RN HESI Maternity Exam Latest 2024

A primigravida arrives at the observation unit of the maternity unit because thinks is in Labor. The nurse applies the external foetal heart monitor and determines that the foetal 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? - Contractions decrease with walking. A primipara has delivered a stillborn foetus at 30 weeks gestation. To asses the parents in the grieving process which intervention is most for the nurse to implement? A. explain the possible cause of the fetal demise B. Provide a time for the parents to hold their infant in privacy C. Encourage the parents to seek counseling within the next few weeks D. Assist the couple to request autopsy - B. provide a time for the parents to hold their infant in privacy What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (the) fistula ? A. body temperature B. level of pain C. time of first void D. number of vessels in the cord - A. body temperature What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation? A. Level of pain sensation B. Station of presenting part C. Variability of fetal heart rate D. Maternal blood pressure - D. Maternal blood pressure A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only) A. 120 B. 70 C. 65 D. 75 - D. 75 A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply) A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does not hurt his mother C. Remind him that his mother breastfed him too D. Suggest that the baby can also drink from a bottle E. Clarify that breastfeeding is his mother's choice - A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does not hurt his mother C. Remind him that his mother breastfed him too The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? A. Place the infant in side-lying to facilitate the exam B. Hold the penis and retract the foreskin gently C. Cleanse the penis with an antiseptic-soaked pad D. Place the infant in warm room and use a calm approach - D. Place the infant in warm room and use a calm approach 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? A. Betamethasone (Celestone) 12 mg deep IM B. Butorphanol 1 mg IV push q2h PRN pain C. Ampicillin 1 Gram IV push q8h D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x3 - A. Betamethasone (Celestone) 12 mg deep IM A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? A. Auscultate the lungs for respiratory pneumonia. B. Draw blood to analyze for streptococcal infection C. Change to latex-free gloves when handling infant D. Apply zinc oxide to perineum with each diaper change - C. Change to latex-free gloves when handling infant The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client? A. Clonidine hydrochloride B. Carbamazepine C. Furosemide D. Magnesium sulfate - D. Magnesium sulfate 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 101.2F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? A. Round ligament strain B. Chorioamnionitis C. Abruptio placenta D. Viral infection. - B. Chorioamnionitis A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important to implement? A. Provide a bottle of electrolyte solution B. Infuse normal saline intravenously C. Administer an antipyretic rectally D. Apply external cooling blanket - B. Infuse normal saline intravenously A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement? A. remove restraints q4h for 30 minutes and place gloves on the child's hands B. record observations of the restraints q2h and ensure that they are in place at all times C. obtain the HCP advice as to when the restraints should be removed D. remove restraints one at a time to provide ROM exercises - D. remove restraints one at a time to provide ROM exercises A new mother calls the nurse stating that she wants to start feeding her 6-month- old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? A. encourage the mother to schedule a developmental assessment of the infant B. advise the mother to wait at least another month before starting any solid foods C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal D. reassure the mother that the infant is old enough to eat iron-fortified cereal - D. reassure the mother that the infant is old enough to eat iron-fortified cereal While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first? A. Prepare for a potential cesarean B. Allow the client to begin pushing C. Administer oxygen at 10/L by mask D. Change the maternal position - D. Change the maternal position A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam) after delivery of an infant who is Rh-positive. Which information should the nure provide this client? A. RhoGam is not necessary unless all her pregnancies are Rh-positive B. The R-positive factor from the fetus threatens her blood cells C. The mother should receive RhoGam when the baby is Rh-negative D. RhoGam prevents maternal antibody formation for future Rh-positive babies - D. RhoGam prevents maternal antibody formation for future Rh-positive babies A 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? A. Weak cry without any tears B. Bulging fontanel C. Visible peristaltic wave. D. Palpable mass in the right upper quadrant - A. Weak cry without any tears A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? A. Suction the oral and nasal passages B. Give oxygen by positive pressure C. Stimulate the infant to cry D. Turn the infant onto the right side - C. Stimulate the infant to cry 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 feels the need to bear down and push. What information is most important for the nurse to obtain first? A. the estimated amount of fluid B. time the membranes ruptured C. color and consistency of the fluid D. any odor noted when membranes ruptured. - C. color and consistency of the fluid An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which action should the nurse implement first?A. Administer morphine sulphate. B. Start IV fluids. C. Place the infant in a knee-chest position D. Provide 100% oxygen by face mask. - C. Place the infant in a knee-chest position A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication? A. jaundice B. poor appetite C. brain damage D. hypoglycemia - A. jaundice The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediatly? A. Bilirubin