HESI RN Exit Exam 2024 NGN: Maternal-
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Newborn & Pediatric Nursing Integration**
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**Question 157**
A nurse is assessing a newborn who is 2 hours old. The newborn has acrocyanosis, a heart rate of 140
bpm, irregular respirations, and a Moro reflex that is present bilaterally. Which finding should the nurse
report to the healthcare provider?
A. Acrocyanosis of the hands and feet
B. Heart rate of 140 bpm
C. Irregular respirations
D. Moro reflex present bilaterally
💫ANSWER✔️✔️: C. Irregular respirations
💫RATIONALE✔️✔️: While newborns have periodic breathing (short pauses <10 seconds), persistent
irregular respirations with grunting, flaring, or retractions are abnormal. Acrocyanosis (bluish
hands/feet) is normal for the first 24 hours due to immature circulation. Heart rate 120-160 bpm is
normal. Moro reflex should be present.
---
**Question 158**
A nurse is teaching a client at 28 weeks gestation about signs of preterm labor. Which statement by the
client indicates correct understanding?
A. "I should call my provider if I have menstrual-like cramping that comes and goes."
B. "It's normal to have a low backache that doesn't go away with rest."
C. "I will drink extra fluids if I feel my uterus tightening."
,D. "I should wait to see if contractions stop before calling my provider."
💫ANSWER✔️✔️: A. "I should call my provider if I have menstrual-like cramping that comes and goes."
💫RATIONALE✔️✔️: Menstrual-like cramping, low backache, pelvic pressure, uterine contractions (even
painless), and change in vaginal discharge are signs of preterm labor. The client should notify the
provider immediately, not wait. Increased fluids may help with Braxton Hicks but not true preterm labor.
---
**Question 159**
A nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor. The nurse notes
that the client's contractions are lasting 100 seconds with a frequency of every 1.5 minutes. The fetal
heart rate is 90 bpm with late decelerations. What is the priority action?
A. Decrease the oxytocin infusion rate
B. Stop the oxytocin infusion
C. Reposition the client on her left side
D. Administer oxygen via face mask at 10 L/min
💫ANSWER✔️✔️: B. Stop the oxytocin infusion
💫RATIONALE✔️✔️: This is uterine hyperstimulation (excessive contractions) causing fetal distress (late
decelerations, bradycardia). The priority is to stop the oxytocin immediately. Then reposition the client,
administer oxygen, increase IV fluids, and notify the provider. Stopping the oxytocin is the first and most
critical step.
---
**Question 160**
A nurse is assessing a 6-month-old infant in the well-child clinic. Which developmental milestone would
the nurse expect the infant to have achieved?
A. Sitting unsupported for several minutes
B. Transferring a rattle from one hand to the other
, C. Crawling on hands and knees
D. Pulling to a standing position
💫ANSWER✔️✔️: B. Transferring a rattle from one hand to the other
💫RATIONALE✔️✔️: By 6 months, infants typically can transfer objects between hands, roll over both
ways, and sit with support. Sitting unsupported occurs around 8 months. Crawling is 7-10 months.
Pulling to stand is 9-12 months.
---
**Question 161**
A nurse is providing discharge teaching to a client who gave birth 24 hours ago. The client asks, "When
will my breast milk come in?" Which response is correct?
A. "Your milk will come in immediately after delivery."
B. "Colostrum is present now; mature milk typically comes in 3-5 days after birth."
C. "You will not produce milk until your baby is 1 week old."
D. "Your milk will come in when you stop producing colostrum, usually at day 7."
💫ANSWER✔️✔️: B. "Colostrum is present now; mature milk typically comes in 3-5 days after birth."
💫RATIONALE✔️✔️: Colostrum (early, antibody-rich milk) is present from late pregnancy through the first
few days postpartum. Mature milk "comes in" (increased volume, white appearance) around day 3-5
postpartum, triggered by the drop in progesterone after placental delivery.
---
**Question 162**
A nurse is caring for a child with suspected appendicitis. Which finding is most indicative of a perforated
appendix?
