HESI RN PEDIATRICS EXAM
1. The nurse is planning postoperative care for a child who has had a cleft lip
repair. What is the most important reason to minimize this child's crying during
the recovery period?
A. Tear formation increases salivation.
B. This behavior increases respirations.
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line
Rationale:
Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance
of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a
problem for the child with a cleft lip repair.
2. An infant is receiving digoxin for congestive heart failure. The apical heart
rate is assessed at 80 beats/min. What intervention should the nurse
implement?
A. Call for a portable chest radiograph.
B. Obtain a therapeutic drug level.
C. Reassess the heart rate in 30 minutes.
D. Administer digoxin immune Fab stat.
Rationale:
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so
assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time.
Option C provides helpful assessment data but does not address the cause of the problem and delays
needed intervention.
Option D is indicated for a serious, life-threatening overdose with digoxin.
3. The nurse admits a child to the intensive care unit with a possible diagnosis
of Wilms tumor - What is the most safety precaution for child?
A. maintain NPO status
B. Limit visitors to the immediate family
C. Place a do not palpate abdomen sign on head
of bed
D. Encourage ambulation in the pre-operative period
Rationale:
Protect child from injury; place a sign on bed stating "no abdominal palpation" (to
,prevent accidental fragmentation and dislodging into the abdominal cavity). The other option choices are
not relevant at this time.
4. The nurse is preparing a teaching plan for the mother of a child who has been
diagnosed with celiac disease. Choosing which lunch will be within the
therapeutic management of a child with celiac disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit
dessert
C. Tuna salad sandwich on whole wheat bread, milk,
and ice cream
D. Turkey sandwich on rye bread, orange juice, and
fresh fruit
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing
oats, wheat, rye, or barley.
5. A 6-month-old male infant is admitted to the postanesthesia care unit with
elbow restraints in place. He has an endotracheal tube and is ventilator-
dependent but will be extubated soon following recovery from anesthesia. Which
nursing intervention should be included in this child's plan of care?
A. Keep restraints on at all times to prevent
unplanned extubation.
B. Remove restraints one at a time and provide
range-of-motion exercises.
C. Remove all restraints simultaneously and provide
play activities.
D. Document the reason for application of the
restraints every 72 hours.
Rationale:
Removing restraints one at a time is safer than option C. The infant should have the restrained
extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion
exercises should be performed with these assessments. Under no circumstances should restraints be
applied to the client continuously. Documentation of assessment findings regarding the restrained
extremities must occur much more frequently than every 72 hours; however, the reason for using
restraints must be justified and should be stated in the medical record.
,6. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning
care to a newly admitted child with bacterial meningitis. What is the most
important instruction for the nurse to review with the UAP?
A. Use designated isolation precautions.
B. Keep the lighting in the room dim.
C. Allow the parents to assist with care.
D. Report any pain that the child experiences.
Rationale:
All these are important measures to review with the UAP, but the most important is option A. Improper
use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D
promote client comfort and reduce anxiety but are of a lower priority than option A.
7. The nurse is caring for a child with intussusception who is scheduled for a
barium enema prior to a surgical procedure. Which action should the nurse
take first?
A. Evacuate the bowel of impacted feces
B. Admnister magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into another, causes
intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical
treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the
area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a
clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A
barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally
removes any remaining barium.
, 8. A 3-week-old infant is referred to an orthopedic clinic because the
pediatrician heard a click when flexing the child's right hip during a routine
physical examination. The orthopedic physician suspects that the child might
have developmental dysplasia of the hip (DDH). The parents ask the nurse to
identify risk factors commonly associated with DDH. Which response is
accurate?
A. Vertex delivery
B. Male gender
C. Breech presentation
D. Second-born child
Rationale:
Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech
position, not the vertex (head-first) position. Twice as many females as males present in the breech
position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur
with first-born children, not subsequent siblings, possibly because of the unstretched uterus and
compaction of the surrounding abdominal contents, which tend to increase compression on the
uterus in the nulliparous woman.
9. The nurse is teaching the parents of a 2-year-old child with a congenital
heart defect about signs and symptoms of congestive heart failure. Which
information about the child is most important for the parents to report to the
health care provider?
A. Sits or squats frequently when playing outdoors
B. Exhibits a sudden and unexplained weight gain
C. Is not completely toilet-trained and has some
accidents
D. Demonstrates irritation and fatigue 1 hour before
bedtime
Rationale:
Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure.
Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common;
2-year-olds are not expected to be toilet-trained. Option D is normal.
