2023 HESI MATERNITY /PEDIATRICS (PEDS)
EXAM COMPLETE QUESTIONS AND ANSWERS.
A 3-month-old with myelomeningocele and atonic bladder is catheterized every
four hours to prevent urinary retention. The home health nurse notes that the
child has developed episodes of sneezing, urticaria,, watery eyes, ad a rash in the
diaper area. What action is most important for the nurse to take?
• Change to latex - free gloves when handling infant
The 6-week-old infant diagnosed with pyloric stenosis has recently developed
projectile vomiting. Which assessment finding indicates to the nurse that the infant
is becoming dehydrated?
• Crying without tears
A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which
intervention is most important for the nurse to implement?
• Assess bilateral lung sounds
A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500
ML with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many
mL/hour should bethe nurse program into the infusion pump?
• 75mL/hour
A 36-week primigravida is admitted to labor and delivery with severe abdominal
painand bright red vaginal bleeding. Her abdomen is rigid and tender to touch.
The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120
beats/minute.
What action should the nurse implement first?
• Notify healthcare provider at patients' bedside
A 39 week gestation, a multigravida is having a non-stress test (NST). The
fetal heart rate (FHR) has remained non- reactive during the 30 minutes of
evaluation. Based onthis finding, which action should the nurse implement?
• Place an acoustic simulator on the abdomen.
Artificial rupture of the membranes of a laboring client reveals meconium-
stained fluid. What intervention has the greatest priority?
,• Have a meconium aspirator available at delivery
At 20 weeks gestation, a client who has gained 20 pounds during pregnant states
that she is felling fetal movement. Fundal height measurement is 20 cm, and the
clients only
complaint is that her breasts are leaking clear fluid. Which assessment finding
warrants further evaluation?
• Gestational weight gain.
A client at 35 weeks gestation complains of a "pain whenever the baby moves."
On assessment, the nurse notes the client's temperature to be 101.2 F, with
severe abdominal or uterine tenderness on palpation. The nurse knows that these
findings areindicative of what condition?
• Chorioamnionitis
A client at 40-weeks gestation presents to the obstetrical floor and indicates that
the amniotic membranes ruptured spontaneously at home. She is in active labor,
and feelsthe need to bear down and push. What information is most important
foe the nurse to obtain first?
• Color and consistency of fluid
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 theclient's condition, what information is most important for the
nurse to provide?
• Maternal blood pressure
A client whose labor is being augmented with an oxytocin (Pitocin) infusion
requests an epidural for pain control. Findings of the last vaginal exam,
performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2
station. What action should the nurse implement first?
o- Determine current cervical dilation
A community health nurse visits a family in which a 16-year old unmarried
daughter ispregnant with her first child and is at 32 weeks gestation. The client
tells the nurse thatshe has been intermittent back pain since the night before.
What is the priority nursing intervention?
, • ask the client if she has experienced any recent changes in vaginal discharge
The current vital signs for a primipara who delivered vaginally during the
previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory
rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse
implement?
• Document vital signs in record (normal)
A four-year-old boy was recently diagnosis with Duchenne muscular dystrophy
(DMD).Which characteristic of the disease is most important for the nurse to
focus on during initial teaching?
• Lower legs become progressively weaker, causing a wedding, unsteady gait
A full-term 24 hour old infant in the nursery regurgitates and suddenly turns
cyanotic. What should the nurse do first?
• Stimulate the infant to cry
The healthcare provider prescribes amoxicillin 500 mg PO every eight hours for
a childwho weighs 77 pounds. The available suspension is labeled, amoxicillin
suspension 250 mg/5 ml. The recommended maximum does is 50 mg/kg/24 hour.
How many mL should the nurse administer in a single dose based on the child's
weight? (enter the numerical value only. If rounding is required, round to the
whole number.)
• 10mL/dose
An infant is placed in a radiant warmer immediately after birth. At one hour of
age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is
the first action that the nurse should take?
• Determine infants blood sugar level
An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. What
actionshould the nurse implement first?
• Place the infant in a knee -chest position
Insulin therapy is initiated for a 12 year-old child who is admitted with diabetic
ketoacidosis (DKA). Which action is important for the nurse to include in the child
planof care?
