HESI OB 2023/ 2024 EXAM QUESTIONS AND
ANSWERS
What nursing action should be implemented when intermittently gavage-feeding a
preterm infant?
Allow formula to flow by gravity.
Avoid letting infant suck on tube.
Insert feeding tube through
nares.Apply steady pressure to
syringe.Rationale
Gavage feeding is commonly used to feed preterm infants who are born at less
than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who
are unable to tolerate oral feedings. The feeding should flow by gravity (A) to
avoid over-distention and a sudden sensation of fullness that may cause vomiting.
Allowing the infant to suck on the tube, not (B), permits observation of the sucking
response. The feeding tube should be inserted orally, since nasal insertion (C)
impedes obligatory nose breathing and may irritate delicate nasal mucosa. (D) can
result in vomiting if the rate of administration is too fast. A
client is receiving an oxytocin infusion for induction of labor. When the client
begins active labor, the fetal heart rate (FHR) slows at the onset of several
contractions with subsequent return to baseline before each contraction ends.
What action should the nurse implement?
Insert an internal monitor
device.Change the woman's
position.
Discontinue the oxytocin infusion.
Document the finding in the client
record.Rationale
Early FHR decelerations are a normal finding during active labor that occurs due to
fetal head compression, so the finding should be documented in the client record
(D). Although the client's status should be monitored continuously, this is a
reassuring FHR pattern, so (A, B, and C) are not indicated.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
Avoid alcohol because it is excreted in breast milk.
Avoid spicy foods to prevent infant colic.
Increase caloric intake by approximately 500 calories/day.
Double prenatal milk intake to improve Vitamin D transfer to the infant.
Rationale
Alcohol should be avoided while breastfeeding because, when consumed by the
mother, it is excreted in breast milk (A). It also adversely effects the milk ejection
,reflex. While (B) may cause some gastric upset in some babies, it does not cause
colic. (C) should also be included in diet teaching for a breastfeeding mother, but
because it does not involve safety to the infant it does not have the same degree
of importance as (A). Recent research has shown that infants receive very little
Vitamin D via the breastmilk and some sources recommend Vitamin D
supplementation in exclusively breastfed babies to prevent rickets.
, An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours
old and appears large for gestational age, flushed, and tremulous. What
procedure should the nurse follow to implement a glucose screening? (Arrange
the examination process from first on top to last on the bottom.)
Correct Answer:
• 1.
Wrap the infant's foot with a heel warmer for 5 minutes.
• 2.
Collect a spring-loaded automatic puncture device.
• 3.
Restrain the newborn's foot with your free hand.
• 4.
Cleanse puncture site on the lateral aspect of the heel.
Rationale
Obtaining capillary blood for the glucose screening for a infant that is macrosomic
and at risk for hypoglycemia should begin with wrapping the infant'sfoot with a
heel warmer for 5 to 10 minutes to facilitate vasodilation to obtain an adequate
blood sample volume. Next, a spring loaded automatic puncture device should be
obtained to puncture the skin because it is less traumatic than a manual lancet.
Then, the nurse's hand is used to restrain the foot as the puncture site on the
lateral aspect of the heel is cleansed.
The nurse observes a male newborn who is displaying a rigid posture with his eyes
tightly closed and grimacing as he is crying after an invasive procedure. Thebaby's
blood pressure is elevated on the Dinamap display. What action should the nurse
implement?
Obtain a serum glucose level.
Give the infant medication for
pain. Feed the newborn 1 ounce of
for mula . R equ es t a geneti c
consultation.
Rationale
A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture,
and an increase in blood pressure are indicative of pain in the neonate, so
, analgesia should be given for pain (B). The symptoms of hypoglycemia (A) are
jitteriness and mottling. The signs of hunger include rooting, tongue extrusion
ANSWERS
What nursing action should be implemented when intermittently gavage-feeding a
preterm infant?
Allow formula to flow by gravity.
Avoid letting infant suck on tube.
Insert feeding tube through
nares.Apply steady pressure to
syringe.Rationale
Gavage feeding is commonly used to feed preterm infants who are born at less
than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who
are unable to tolerate oral feedings. The feeding should flow by gravity (A) to
avoid over-distention and a sudden sensation of fullness that may cause vomiting.
Allowing the infant to suck on the tube, not (B), permits observation of the sucking
response. The feeding tube should be inserted orally, since nasal insertion (C)
impedes obligatory nose breathing and may irritate delicate nasal mucosa. (D) can
result in vomiting if the rate of administration is too fast. A
client is receiving an oxytocin infusion for induction of labor. When the client
begins active labor, the fetal heart rate (FHR) slows at the onset of several
contractions with subsequent return to baseline before each contraction ends.
What action should the nurse implement?
Insert an internal monitor
device.Change the woman's
position.
Discontinue the oxytocin infusion.
Document the finding in the client
record.Rationale
Early FHR decelerations are a normal finding during active labor that occurs due to
fetal head compression, so the finding should be documented in the client record
(D). Although the client's status should be monitored continuously, this is a
reassuring FHR pattern, so (A, B, and C) are not indicated.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
Avoid alcohol because it is excreted in breast milk.
Avoid spicy foods to prevent infant colic.
Increase caloric intake by approximately 500 calories/day.
Double prenatal milk intake to improve Vitamin D transfer to the infant.
Rationale
Alcohol should be avoided while breastfeeding because, when consumed by the
mother, it is excreted in breast milk (A). It also adversely effects the milk ejection
,reflex. While (B) may cause some gastric upset in some babies, it does not cause
colic. (C) should also be included in diet teaching for a breastfeeding mother, but
because it does not involve safety to the infant it does not have the same degree
of importance as (A). Recent research has shown that infants receive very little
Vitamin D via the breastmilk and some sources recommend Vitamin D
supplementation in exclusively breastfed babies to prevent rickets.
, An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours
old and appears large for gestational age, flushed, and tremulous. What
procedure should the nurse follow to implement a glucose screening? (Arrange
the examination process from first on top to last on the bottom.)
Correct Answer:
• 1.
Wrap the infant's foot with a heel warmer for 5 minutes.
• 2.
Collect a spring-loaded automatic puncture device.
• 3.
Restrain the newborn's foot with your free hand.
• 4.
Cleanse puncture site on the lateral aspect of the heel.
Rationale
Obtaining capillary blood for the glucose screening for a infant that is macrosomic
and at risk for hypoglycemia should begin with wrapping the infant'sfoot with a
heel warmer for 5 to 10 minutes to facilitate vasodilation to obtain an adequate
blood sample volume. Next, a spring loaded automatic puncture device should be
obtained to puncture the skin because it is less traumatic than a manual lancet.
Then, the nurse's hand is used to restrain the foot as the puncture site on the
lateral aspect of the heel is cleansed.
The nurse observes a male newborn who is displaying a rigid posture with his eyes
tightly closed and grimacing as he is crying after an invasive procedure. Thebaby's
blood pressure is elevated on the Dinamap display. What action should the nurse
implement?
Obtain a serum glucose level.
Give the infant medication for
pain. Feed the newborn 1 ounce of
for mula . R equ es t a geneti c
consultation.
Rationale
A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture,
and an increase in blood pressure are indicative of pain in the neonate, so
, analgesia should be given for pain (B). The symptoms of hypoglycemia (A) are
jitteriness and mottling. The signs of hunger include rooting, tongue extrusion
