positive scarf sign on the affected side. B. Observe for an asymmetrical Moro (startle) reflex. C. Watch for swelling of fingers on the affected side. D. Note paralysis of the affected extremity and muscles.

Correct Answer: B

Rationale: Crepitus in a newborn's chest following vaginal delivery may indicate a clavicle fracture. Observing for an asymmetrical Moro reflex is essential because it can indicate potential nerve damage or fracture, which may be associated with the crepitus identified during the examination.

Question 5 of 5

A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?

A. Jaundice. B. Poor feeding. C. Brain injury. D. Hypoglycemia.

Correct Answer: A

Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates.
Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.

Nurselytic

HESI RN

HESI RN