HESI Exit PN | HESI Exit PN Exam Version 3
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A pregnant client at 34 weeks gestation presents with sudden-onset painless vaginal
bleeding. Which nursing action is the highest priority?
A. Assess the fetal heart rate and maternal vital signs.
B. Perform a sterile vaginal exam to check dilation.
C. Encourage the client to walk to stimulate labor.
D. Prepare for immediate oxytocin administration.
Correct Answer: A
Expert Explanation: Painless vaginal bleeding in the third trimester is a hallmark
sign of placenta previa. Performing a vaginal exam is strictly contraindicated as it
can cause massive hemorrhage. The nurse must first establish fetal well-being and
maternal stability through monitoring. Assessment of heart rate and vital signs
provides the data needed for immediate medical intervention. Ensuring safety for
both mother and fetus is the cornerstone of emergency obstetric care.
2. The nurse is providing instructions to a mother of a 6-month-old infant regarding
the introduction of solid foods. Which food item should be introduced first?
A. Iron-fortified rice cereal
,B. Whole milk
C. Mashed bananas
D. Pureed chicken
Correct Answer: A
Expert Explanation: Iron-fortified cereal is the standard first solid food introduced
to infants at 6 months of age. At this stage, fetal iron stores begin to deplete, making
supplementation through diet necessary. Rice cereal is preferred over other grains
because it is easily digested and has a low risk of allergic reactions. The nurse
should advise mixing it with breast milk or formula to ease the transition. Other
solids like fruits and vegetables are introduced one at a time after cereals are
tolerated.
3. A client in active labor receives an epidural block. Ten minutes later, her blood
pressure drops from 120/80 to 90/50. What is the immediate nursing action?
A. Place the client in a supine position.
B. Increase the rate of the intravenous infusion.
C. Administer an oral glucose supplement.
D. Prepare for an emergency cesarean section.
Correct Answer: B
,Expert Explanation: Hypotension is a common side effect of epidural anesthesia
due to sympathetic block and vasodilation. Increasing intravenous fluids expands
the circulating volume to counteract the drop in blood pressure. The nurse should
also turn the client to a side-lying position to prevent aortocaval compression.
Oxygen administration may be necessary if fetal heart patterns show distress.
Promptly addressing maternal hypotension is vital to maintain adequate placental
perfusion.
4. The nurse is assessing a newborn and observes a small, flat, blue-gray area on the
infant’s lower back. How should the nurse document this finding?
A. Mongolian spot
B. Nevus flammeus (port-wine stain)
C. Ecchymosis related to birth trauma
D. Telangiectatic nevi (stork bites)
Correct Answer: A
Expert Explanation: Mongolian spots are benign, flat, blue-black or gray-blue
pigmented areas typically found on the sacrum or buttocks. They are common in
newborns of African, Asian, or Mediterranean descent and usually fade over time. It
is essential to document these findings accurately to avoid confusion with signs of
physical abuse. No treatment is required as they are not pathological. Educating the
, parents about the nature of these spots provides reassurance during the postpartum
period.
5. A 4-year-old child is admitted with a suspected diagnosis of epiglottitis. Which
action should the nurse avoid?
A. Using a tongue blade to examine the throat.
B. Monitoring oxygen saturation levels.
C. Allowing the child to sit in a tripod position.
D. Preparing for possible tracheal intubation.
Correct Answer: A
Expert Explanation: In cases of suspected epiglottitis, inserting a tongue blade or
swab into the throat can trigger a laryngospasm. Laryngospasm leads to complete
airway obstruction, which is a life-threatening emergency. The nurse should
prioritize keeping the child calm and in a position of comfort, such as the tripod
position. Assessment should be limited to non-invasive observations until a
physician is ready to secure the airway. Safety protocols for epiglottitis always
emphasize ‘nothing in the throat’.
6. A nurse is caring for a 2-year-old toddler. Which developmental milestone is
appropriate for this age group?
