HESI RN Maternity Exam 7n

Extract:

Question 1 of 5

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4Â° F (38Â° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

Correct Answer: C

Rationale: All vital signs are within normal postpartum ranges. Documenting them is appropriate, as no immediate intervention is indicated based on these findings.

Question 2 of 5

The nurse is evaluating the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

A. Uses gestures with 1 to 2 word sentences. B. Uses 1 word sentences. C. Speaks in simple sentences with four or more words. D. Recognizes most letters and numbers.

Correct Answer: C

Rationale: By age 3, children typically speak in simple sentences with four or more words. Gestures with 1-2 word sentences and single-word sentences are milestones for younger children, and recognizing letters/numbers is expected around age 4-5.

Question 3 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

Correct Answer: A,B

Rationale: A manual resuscitation bag and advanced airway kit are critical for managing potential respiratory failure during IV placement in a child with respiratory distress.

Question 4 of 5

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child's back. Which parental statement indicates understanding of the procedure?

A. The skin incision should be kept moist by periodically wetting the dressing. B. When changing the dressing, the tape should be removed rapidly from the edges. C. The incision should be protected from fecal contamination by an intact dressing. D. To ensure easy removal of the sutures, the dressing should be kept dry.

Correct Answer: C

Rationale: An intact dressing prevents fecal contamination, reducing infection risk. Keeping the incision moist or removing tape rapidly can disrupt healing, and while a dry dressing aids suture removal, preventing contamination is the priority.

Question 5 of 5

The nurse is educating parents on how to prevent recurrent otitis media in their infant. What advice should the nurse give?

A. Inspect the infant's ears daily. B. Position the infant prone after feeding. C. Breastfeed frequently. D. Avoid exposure to smoke.

Correct Answer: D

Rationale: Avoiding smoke exposure reduces Eustachian tube irritation, decreasing otitis media risk. Daily ear inspections don't prevent infections, prone positioning increases SIDS risk, and breastfeeding, while beneficial, is not specific to otitis media prevention.