A. Rebound tenderness in the right lower quadrant
B. Sudden relief of pain followed by abdominal rigidity
C. Anorexia and nausea
**
Newborn & Pediatric Nursing Integration**
---
**Question 157**
A nurse is assessing a newborn who is 2 hours old. The newborn has acrocyanosis, a heart rate of 140
bpm, irregular respirations, and a Moro reflex that is present bilaterally. Which finding should the nurse
report to the healthcare provider?
A. Acrocyanosis of the hands and feet
B. Heart rate of 140 bpm
C. Irregular respirations
D. Moro reflex present bilaterally
💫ANSWER✔️✔️: C. Irregular respirations
💫RATIONALE✔️✔️: While newborns have periodic breathing (short pauses <10 seconds), persistent
irregular respirations with grunting, flaring, or retractions are abnormal. Acrocyanosis (bluish
hands/feet) is normal for the first 24 hours due to immature circulation. Heart rate 120-160 bpm is
normal. Moro reflex should be present.
---
**Question 158**
A nurse is teaching a client at 28 weeks gestation about signs of preterm labor. Which statement by the
client indicates correct understanding?
A. "I should call my provider if I have menstrual-like cramping that comes and goes."
B. "It's normal to have a low backache that doesn't go away with rest."
C. "I will drink extra fluids if I feel my uterus tightening."
,D. "I should wait to see if contractions stop before calling my provider."
💫ANSWER✔️✔️: A. "I should call my provider if I have menstrual-like cramping that comes and goes."
💫RATIONALE✔️✔️: Menstrual-like cramping, low backache, pelvic pressure, uterine contractions (even
painless), and change in vaginal discharge are signs of preterm labor. The client should notify the
provider immediately, not wait. Increased fluids may help with Braxton Hicks but not true preterm labor.
---
**Question 159**
A nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor. The nurse notes
that the client's contractions are lasting 100 seconds with a frequency of every 1.5 minutes. The fetal
heart rate is 90 bpm with late decelerations. What is the priority action?
A. Decrease the oxytocin infusion rate
B. Stop the oxytocin infusion
C. Reposition the client on her left side
D. Administer oxygen via face mask at 10 L/min
💫ANSWER✔️✔️: B. Stop the oxytocin infusion
💫RATIONALE✔️✔️: This is uterine hyperstimulation (excessive contractions) causing fetal distress (late
decelerations, bradycardia). The priority is to stop the oxytocin immediately. Then reposition the client,
administer oxygen, increase IV fluids, and notify the provider. Stopping the oxytocin is the first and most
critical step.
---
**Question 160**
A nurse is assessing a 6-month-old infant in the well-child clinic. Which developmental milestone would
the nurse expect the infant to have achieved?
A. Sitting unsupported for several minutes
B. Transferring a rattle from one hand to the other
, C. Crawling on hands and knees
D. Pulling to a standing position
💫ANSWER✔️✔️: B. Transferring a rattle from one hand to the other
💫RATIONALE✔️✔️: By 6 months, infants typically can transfer objects between hands, roll over both
ways, and sit with support. Sitting unsupported occurs around 8 months. Crawling is 7-10 months.
Pulling to stand is 9-12 months.
---
**Question 161**
A nurse is providing discharge teaching to a client who gave birth 24 hours ago. The client asks, "When
will my breast milk come in?" Which response is correct?
A. "Your milk will come in immediately after delivery."
B. "Colostrum is present now; mature milk typically comes in 3-5 days after birth."
C. "You will not produce milk until your baby is 1 week old."
D. "Your milk will come in when you stop producing colostrum, usually at day 7."
💫ANSWER✔️✔️: B. "Colostrum is present now; mature milk typically comes in 3-5 days after birth."
💫RATIONALE✔️✔️: Colostrum (early, antibody-rich milk) is present from late pregnancy through the first
few days postpartum. Mature milk "comes in" (increased volume, white appearance) around day 3-5
postpartum, triggered by the drop in progesterone after placental delivery.
---
**Question 162**
A nurse is caring for a child with suspected appendicitis. Which finding is most indicative of a perforated
appendix?
A. Rebound tenderness in the right lower quadrant
B. Sudden relief of pain followed by abdominal rigidity
C. Anorexia and nausea