A. Drawing a person with at least six body parts.
Comprehensive Review | Questions with Correct
Answers and Expert Explanation for Each Question
| Nursing Exit Assessment
1. A pregnant client at 34 weeks gestation presents with sudden-onset painless vaginal
bleeding. Which nursing action is the highest priority?
A. Assess the fetal heart rate and maternal vital signs.
B. Perform a sterile vaginal exam to check dilation.
C. Encourage the client to walk to stimulate labor.
D. Prepare for immediate oxytocin administration.
Correct Answer: A
Expert Explanation: Painless vaginal bleeding in the third trimester is a hallmark
sign of placenta previa. Performing a vaginal exam is strictly contraindicated as it
can cause massive hemorrhage. The nurse must first establish fetal well-being and
maternal stability through monitoring. Assessment of heart rate and vital signs
provides the data needed for immediate medical intervention. Ensuring safety for
both mother and fetus is the cornerstone of emergency obstetric care.
2. The nurse is providing instructions to a mother of a 6-month-old infant regarding
the introduction of solid foods. Which food item should be introduced first?
A. Iron-fortified rice cereal
,B. Whole milk
C. Mashed bananas
D. Pureed chicken
Correct Answer: A
Expert Explanation: Iron-fortified cereal is the standard first solid food introduced
to infants at 6 months of age. At this stage, fetal iron stores begin to deplete, making
supplementation through diet necessary. Rice cereal is preferred over other grains
because it is easily digested and has a low risk of allergic reactions. The nurse
should advise mixing it with breast milk or formula to ease the transition. Other
solids like fruits and vegetables are introduced one at a time after cereals are
tolerated.
3. A client in active labor receives an epidural block. Ten minutes later, her blood
pressure drops from 120/80 to 90/50. What is the immediate nursing action?
A. Place the client in a supine position.
B. Increase the rate of the intravenous infusion.
C. Administer an oral glucose supplement.
D. Prepare for an emergency cesarean section.
Correct Answer: B
,Expert Explanation: Hypotension is a common side effect of epidural anesthesia
due to sympathetic block and vasodilation. Increasing intravenous fluids expands
the circulating volume to counteract the drop in blood pressure. The nurse should
also turn the client to a side-lying position to prevent aortocaval compression.
Oxygen administration may be necessary if fetal heart patterns show distress.
Promptly addressing maternal hypotension is vital to maintain adequate placental
perfusion.
4. The nurse is assessing a newborn and observes a small, flat, blue-gray area on the
infant’s lower back. How should the nurse document this finding?
A. Mongolian spot
B. Nevus flammeus (port-wine stain)
C. Ecchymosis related to birth trauma
D. Telangiectatic nevi (stork bites)
Correct Answer: A
Expert Explanation: Mongolian spots are benign, flat, blue-black or gray-blue
pigmented areas typically found on the sacrum or buttocks. They are common in
newborns of African, Asian, or Mediterranean descent and usually fade over time. It
is essential to document these findings accurately to avoid confusion with signs of
physical abuse. No treatment is required as they are not pathological. Educating the
, parents about the nature of these spots provides reassurance during the postpartum
period.
5. A 4-year-old child is admitted with a suspected diagnosis of epiglottitis. Which
action should the nurse avoid?
A. Using a tongue blade to examine the throat.
B. Monitoring oxygen saturation levels.
C. Allowing the child to sit in a tripod position.
D. Preparing for possible tracheal intubation.
Correct Answer: A
Expert Explanation: In cases of suspected epiglottitis, inserting a tongue blade or
swab into the throat can trigger a laryngospasm. Laryngospasm leads to complete
airway obstruction, which is a life-threatening emergency. The nurse should
prioritize keeping the child calm and in a position of comfort, such as the tripod
position. Assessment should be limited to non-invasive observations until a
physician is ready to secure the airway. Safety protocols for epiglottitis always
emphasize ‘nothing in the throat’.
6. A nurse is caring for a 2-year-old toddler. Which developmental milestone is
appropriate for this age group?
A. Drawing a person with at least six body parts.
