HESI RN Maternity|Peds REVIEW

1. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client’s teaching plan? A. Oral contraceptive use for at least one year. 2. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory distress syndrome? C. Betamethasone (Celestone) 12 mg deep IM. 3. The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which information should the nurse provide the client about this finding? B. Both the lower uterine segment and the fundus must be massaged. 4. Which instruction should the nurse include in the discharge teaching plan of a 7-year- old girl with a history of frequent urinary tract infections? D. Monitor for changes in urinary odor. 5. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet? B. Chicken. 6. The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How many ml should the nurse administer? 0.3 7. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? C. Blood pressure 149/90. 8. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and a 12-year-old sibling are the child bedside. Which instruction best supports this family? A. “ While waiting for the healthcare provider, only one visitor may stay with the child” 9. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? C. Exercise in a swimming pool. 10. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment finding confirms to the nurse that the client is not labor at this time? D. Contractions decrease with walking. 11. Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest? D. Checkers 12. The nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child? B. Peanut butter and banana sandwich with orange juice. 13. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding? C. The TSH is high because of the low production of T4 by the thyroid. 14. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? D. Stimulate the infant to cry. 15. At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to administer a rubella vaccine to this client? D. Early postpartum, within 72 hours of delivery. 16. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? D. Contraction pattern. 17. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? A. Check the differential, since the WBC is normal for this client. 18. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client’s condition, what information is most important for the nurse to provide? A. Maternal blood pressure. 19. While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement? A. Inspect the posterior oropharynx. 20. During a routine clinic visit, the nurse determines that a 5-year-old boy’s blood pressure is 112/70. When calculating the child’s blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next? A. Compare the child’s blood pressure with readings from previous visits. 21. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? C. Offer information about ultrasonography and genotyping to determine sex assignment. 22. A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child’s hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice? A. Rewash the child’s hair following a 24-hour isolation period. B. Wash the child’s bed linens and clothing in hot soapy water. C. Take the child to a hair salon for a shampoo and a shorter haircut. D. Dispose of the child’s brusches, combs, and others hair accessories.