HESI RN
HESI Maternity Test Bank Questions
Question 1 of 9
The healthcare provider is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant's care?
Correct Answer: C
Rationale: A high respiratory rate in a newborn is concerning as it may indicate respiratory distress, which requires immediate attention to ensure adequate oxygenation. Monitoring and addressing respiratory issues take precedence over other parameters in the initial assessment of a newborn.
Question 2 of 9
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.
Question 3 of 9
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: Scheduling a test for Lyme disease if a rash appears is the correct action to take in this situation. Lyme disease can be transmitted through tick bites, and a rash is a common early symptom. Testing for Lyme disease is essential for timely diagnosis and treatment to prevent complications.
Question 4 of 9
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for a client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump?
Correct Answer: A
Rationale: To calculate the infusion rate, first, determine the total volume to be infused (6 grams of magnesium sulfate) over a specific time frame (20 minutes). Then, calculate the concentration of magnesium sulfate in the IV bag to determine the mL/hour rate. In this case, with 20 grams of magnesium sulfate in 500 mL of solution, there are 4 grams of magnesium sulfate per 100 mL. Since 6 grams are required, the nurse should set the pump to deliver 150 mL/hour to infuse the prescribed dose over 20 minutes. This calculation ensures the correct dose is delivered within the specified time frame.
Question 5 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 6 of 9
A newborn with a yellow abdomen and chest is being assessed. What should the nurse do?
Correct Answer: A
Rationale: Assessing the bilirubin level helps determine the severity of jaundice in the newborn.
Question 7 of 9
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the healthcare provider take?
Correct Answer: C
Rationale: Placing the woman in a lateral position is the appropriate action to improve venous return and cardiac output, helping to stabilize the blood pressure. This position can alleviate pressure on the inferior vena cava, reducing the risk of hypotension associated with epidural anesthesia.
Question 8 of 9
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?
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 9 of 9
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.