HESI RN Maternity Exam 7n

Extract:

Question 1 of 5

A 3-year-old female patient woke up this morning feeling agitated and with a fever of 103.4Â° F (39.7Â° C). She was crying yesterday and reported back pain. She has a history of asthma controlled by daily cetirizine and occasional albuterol. She has had two urinary tract infections (UTIs) in the past 4 months. Given the patient's history and current condition, which condition is she most likely experiencing, what actions should the nurse take, and what parameters should the nurse monitor?

Correct Answer: A

Rationale: Fever, agitation, and back pain with a UTI history suggest a recurrent UTI. Administering an antipyretic addresses fever, a key symptom, while further evaluation confirms the diagnosis.

Question 2 of 5

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?

A. Assess for bladder distention. B. Listen for bowel sounds. C. Document the observation. D. Check the scrotum for testicular descent.

Correct Answer: C

Rationale: Voiding from the ventral penis suggests hypospadias, a congenital condition. Documenting this finding ensures it is reported and addressed appropriately.

Question 3 of 5

The nurse is providing information to a parent of a six-month old about vaccinations. Which statement made by the parent should the nurse recognize as understanding the information?

A. Immunocompromised children can be given a live virus vaccine. B. Children with febrile illness should not receive a vaccine. C. Second doses of vaccines can be given to children with prior allergic reactions. D. Breastfed children cannot receive a vaccine until after the introduction of solid foods.

Correct Answer: B

Rationale: Vaccinations should be delayed in children with febrile illness to avoid complications. Live vaccines are contraindicated in immunocompromised children, allergic reactions preclude second doses, and breastfeeding does not affect vaccination timing.

Question 4 of 5

Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8Â° F (35.8Â° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?

A. Place a pulse oximeter on the heel B. Swaddle the infant in a warm blanket C. Document the findings in the record D. Obtain a heel stick blood glucose level

Correct Answer: D

Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia. A heel stick glucose test is urgent to confirm and treat this condition.

Question 5 of 5

A 3-year-old male was brought into the emergency room this morning with a sudden onset of 'fast and noisy breathing'. According to his parents, he had sneezing and a runny nose last week but seemed to have recovered. The child lives with 2 older, school-age siblings, his parents, and 3 dogs. He was born at 37 weeks' gestation. The parents deny smoking, but his grandmother cares for him in the afternoons and smokes outside when she is at the house. He has no significant medical history. He has received all vaccines except for those due at 3 years. Upon exam, the child is? Which two items must the nurse ensure are available before attempting to place the intravenous line?

A. Manual resuscitation bag B. An advanced airway kit C. A dose of subcutaneous epinephrine D. The child's favorite toy E. Nebulized albuterol

Correct Answer: A,B

Rationale: A manual resuscitation bag and advanced airway kit ensure preparedness for respiratory compromise during IV placement.