HESI RN
HESI RN Maternal Newborn I Questions
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 1 of 5
Which pain scales would be appropriate for this client? Select all that apply.
Correct Answer: A,B
Rationale: FLACC and Riley Infant Pain Scales assess behavioral cues in nonverbal infants, suitable for a 4-month-old post-surgery. Other scales require cognitive abilities beyond this age.
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 2 of 5
The nurse knows that the mastitis in this scenario is most likely caused by... as evidenced by...
| Plugged duct |
| Breast abscess |
| Engorgement |
| Nipple trauma with cracked skin |
| Firm, red, warm area on the right breast |
| Pus draining from the nipple |
| Generalized swelling of the entire breast |
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:
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 3 of 5
Which are the 3 most likely reasons that the infant is crying?
| Hunger |
| Opioid withdrawal |
| Hemorrhage |
| Separation anxiety |
| Pain |
| Hypovolemia |
| Hypoxia |
Correct Answer: A,E,F
Rationale: Hunger due to NPO status, postoperative pain, and hypovolemia from surgical fluid losses are likely causes of crying. No evidence supports withdrawal, hemorrhage, anxiety, or hypoxia.
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 4 of 5
Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.
Correct Answer: D,G
Rationale: Normal temperature, resolved redness, and effective breastfeeding every 2-3 hours in varied positions confirm mastitis resolution. Creased nipples, persistent pain, or exclusive pumping suggest ongoing issues.
Extract:
Question 5 of 5
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?
Correct Answer: B
Rationale: Albumin increases oncotic pressure, reducing edema by drawing fluid back into circulation in nephrotic syndrome.