HESI RN
HESI Maternity Test Bank Questions
Question 1 of 5
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 2 of 5
A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?
Correct Answer: D
Rationale: In this scenario, the correct action for the school nurse to take is D) Schedule a test for Lyme disease if a rash appears. This is the most appropriate response because tick bites can potentially transmit Lyme disease, which is caused by the bacterium Borrelia burgdorferi. By scheduling a test for Lyme disease if a rash appears, the nurse is following best practice guidelines to ensure early detection and treatment if necessary. Option A) Refer the mother to the Centers for Disease Control and Prevention is not the most immediate or practical step to take in this situation. The school nurse should first assess the child's symptoms and provide appropriate care before considering external referrals. Option B) Report the incident to the school principal is not the most urgent action needed. While it is important to document incidents, the immediate concern is the child's health and potential risk of Lyme disease. Option C) Culture the bite site when the child returns to school is not a recommended course of action. Lyme disease testing involves blood tests, not culturing the bite site, and waiting for the child to return to school may delay necessary testing and treatment. In an educational context, it is crucial for school nurses to be knowledgeable about common health risks, like tick bites and Lyme disease, especially in areas where these are prevalent. Prompt and appropriate actions can help prevent complications and ensure the well-being of students under their care. It is essential for school nurses to stay updated on best practices for managing various health concerns that may arise in a school setting.
Question 3 of 5
A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the healthcare provider be reported to immediately?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Numbness and inability to move fingers. When a cast is applied and elevated above the level of the heart during the drying process, there is a risk of compartment syndrome developing. Compartment syndrome occurs when there is increased pressure within a muscle compartment, leading to decreased blood flow and potential nerve damage. Numbness and the inability to move fingers are indicative of nerve compression and impaired circulation, which are serious complications requiring immediate attention to prevent permanent damage. Option A) Itching sensation under the cast is a common sensation due to the drying process and is not typically a cause for immediate concern. Option B) Swelling of fingers with brisk capillary refill is a normal response to the elevation of the cast and should resolve once the cast is fully dried and the limb is lowered. Option D) Visible bruising above the cast may indicate minor trauma during the application of the cast but is not a critical finding that requires immediate reporting. Educationally, it is important for healthcare providers to understand the signs and symptoms of compartment syndrome to prevent complications such as tissue necrosis and permanent nerve damage. Prompt recognition and intervention are crucial in managing this condition effectively and ensuring optimal patient outcomes.
Question 4 of 5
A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 mL of D5W. How many milliliters of the solution should the nurse administer?
Correct Answer: D
Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.
Question 5 of 5
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
Correct Answer: B
Rationale: Chorea, or sudden aimless movements associated with rheumatic fever, is temporary in nature and will eventually disappear on its own. It is important for the nurse to reassure the parents that these movements are part of the condition and typically resolve over time without the need for permanent lifestyle changes or strict discipline. Providing accurate information and reassurance to the parents can help alleviate concerns and promote understanding of the condition's course.