1. The nurse is planning postoperative care for a child who has had a cleft lip
repair. What is the most important reason to minimize this child's crying during
the recovery period?
A. Tear formation increases salivation.
B. This behavior increases respirations.
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line
Rationale:
Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance
of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a
problem for the child with a cleft lip repair.
2. An infant is receiving digoxin for congestive heart failure. The apical heart
rate is assessed at 80 beats/min. What intervention should the nurse
implement?
A. Call for a portable chest radiograph.
B. Obtain a therapeutic drug level.
C. Reassess the heart rate in 30 minutes.
D. Administer digoxin immune Fab stat.
Rationale:
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so
assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time.
Option C provides helpful assessment data but does not address the cause of the problem and delays
needed intervention.
Option D is indicated for a serious, life-threatening overdose with digoxin.
3. The nurse admits a child to the intensive care unit with a possible diagnosis
of Wilms tumor - What is the most safety precaution for child?
A. maintain NPO status
B. Limit visitors to the immediate family
C. Place a do not palpate abdomen sign on head
of bed
D. Encourage ambulation in the pre-operative period
Rationale:
Protect child from injury; place a sign on bed stating "no abdominal palpation" (to
,prevent accidental fragmentation and dislodging into the abdominal cavity). The other option choices are
not relevant at this time.
4. The nurse is preparing a teaching plan for the mother of a child who has been
diagnosed with celiac disease. Choosing which lunch will be within the
therapeutic management of a child with celiac disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit
dessert
C. Tuna salad sandwich on whole wheat bread, milk,
and ice cream
D. Turkey sandwich on rye bread, orange juice, and
fresh fruit
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing
oats, wheat, rye, or barley.
5. A 6-month-old male infant is admitted to the postanesthesia care unit with
elbow restraints in place. He has an endotracheal tube and is ventilator-
dependent but will be extubated soon following recovery from anesthesia. Which
nursing intervention should be included in this child's plan of care?
A. Keep restraints on at all times to prevent
unplanned extubation.
B. Remove restraints one at a time and provide
range-of-motion exercises.
C. Remove all restraints simultaneously and provide
play activities.
D. Document the reason for application of the
restraints every 72 hours.
Rationale:
Removing restraints one at a time is safer than option C. The infant should have the restrained
extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion
exercises should be performed with these assessments. Under no circumstances should restraints be
applied to the client continuously. Documentation of assessment findings regarding the restrained
extremities must occur much more frequently than every 72 hours; however, the reason for using
restraints must be justified and should be stated in the medical record.
,6. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning
care to a newly admitted child with bacterial meningitis. What is the most
important instruction for the nurse to review with the UAP?
A. Use designated isolation precautions.
B. Keep the lighting in the room dim.
C. Allow the parents to assist with care.
D. Report any pain that the child experiences.
Rationale:
All these are important measures to review with the UAP, but the most important is option A. Improper
use of isolation precautions can place other staff and clients at risk for infection. Options B, C, and D
promote client comfort and reduce anxiety but are of a lower priority than option A.
7. The nurse is caring for a child with intussusception who is scheduled for a
barium enema prior to a surgical procedure. Which action should the nurse
take first?
A. Evacuate the bowel of impacted feces
B. Admnister magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into another, causes
intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical
treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the
area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a
clear liquid diet for the entire day; then magnesium sulfate is administered for bowel evacuation. A
barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally
removes any remaining barium.
, 8. A 3-week-old infant is referred to an orthopedic clinic because the
pediatrician heard a click when flexing the child's right hip during a routine
physical examination. The orthopedic physician suspects that the child might
have developmental dysplasia of the hip (DDH). The parents ask the nurse to
identify risk factors commonly associated with DDH. Which response is
accurate?
A. Vertex delivery
B. Male gender
C. Breech presentation
D. Second-born child
Rationale:
Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech
position, not the vertex (head-first) position. Twice as many females as males present in the breech
position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur
with first-born children, not subsequent siblings, possibly because of the unstretched uterus and
compaction of the surrounding abdominal contents, which tend to increase compression on the
uterus in the nulliparous woman.
9. The nurse is teaching the parents of a 2-year-old child with a congenital
heart defect about signs and symptoms of congestive heart failure. Which
information about the child is most important for the parents to report to the
health care provider?
A. Sits or squats frequently when playing outdoors
B. Exhibits a sudden and unexplained weight gain
C. Is not completely toilet-trained and has some
accidents
D. Demonstrates irritation and fatigue 1 hour before
bedtime
Rationale:
Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure.
Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common;
2-year-olds are not expected to be toilet-trained. Option D is normal.
