HESI Maternity Test Bank

Question 1 of 5

The healthcare provider is preparing to suture a 10-year-old with a lacerated forehead. Both parents and the 12-year-old sibling are at the child's bedside. Which instruction best supports the family?

A. While waiting for the healthcare provider, only one family member may stay with the child. B. All family members should leave while the healthcare provider sutures the child's forehead. C. It is best if the sibling goes to the waiting room until the suturing is completed. D. Please decide among yourselves who will stay when the healthcare provider begins suturing.

Correct Answer: D

Rationale: Involving the family in the decision of who will stay during the suturing procedure supports their comfort and participation in the child's care, promoting a sense of control and family-centered care.

Question 2 of 5

A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?

A. Weigh the baby daily, and if she is gaining weight, she is eating enough. B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry. D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.

Correct Answer: B

Rationale: The correct answer is B. Adequate voiding is a sign that the baby is receiving enough milk. Pale straw-colored urine 6 to 10 times a day indicates proper hydration and nutrition. This is a reliable indicator of adequate breast milk intake for the infant.

Question 3 of 5

At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?

A. Round ligament strain. B. Chorioamnionitis. C. Abruptio placenta. D. Viral infection.

Correct Answer: B

Rationale: The client's symptoms of fever and abdominal tenderness, along with the gestational age, are classic signs of chorioamnionitis, an infection of the amniotic fluid. This condition requires prompt recognition and treatment to prevent maternal and fetal complications.

Question 4 of 5

An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?

A. Place the infant in a knee-chest position. B. Administer morphine sulfate. C. Start intravenous fluids. D. Provide 100% oxygen by face mask.

Correct Answer: A

Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.

Question 5 of 5

When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?

A. Measure bilirubin levels using transcutaneous bilirubinometry. B. Evaluate cord blood Coombs test results. C. Review maternal medical records for blood type and Rh factor. D. Prepare the newborn for phototherapy.

Correct Answer: A

Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.

Nurselytic

HESI RN

HESI RN