EXAM COMPLETE QUESTIONS AND ANSWERS.
A 3-month-old with myelomeningocele and atonic bladder is catheterized every
four hours to prevent urinary retention. The home health nurse notes that the
child has developed episodes of sneezing, urticaria,, watery eyes, ad a rash in the
diaper area. What action is most important for the nurse to take?
• Change to latex - free gloves when handling infant
The 6-week-old infant diagnosed with pyloric stenosis has recently developed
projectile vomiting. Which assessment finding indicates to the nurse that the infant
is becoming dehydrated?
• Crying without tears
A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which
intervention is most important for the nurse to implement?
• Assess bilateral lung sounds
A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500
ML with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many
mL/hour should bethe nurse program into the infusion pump?
• 75mL/hour
A 36-week primigravida is admitted to labor and delivery with severe abdominal
painand bright red vaginal bleeding. Her abdomen is rigid and tender to touch.
The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120
beats/minute.
What action should the nurse implement first?
• Notify healthcare provider at patients' bedside
A 39 week gestation, a multigravida is having a non-stress test (NST). The
fetal heart rate (FHR) has remained non- reactive during the 30 minutes of
evaluation. Based onthis finding, which action should the nurse implement?
• Place an acoustic simulator on the abdomen.
Artificial rupture of the membranes of a laboring client reveals meconium-
stained fluid. What intervention has the greatest priority?
,• Have a meconium aspirator available at delivery
At 20 weeks gestation, a client who has gained 20 pounds during pregnant states
that she is felling fetal movement. Fundal height measurement is 20 cm, and the
clients only
complaint is that her breasts are leaking clear fluid. Which assessment finding
warrants further evaluation?
• Gestational weight gain.
A client at 35 weeks gestation complains of a "pain whenever the baby moves."
On assessment, the nurse notes the client's temperature to be 101.2 F, with
severe abdominal or uterine tenderness on palpation. The nurse knows that these
findings areindicative of what condition?
• Chorioamnionitis
A client at 40-weeks gestation presents to the obstetrical floor and indicates that
the amniotic membranes ruptured spontaneously at home. She is in active labor,
and feelsthe need to bear down and push. What information is most important
foe the nurse to obtain first?
• Color and consistency of fluid
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 theclient's condition, what information is most important for the
nurse to provide?
• Maternal blood pressure
A client whose labor is being augmented with an oxytocin (Pitocin) infusion
requests an epidural for pain control. Findings of the last vaginal exam,
performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2
station. What action should the nurse implement first?
o- Determine current cervical dilation
A community health nurse visits a family in which a 16-year old unmarried
daughter ispregnant with her first child and is at 32 weeks gestation. The client
tells the nurse thatshe has been intermittent back pain since the night before.
What is the priority nursing intervention?
, • ask the client if she has experienced any recent changes in vaginal discharge
The current vital signs for a primipara who delivered vaginally during the
previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory
rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse
implement?
• Document vital signs in record (normal)
A four-year-old boy was recently diagnosis with Duchenne muscular dystrophy
(DMD).Which characteristic of the disease is most important for the nurse to
focus on during initial teaching?
• Lower legs become progressively weaker, causing a wedding, unsteady gait
A full-term 24 hour old infant in the nursery regurgitates and suddenly turns
cyanotic. What should the nurse do first?
• Stimulate the infant to cry
The healthcare provider prescribes amoxicillin 500 mg PO every eight hours for
a childwho weighs 77 pounds. The available suspension is labeled, amoxicillin
suspension 250 mg/5 ml. The recommended maximum does is 50 mg/kg/24 hour.
How many mL should the nurse administer in a single dose based on the child's
weight? (enter the numerical value only. If rounding is required, round to the
whole number.)
• 10mL/dose
An infant is placed in a radiant warmer immediately after birth. At one hour of
age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is
the first action that the nurse should take?
• Determine infants blood sugar level
An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. What
actionshould the nurse implement first?
• Place the infant in a knee -chest position
Insulin therapy is initiated for a 12 year-old child who is admitted with diabetic
ketoacidosis (DKA). Which action is important for the nurse to include in the child
planof care?
