PEDS & MATERNITY HESI TEST WITH COMPLETE SOLUTIONS
EXAM LATEST COMPLETE 112 QUESTIONS AND DETAILED
CORRECT ANSWERS JUST RELEASED
Question 1
A 3-month-old infant 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, and a rash in the diaper area. What action is most important
for the nurse to take?
A) Administer an antihistamine to the infant.
B) Apply a topical steroid cream to the diaper rash.
C) Change the infant's formula.
D) Change to latex-free gloves when handling the infant.
E) Recommend consultation with an allergist.
Correct Answer: D) Change to latex-free gloves when handling the infant.
Rationale: Infants with myelomeningocele are at a significantly increased risk for
developing a latex allergy due to frequent exposure to latex products (e.g., during
catheterization) from birth. The symptoms of sneezing, urticaria, watery eyes, and rash are
classic signs of an allergic reaction, and given the context, a latex allergy is highly
suspected. Switching to latex-free gloves is the most important immediate action to
eliminate the allergen exposure.
Question 2
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) Increased urine output
B) Fontanelles appear bulging
C) Skin turgor is elastic
D) Crying without tears
E) Moist mucous membranes
Correct Answer: D) Crying without tears
Rationale: Projectile vomiting in pyloric stenosis leads to significant fluid loss. Crying
without tears is a classic sign of dehydration in infants, indicating a depletion of
extracellular fluid volume. Other signs of dehydration include decreased urine output,
sunken fontanelles, and poor skin turgor.
Question 3
A 6-year-old child with heart failure (HF) gained 2 pounds in the last 24 hours. Which
intervention is most important for the nurse to implement?
A) Document the weight gain in the child's chart.
B) Administer a prescribed diuretic.
C) Increase the child's fluid restriction.
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D) Assess bilateral lung sounds.
E) Review the child's dietary intake for the last 24 hours.
Correct Answer: D) Assess bilateral lung sounds.
Rationale: A rapid weight gain of 2 pounds in 24 hours for a child with heart failure is
indicative of fluid retention. Fluid overload in HF can quickly lead to pulmonary edema.
Assessing bilateral lung sounds is the most important intervention to detect crackles or
diminished breath sounds, which would indicate worsening pulmonary congestion and
require immediate medical intervention.
Question 4
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 the nurse
program into the infusion pump?
A) 25 mL/hour
B) 50 mL/hour
C) 75 mL/hour
D) 100 mL/hour
E) 125 mL/hour
Correct Answer: C) 75 mL/hour
Rationale: First, calculate how many mL are in 1 gram of magnesium sulfate: 500 mL / 20
grams = 25 mL/gram. Next, calculate the infusion rate in mL/hour: 3 grams/hour * 25
mL/gram = 75 mL/hour. Therefore, the nurse should program the infusion pump to deliver
75 mL/hour.
Question 5
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) Prepare for an immediate vaginal delivery.
B) Obtain an order for pain medication.
C) Administer IV fluids rapidly.
D) Notify the healthcare provider at the patient's bedside.
E) Apply an internal fetal scalp electrode.
Correct Answer: D) Notify the healthcare provider at the patient's bedside.
Rationale: The client's symptoms (severe abdominal pain, bright red vaginal bleeding,
rigid/tender abdomen, fetal bradycardia, maternal tachycardia) are classic signs of
placental abruption, a life-threatening obstetric emergency for both mother and fetus.
Immediate notification of the healthcare provider is paramount to initiate emergency
interventions, which will likely include preparation for an emergency cesarean section.
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Question 6
A 39-week gestation multigravida is having a non-stress test (NST). The fetal heart rate (FHR)
has remained non-reactive during the 30 minutes of evaluation. Based on this finding, which
action should the nurse implement?
A) Administer a tocolytic medication.
B) Immediately prepare the client for a cesarean section.
C) Place an acoustic simulator on the abdomen.
D) Discontinue the NST and send the client home.
E) Notify the healthcare provider of a positive NST.
Correct Answer: C) Place an acoustic simulator on the abdomen.
Rationale: A non-reactive NST indicates that the fetal heart rate has not accelerated
appropriately in response to fetal movement. Before concluding the NST is truly non-
reactive and proceeding to further testing (e.g., biophysical profile or contraction stress
test), the nurse should attempt to stimulate the fetus. An acoustic simulator (vibroacoustic
stimulation) is a common method to awaken a sleeping fetus and elicit accelerations.
Question 7
Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What
intervention has the greatest priority?
A) Begin continuous fetal heart rate monitoring.
B) Prepare for immediate induction of labor.
C) Have a meconium aspirator available at delivery.
D) Administer prophylactic antibiotics.
E) Educate the client about the implications of meconium.
Correct Answer: C) Have a meconium aspirator available at delivery.
