HESI RN
HESI Maternity Test Bank
1. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
- A. Notify the healthcare provider immediately.
- B. Suction the infant's nares, then the oral cavity.
- C. Check the infant's oxygen saturation rate.
- D. Position the infant on the right side.
Correct answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.
2. A client addicted to heroin and newly pregnant asks a nurse about ensuring her baby's health while on methadone. What should the nurse advise?
- A. Sign up for group therapy sessions.
- B. Discontinue the methadone right away.
- C. Start prenatal care as soon as possible.
- D. Describe genetic testing protocol.
Correct answer: C
Rationale: Initiating prenatal care promptly is essential for monitoring the well-being of both the mother and the fetus, particularly in high-risk pregnancies involving substance use. Early prenatal care allows for timely interventions, education, and support to promote a healthier pregnancy and birth outcomes. Choice A is incorrect because while group therapy may be beneficial, initiating prenatal care is more crucial at this stage. Choice B is incorrect as abrupt discontinuation of methadone can be harmful and should be managed under medical supervision. Choice D is incorrect as genetic testing is not the immediate priority in this scenario.
3. A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
- A. Nausea and vomiting.
- B. Risk for infection.
- C. Sleep deprivation.
- D. Fluid volume excess.
Correct answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client. Choices A, B, and C are not the highest priority in this situation. Nausea and vomiting, risk for infection, and sleep deprivation are important but do not pose an immediate threat to the client's physiologic stability compared to the risk of heart failure due to fluid volume excess.
4. At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?
- A. Round ligament strain.
- B. Chorioamnionitis.
- C. Abruptio placentae.
- D. Viral infection.
Correct answer: B
Rationale: The client's symptoms of fever and abdominal tenderness, along with the gestational age, are classic signs of chorioamnionitis, an infection of the amniotic fluid. Chorioamnionitis is a serious condition that requires prompt recognition and treatment to prevent maternal and fetal complications. Round ligament strain (Choice A) typically presents with sharp, stabbing pain on the sides of the abdomen and is not associated with fever or uterine tenderness. Abruptio placentae (Choice C) presents with sudden-onset vaginal bleeding and severe abdominal pain, often with a board-like uterus. Viral infections (Choice D) may present with a variety of symptoms, but the combination of fever, abdominal tenderness, and gestational age in this scenario points more towards chorioamnionitis.
5. The healthcare provider is preparing to suture a 10-year-old with a lacerated forehead. Both parents and the 12-year-old sibling are at the child’s bedside. Which instruction best supports the family?
- A. While waiting for the healthcare provider, only one family member may stay with the child.
- B. All family members should leave while the healthcare provider sutures the child’s forehead.
- C. It is best if the sibling goes to the waiting room until the suturing is completed.
- D. Please decide among yourselves who will stay when the healthcare provider begins suturing.
Correct answer: D
Rationale: Choice D is the best instruction as it involves the family in the decision-making process, allowing them to choose who will stay with the child during the suturing procedure. This approach supports the family's comfort and participation in the child's care, promoting a sense of control and family-centered care. Choices A, B, and C do not promote family involvement and may lead to feelings of exclusion or lack of control among the family members.
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