HESI RN
HESI Maternity Test Bank
1. A new mother asks the LPN/LVN, 'How do I know that my daughter is getting enough breast milk?' Which explanation should the nurse provide?
- A. Weigh the baby daily, and if she is gaining weight, she is eating enough.
- B. Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day.
- C. Offer the baby extra bottle milk after her feeding, and see if she is still hungry.
- D. If you're concerned, you might consider bottle feeding so that you can monitor her intake.
Correct answer: B
Rationale: The correct answer is B. Adequate voiding is a sign that the baby is receiving enough milk. Pale straw-colored urine 6 to 10 times a day indicates proper hydration and nutrition. This is a reliable indicator of adequate breast milk intake for the infant. Choice A is incorrect because weight gain alone may not always indicate sufficient milk intake. Choice C is incorrect because supplementing with bottle milk can interfere with establishing breastfeeding. Choice D is incorrect as it suggests switching to bottle feeding, which is not necessary if the baby is latching and voiding well.
2. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
- A. Ask the mother to stop feeding, comfort the infant, and then assist the mother to help the baby latch on.
- B. Use a nipple shield to help the baby latch on.
- C. Try a different breastfeeding position.
- D. Have another person help the mother with breastfeeding.
Correct answer: A
Rationale: In this scenario, the best intervention is to ask the mother to stop feeding, comfort the infant, and then assist her in helping the baby latch on. Stopping the feeding and providing comfort can reduce the infant's frustration and create a calmer environment for successful breastfeeding. Choice B, using a nipple shield, may not address the underlying issue causing the baby's difficulty latching. Choice C, trying a different breastfeeding position, can be attempted after the baby is calm and ready to latch. Choice D, having another person help, may not be necessary if the mother can be guided effectively on latching techniques.
3. A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the healthcare provider that the drug is effective?
- A. Slowly increasing urinary output over the last week.
- B. Respiratory rate changes from the 40s to the 60s.
- C. Changes in apical heart rate from the 180s to the 140s.
- D. Change in indirect bilirubin from 12 mg/dl to 8 mg/dl.
Correct answer: C
Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective. Choices A, B, and D are incorrect because they do not directly reflect the expected outcome of epoetin alfa therapy. Increasing urinary output, changes in respiratory rate, and decreasing bilirubin levels are not primary indicators of the drug's effectiveness in this context.
4. The nurse is planning care for a 4-year-old girl diagnosed with a developmental disability. What should be the primary focus of treatment for this child?
- A. Teach her social skills.
- B. Assist in preventing further disability.
- C. Ensure her participation in group activities.
- D. Help her achieve her maximum potential.
Correct answer: D
Rationale: The primary focus of treatment for a child diagnosed with a developmental disability should be helping them achieve their maximum potential. This approach aims to optimize the child's physical, emotional, cognitive, and social abilities, focusing on enhancing their overall well-being and quality of life. By supporting the child in reaching their highest level of functioning, caregivers can promote independence, self-esteem, and personal growth, which are essential components of holistic care for individuals with developmental disabilities. Teaching social skills (choice A) is important but is just one aspect of the comprehensive care needed. Preventing further disability (choice B) may not always be entirely achievable, but maximizing potential is a more realistic goal. Ensuring participation in group activities (choice C) is valuable for social development, but the primary focus should be on overall potential and well-being.
5. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?
- A. Monitor urinary output
- B. Auscultate bowel sounds
- C. Observe appearance of stool
- D. Record percent of diet consumed
Correct answer: A
Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.
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