Rationale: Meconium-stained amniotic fluid places the newborn at risk for meconium
aspiration syndrome, which can cause severe respiratory distress. The greatest priority is to
be prepared to suction meconium from the infant's airway at birth (specifically the trachea
if the infant is not vigorous) using a meconium aspirator, to prevent aspiration into the
lungs.
Question 8
At 20 weeks gestation, a client who has gained 20 pounds during pregnancy states that she is
feeling fetal movement. Fundal height measurement is 20 cm, and the client's only complaint is
that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?
A) Fetal movement
B) Fundal height measurement
C) Leaking clear fluid from breasts
D) Gestational weight gain
E) Absence of nausea and vomiting
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Correct Answer: D) Gestational weight gain.
Rationale: At 20 weeks gestation, the expected fundal height is typically 20 cm, and feeling
fetal movement (quickening) is normal. Leaking clear fluid (colostrum) from the breasts is
also a normal physiological change. However, a weight gain of 20 pounds by 20 weeks is
excessive (typically 1-4 pounds in the first trimester, then 1 pound/week). Excessive weight
gain warrants further evaluation to assess for underlying causes (e.g., fluid retention,
gestational diabetes) and to provide nutritional counseling.
Question 9
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 (38.4°C), with severe abdominal or uterine
tenderness on palpation. The nurse knows that these findings are indicative of what condition?
A) Placental abruption
B) Preterm labor
C) Chorioamnionitis
D) Preeclampsia
E) Appendicitis
Correct Answer: C) Chorioamnionitis
Rationale: The findings of maternal fever (101.2 F), uterine tenderness, and pain with fetal
movement in a client at 35 weeks gestation are highly indicative of chorioamnionitis (intra-
amniotic infection). This is a serious complication requiring prompt treatment with
antibiotics and often delivery.
Question 10
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) Time the membranes ruptured.
B) Number of previous pregnancies.
C) Gravidity and parity.
D) Color and consistency of fluid.
E) Last oral intake.
Correct Answer: D) Color and consistency of fluid.
Rationale: When membranes rupture, the color and consistency of the amniotic fluid are
critical pieces of information. Meconium-stained fluid (greenish-brown) indicates fetal
distress and necessitates preparation for potential neonatal aspiration interventions.
Cloudy or foul-smelling fluid suggests infection. This information takes priority over other
historical data in this acute labor situation.
Question 11
A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after
EXAM LATEST COMPLETE 112 QUESTIONS AND DETAILED
CORRECT ANSWERS JUST RELEASED
Question 1
A 3-month-old infant 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, and a rash in the diaper area. What action is most important
for the nurse to take?
A) Administer an antihistamine to the infant.
B) Apply a topical steroid cream to the diaper rash.
C) Change the infant's formula.
D) Change to latex-free gloves when handling the infant.
E) Recommend consultation with an allergist.
Correct Answer: D) Change to latex-free gloves when handling the infant.
Rationale: Infants with myelomeningocele are at a significantly increased risk for
developing a latex allergy due to frequent exposure to latex products (e.g., during
catheterization) from birth. The symptoms of sneezing, urticaria, watery eyes, and rash are
classic signs of an allergic reaction, and given the context, a latex allergy is highly
suspected. Switching to latex-free gloves is the most important immediate action to
eliminate the allergen exposure.
Question 2
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) Increased urine output
B) Fontanelles appear bulging
C) Skin turgor is elastic
D) Crying without tears
E) Moist mucous membranes
Correct Answer: D) Crying without tears
Rationale: Projectile vomiting in pyloric stenosis leads to significant fluid loss. Crying
without tears is a classic sign of dehydration in infants, indicating a depletion of
extracellular fluid volume. Other signs of dehydration include decreased urine output,
sunken fontanelles, and poor skin turgor.
Question 3
A 6-year-old child with heart failure (HF) gained 2 pounds in the last 24 hours. Which
intervention is most important for the nurse to implement?
A) Document the weight gain in the child's chart.
B) Administer a prescribed diuretic.
C) Increase the child's fluid restriction.
,[Type here]
D) Assess bilateral lung sounds.
E) Review the child's dietary intake for the last 24 hours.
Correct Answer: D) Assess bilateral lung sounds.
Rationale: A rapid weight gain of 2 pounds in 24 hours for a child with heart failure is
indicative of fluid retention. Fluid overload in HF can quickly lead to pulmonary edema.
Assessing bilateral lung sounds is the most important intervention to detect crackles or
diminished breath sounds, which would indicate worsening pulmonary congestion and
require immediate medical intervention.
Question 4
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 the nurse
program into the infusion pump?