of 1.5 mg/dl B. Glucose of 80 mg/dl C. Potassium of 4.5 mEq/L D. Sodium of 119 mEq/L - D. Sodium of 119 mEq/L At 39-weeks gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR) has remained nonreactive during the 30 minutes of evaluation. Based on this finding, which action should the nurse implement? A. Initiate an intravenous infusion B. Observe the FHR pattern for 30 more minutes C. Schedule a biophysical profile D. Place an acoustic stimulator on the abdomen - D. Place an acoustic stimulator on the abdomen A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? A. Ask the clients mother to call an ambulance for transport to the hospital immediately. B. Determine what physical activities the client has performed for the past 24 hours C. Teach the client if she has experienced any recent changes in vaginal discharge. - C. Teach the client if she has experienced any recent changes in vaginal discharge. Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect? A. Weight gain B. Reduction of fever C. Improved caloric intake D. Reduction of edema - D. Reduction of edema The nurse is conducting postpartum teaching with a mother who is breastfeeding here infant. When discussing birth control, which method should the nurse recommend to this client as beneficial for her to use in preventing an unwanted pregnancy? A. Breastfeed exclusively at least every 3-4 hours B. Condoms and contraceptive foam or gel C. Rhythm method (natural family planning) D. Combined estrogen progesterone oral contraceptives. - B. Condoms and contraceptive foam or gel One day after a vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm2. What action should the nurse take first? A. Check he differential, since the WBC is normal for this client. B. Assess the clients temperature, pulse, and respirations q4h. C. Notify the healthcare provider, since this finding is indicative of infection D. Assess the clients perineal area for signs of a perineal hematoma. - A. Check he differential, since the WBC is normal for this client. The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? A. Encourage the parents to report this to the healthcare provider B. Acknowledge the parents' observation. C. Schedule the newborn for further neurological testing. D. Explain the newborn's normal stepping reflex. - D. Explain the newborn's normal stepping reflex. 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? A. The thyroxine level is low because the TSH level is high. B. High thyroxine levels normally occur in breastfeeding infants. C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth D. The TSH is high because of the low production of T4 by the thyroid. - D. The TSH is high because of the low production of T4 by the thyroid. The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning this infants care? A. Blood pressure 76/42 mm/Hg B. Faint heart murmur C. Respiratory rate 76 breaths/min D. Blood glucose 45 mg/dl - C. Respiratory rate 76 breaths/min At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she is feeling 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? A. Presence of fetal movements. B. Gestational weight gain C. Fundal height measurement D. Leakage from breasts - B. Gestational weight gain 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? - Oral contraceptive use for at least one year. A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet? A. Carrots B. Chicken C. Yogurt D. Cheese - B. Chicken 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 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? - Both the lower uterine segment and the fundus must be massaged. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? A. Respiratory rate of 22 breaths/min B. A large amount of lochia rubra C. Blood pressure 149/90 D. Positive Homan's sign - C. Blood pressure 149/90 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? - Early postpartum, within 72 hours of delivery. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? A. Pain level B. Blood pressure C. Infusion site D. Contraction pattern - D. Contraction pattern. A client delivers a viable infant , but begins to have excessive uncontrolled vaginal .. notifying the healthcare provider of the clients condition ,What information is most important A. Maternal blood pressure B. Maternal apical pulse C. Time pitocin infusion completed D. Total amount of pitocin infused - A. Maternal blood pressure. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? A. Discuss the need for cortisol and aldosterone replacement therapy after discharge B. Support the parents in their decision to assign sex of their child according to their preference C. Offer information about ultrasonography and genotyping to determine sex assignment D. Explain that corrective surgical procedures consistent with sex assignment can be delayed - C. Offer information about ultrasonography and genotyping to determine sex assignment During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client. - Elevate the head with two pillows while sleeping. 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 the vital signs in the record. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? - Apply hot packs just before each feeding. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only) - 13 A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? - Place the infant on the abdomen to protect the sac. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which answer should the nurse to provide? - " Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider" 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? A. Notify the health care provider immediately B. Increase the temperature of the radiant warmer C. Assess infant heart rateD. Determine the infants blood sugar level - D. Determine the infant's blood sugar level. