HESI RN
HESI RN Maternity Exam 7n Questions
Extract:
Question 1 of 5
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° 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?
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 2 of 5
A 3-year-old male was brought into the emergency room this morning with a sudden onset of 'fast and noisy breathing'. After reading the history and physical, the nurse suspects the child has _____
Correct Answer: B
Rationale: Croup is likely due to the sudden onset of noisy breathing (stridor) and recent viral symptoms, common in young children.
Question 3 of 5
The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella. How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?
Correct Answer: B
Rationale: MMR vaccination does not directly increase VTE or PPH risk. Evaluating based on overall health and pregnancy factors, with prophylaxis for moderate to high risk, is appropriate per policy.
Question 4 of 5
The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot. What is the most important action for the nurse to perform?
Correct Answer: A
Rationale: Monitoring capillary refill assesses circulation, critical to prevent complications like tissue necrosis from cast compression.
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?
Correct Answer: A,B
Rationale: A manual resuscitation bag and advanced airway kit ensure preparedness for respiratory compromise during IV placement.