HESI RN
HESI Maternity Test Bank Questions
Question 1 of 5
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 2 of 5
The nurse is planning care for a 4-year-old girl who is diagnosed with a developmental disability. What should be the primary focus of treatment for this child?
Correct Answer: D
Rationale: The primary focus of treatment for a child diagnosed with a developmental disability should be to help them achieve their maximum potential. This approach aims to optimize the child's physical, emotional, cognitive, and social abilities, focusing on enhancing their overall well-being and quality of life. By supporting the child in reaching their highest level of functioning, caregivers can promote independence, self-esteem, and personal growth, which are essential components of holistic care for individuals with developmental disabilities.
Question 3 of 5
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
Correct Answer: C
Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding.
Question 4 of 5
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 5 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.