A) 25 mL/hour
B) 50 mL/hour
C) 75 mL/hour
D) 100 mL/hour
E) 125 mL/hour
Correct Answer: C) 75 mL/hour
Rationale: First, calculate how many mL are in 1 gram of magnesium sulfate: 500 mL / 20
grams = 25 mL/gram. Next, calculate the infusion rate in mL/hour: 3 grams/hour * 25
mL/gram = 75 mL/hour. Therefore, the nurse should program the infusion pump to deliver
75 mL/hour.
Question 5
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) Prepare for an immediate vaginal delivery.
B) Obtain an order for pain medication.
C) Administer IV fluids rapidly.
D) Notify the healthcare provider at the patient's bedside.
E) Apply an internal fetal scalp electrode.
Correct Answer: D) Notify the healthcare provider at the patient's bedside.
Rationale: The client's symptoms (severe abdominal pain, bright red vaginal bleeding,
rigid/tender abdomen, fetal bradycardia, maternal tachycardia) are classic signs of
placental abruption, a life-threatening obstetric emergency for both mother and fetus.
Immediate notification of the healthcare provider is paramount to initiate emergency
interventions, which will likely include preparation for an emergency cesarean section.
,[Type here]
Question 6
A 39-week gestation multigravida is having a non-stress test (NST). The fetal heart rate (FHR)
has remained non-reactive during the 30 minutes of evaluation. Based on this finding, which
action should the nurse implement?
A) Administer a tocolytic medication.
B) Immediately prepare the client for a cesarean section.
C) Place an acoustic simulator on the abdomen.
D) Discontinue the NST and send the client home.
E) Notify the healthcare provider of a positive NST.
Correct Answer: C) Place an acoustic simulator on the abdomen.
Rationale: A non-reactive NST indicates that the fetal heart rate has not accelerated
appropriately in response to fetal movement. Before concluding the NST is truly non-
reactive and proceeding to further testing (e.g., biophysical profile or contraction stress
test), the nurse should attempt to stimulate the fetus. An acoustic simulator (vibroacoustic
stimulation) is a common method to awaken a sleeping fetus and elicit accelerations.
Question 7
Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What
intervention has the greatest priority?
A) Begin continuous fetal heart rate monitoring.
B) Prepare for immediate induction of labor.
C) Have a meconium aspirator available at delivery.
D) Administer prophylactic antibiotics.
E) Educate the client about the implications of meconium.
Correct Answer: C) Have a meconium aspirator available at delivery.
Rationale: Meconium-stained amniotic fluid places the newborn at risk for meconium
aspiration syndrome, which can cause severe respiratory distress. The greatest priority is to
be prepared to suction meconium from the infant's airway at birth (specifically the trachea
if the infant is not vigorous) using a meconium aspirator, to prevent aspiration into the
lungs.
Question 8
At 20 weeks gestation, a client who has gained 20 pounds during pregnancy states that she is
feeling fetal movement. Fundal height measurement is 20 cm, and the client's only complaint is
that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation?
A) Fetal movement
B) Fundal height measurement
C) Leaking clear fluid from breasts
D) Gestational weight gain
E) Absence of nausea and vomiting
, [Type here]
Correct Answer: D) Gestational weight gain.
Rationale: At 20 weeks gestation, the expected fundal height is typically 20 cm, and feeling
fetal movement (quickening) is normal. Leaking clear fluid (colostrum) from the breasts is
also a normal physiological change. However, a weight gain of 20 pounds by 20 weeks is
excessive (typically 1-4 pounds in the first trimester, then 1 pound/week). Excessive weight
gain warrants further evaluation to assess for underlying causes (e.g., fluid retention,
gestational diabetes) and to provide nutritional counseling.
Question 9
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 (38.4°C), with severe abdominal or uterine
tenderness on palpation. The nurse knows that these findings are indicative of what condition?
A) Placental abruption
B) Preterm labor
C) Chorioamnionitis
D) Preeclampsia
E) Appendicitis
Correct Answer: C) Chorioamnionitis
Rationale: The findings of maternal fever (101.2 F), uterine tenderness, and pain with fetal
movement in a client at 35 weeks gestation are highly indicative of chorioamnionitis (intra-
amniotic infection). This is a serious complication requiring prompt treatment with
antibiotics and often delivery.
Question 10
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) Time the membranes ruptured.
B) Number of previous pregnancies.
C) Gravidity and parity.
D) Color and consistency of fluid.
E) Last oral intake.
Correct Answer: D) Color and consistency of fluid.
Rationale: When membranes rupture, the color and consistency of the amniotic fluid are
critical pieces of information. Meconium-stained fluid (greenish-brown) indicates fetal
distress and necessitates preparation for potential neonatal aspiration interventions.
Cloudy or foul-smelling fluid suggests infection. This information takes priority over other
historical data in this acute labor situation.
Question 11
A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after