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and 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? A. Alert the neonatal team and prepare for neonatal resuscitation B. Notify the healthcare provider from the client's bedside C. Obtain written consent for an emergency cesarean section D. Draw a blood sample for stat hemoglobin and hematocrit - B. Notify the healthcare provider from the client's bedside A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? A. Turn the client to her left side B. Contact the healthcare provider C. Assess the fetal heart rate D. Check the cervical dilation - C. Assess the fetal heart rate The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? - "What food does your baby usually eat in a normal day?" 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. 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? A. Decrease the oxytocin infusion rate B. Determine current cervical dilation C. Request placement of the epidural D. Give a bolus of intravenous fluids - B. Determine current cervical dilation A client with gestational diabetes is undergoing a non-stress test at 34 weeks gestation. Fetal heart beat is 144 beats / min. The client is instructed to mark the fetal monitor paper by pressing each time the baby moves. After 20 mins the nurse evaluates the fetal monitor strip A. The mother perceives and marks at least four fetal movements B. Fetal movements must be elicited with a vibroacoustic stimulator C. Two fetal heart accelerations of 15 beats/ min x 15 seconds are recorded D. No FHR late decelerations occur in response to fetal movement - C. Two FHR accelerations of 15 beats/minute x 15 seconds are recorded. A newborn who was a breech presentation is admitted to the nursery. Which assessment procedure is a priority for the nurse to perform? - Babinski's reflex. The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life? - Cries vigorously when stimulated. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? - Monitor Blood pressure, pulse, and respirations q4h. What goal is most important for the nurse to include in the plan of care for a client with gestational diabetes? - Restrict carbohydrate intake. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply.) A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. E. Has a disheveled appearance. - A. Avoids eye contact. B. Interacts with a flat affect. C. Reports feeling sad. D. Expresses suicidal thoughts. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. A. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 B. Ampicillin 1 gram IV push q8h. C. Betamethasone (Celestone) 12 mg deep IM D. Butorphanol (Stadol) 1 mg IV push q2h PRN pain - A. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x 3 In preparing a gravid client for a triple screen analysis, which action should the nurse take? A. Prepare to draw blood for analysis. B. Encourage the client to drink 8 oz of water. C. Assist the client to left lateral tilt position. D. Apply an external fetal monitor to the abdomen. - A. Prepare to draw blood for analysis. During a routine first trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. What action should the nurse implement? A. Inform her that this is a normal physiological change. B. Notify the healthcare provider of the complaint. C. Recommend an over-the-counter yeast medication. D. Prepare the client for a sterile speculum exam. - A. Inform her that this is a normal physiological change. Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her vagina. Her uterus is firm and her vital signs are within normal limits. The nurse determines that this sign may indicate which condition? A. Early postpartum hemorrhage. B. Laceration on the cervix C. Expected course in the fourth stage of labor. D. A full urinary bladder. - B. Laceration on the cervix A new mother asks the nurse about an area of swelling on her baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond? A. "This is called caput succedaneum. It will absorb and cause no problems." B. "This is called caput succedaneum. It will have to be drained." C. "This is called a cephalhematoma. It will cause no problems." D. "This is called cephalhematome. It can cause jaundice as it is absorbed." - A. "This is called caput succedaneum. It will absorb and cause no problems." The parents of a male newborn have signed an informed consent for circumcision. What priority intervention should the nurse implement upon completion of the circumcision? A. Offer a pacifier dipped in glucose water. B. Give PRN dose of liquid acetaminophen. C. Place petrolatum gauze dressing on the site. D. Wrap the infant in warm receiving blankets. - C. Place petrolatum gauze dressing on the site. The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority? A. Hyperthermia B. Hyperbilirubinemia C. Polycythemia D. Hypoglycemia - D. Hypoglycemia A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information? A. Sex and size of the infant. B. Fetal growth and gestational age. C. Chromosomal abnormalities. D. Lecithin-sphingomyelin ration. - B. Fetal growth and gestational age. A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin) infusion. Which finding is most important for the nurse to report to the healthcare provider? A. Spontaneous rupture of membranes. B. Fetal heart rate accelerations with fetal movement. C. Absences of uterine contraction of 20 minutes. D. A pattern of fetal late decelerations. - D. A pattern of fetal late decelerations. In determining the one minute Apgar score of a male infant the nurse asses a heart rate of 120 per min ... respiration.. He has a loud cry with stimualtion, good muscle tone, color is acrocyanotic . What should the nurse assign? A. 7 B. 8 C. 9 D. 10 - C. 9 The nurses assessment on a preterm infant reveals decreased muscle tone , sign of respiratory distress , irritability , mottled cool skin.Which intervention should the nurse implement first ? A. Position a radiant warmer on the crib B. Asses infant blood glucose level C. Place infant in side lying position D. Nipple feed 1 ounce of 5%glucose in water - A. Position a radiant warmer on the crib Vaginal prostiglandin gel is used to induce labor women who are 42 weeks of gestation. Thirty minutes after insertion of the gel , the client complains of vaginal warmth, and is experiencing 90 second contractions with fetal heart deceleration. What action should the nurse implement first A. Assess maternal vital signs B. Notify the healthcare provider C. Increase the IV infusion rate D. Turn to a side lying position - D. Turn to a side lying position