HESI RN
HESI RN Maternal Newborn I Questions
Extract:
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Question 1 of 5
Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.
Correct Answer: C,D,F
Rationale: Blood pressure, level of consciousness, and heart rate assess pain intensity and guide safe pain management. Blood type, religion, hearing, and reflexes are not directly relevant.
Extract:
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Question 2 of 5
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
| Options | Appropriate | Not appropriate |
|---|---|---|
| Ask the healthcare provider to prescribe a nonsteroidal anti-inflammatory drug (NSAID) | ||
| Have one of the parents hold the baby | ||
| Perform guided imagery | ||
| Consult a child life specialist | ||
| Encourage the baby's mother to breastfeed the baby | ||
| Wait 1 hour, reassess, and give medication if the FLACC score remains elevated | ||
| Request a prescription for an opioid |
Correct Answer: B,D,G
Rationale: NSAIDs, parental holding, child life consultation, and opioids (if severe) are appropriate. Guided imagery is too advanced, breastfeeding is contraindicated (NPO), and delaying treatment is inappropriate.
Extract:
Question 3 of 5
For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.
Correct Answer: A
Rationale: For a 7 kg infant, 15 mg/kg = 105 mg. At 160 mg/5 mL, 105 mg requires 3.3 mL, providing effective pain relief without toxicity.
Question 4 of 5
An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin 500 mg PO daily and metronidazole 500 mg IV piggy back (IVBP) twice daily (BID). She asks the nurse, 'Why do I have to be in the hospital? Why can't I get my treatment at home?' Which purpose should the nurse provide that supports an effective outcome?
Correct Answer: D
Rationale: Hospitalization ensures supervised IV antibiotics for severe PID unresponsive to outpatient therapy, preventing complications like tubo-ovarian abscess.
Question 5 of 5
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.