HESI RN
HESI Maternity Test Bank Questions
Question 1 of 9
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
Correct Answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client.
Question 2 of 9
Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
Correct Answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation.
Question 3 of 9
When preparing a class on newborn care for expectant parents, what content should be taught concerning the newborn infant born at term gestation?
Correct Answer: C
Rationale: Vernix caseosa is a white, cheesy substance that acts as a protective barrier on the skin of newborns, particularly present in skin folds. It helps to prevent dehydration and protect the delicate skin of the newborn from the amniotic fluid in utero. Educating expectant parents about the presence and function of vernix caseosa can help them understand the importance of its preservation during the immediate postnatal period.
Question 4 of 9
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care?
Correct Answer: A
Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA.
Question 5 of 9
The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?
Correct Answer: D
Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver.
Question 6 of 9
A woman who delivered a 9-pound baby via cesarean section under spinal anesthesia is recovering in the post-anesthesia care unit. Her fundus is firm at the umbilicus, and a continuous trickle of bright red blood with no clots is observed by the nurse. Which action should the nurse implement?
Correct Answer: A
Rationale: In this situation, continuous bleeding despite a firm fundus suggests a possible laceration. The appropriate action for the nurse to take is to assess the woman's blood pressure. This helps determine the severity of blood loss and guides further interventions, such as identifying the need for additional assessments or interventions to control bleeding.
Question 7 of 9
The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
Question 8 of 9
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
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 9 of 9
A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
Correct Answer: A
Rationale: In this scenario, the best intervention is to ask the mother to stop feeding, comfort the infant, and then assist her in helping the baby latch on. Stopping the feeding and providing comfort can reduce the infant's frustration and create a calmer environment for successful breastfeeding.