HESI RN
HESI RN Maternal Newborn I Questions
Extract:
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
Question 1 of 5
The nurse knows that the mastitis in this scenario is most likely caused by... as evidenced by...
Correct Answer: A,E
Rationale: A plugged duct, evidenced by a firm, red, warm area, is the likely cause of mastitis due to milk stasis from missed feedings. Abscess, engorgement, or nipple trauma are less likely without pus, generalized swelling, or reported cracks.
Extract:
Question 2 of 5
During the admission procedure of a school age child, the child states, 'I'm going to have an operation.' Which response is best for the nurse to provide to this child?
Correct Answer: A
Rationale: Asking the child to explain their understanding assesses knowledge, addresses misconceptions, and supports age-appropriate communication.
Extract:
History and Physical
Nurses' Notes
Flow Sheet
Vital signs
The client is a 9-month-old male who was born by cesarean section at 32 weeks gestation. He has been hospitalized once with respiratory syncytial virus at 2 months of age. He is up to date on vaccines.
Exhibits
Review H and P, nurse's note, and flow sheet.
Question 3 of 5
Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
| Remove some of the baby's clothing |
| Clean the area with warm water |
| Alert child protective services |
| Swab the area and send for a culture |
| Hold the vaccines |
| Temperature |
| Parent's understanding of education |
Correct Answer: A,B
Rationale: Miliaria, caused by overdressing, is addressed by removing clothing and cleaning with warm water. Monitoring temperature and parental education prevents recurrence.
Extract:
Question 4 of 5
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Zidovudine within 6-12 hours reduces perinatal HIV transmission risk in newborns of HIV-positive mothers.
Question 5 of 5
A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?
Correct Answer: B
Rationale: Fundal height of 30 cm is below the expected range (32-36 cm) for 34 weeks gestation, suggesting possible intrauterine growth restriction (IUGR) or oligohydramnios, which requires further evaluation. Mild edema is common, weight gain is normal, and a fetal heart rate of 110 bpm is within the acceptable range.