HESI RN
HESI Maternity Test Bank
1. 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.
2. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?
- A. Bathe the infant with an antimicrobial soap.
- B. Measure the head and chest circumference.
- C. Obtain the infant's footprints.
- D. Administer vitamin K (AquaMEPHYTON).
Correct answer: A
Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.
3. A child with ADHD needs help with homework. What should the nurse encourage the parents to do?
- A. Encourage the parents to help the child with homework.
- B. Do the homework for the child.
- C. Set a regular homework schedule.
- D. Provide a quiet environment for homework.
Correct answer: A
Rationale: Encouraging parents to help the child with homework is the most appropriate course of action. By assisting the child, parents can provide necessary support and guidance without taking over the task entirely. This approach fosters independence and helps the child develop academic skills. Option B, doing the homework for the child, is counterproductive as it does not empower the child to learn and grow independently. Option C, setting a regular homework schedule, is important but does not address the immediate need for assistance. Option D, providing a quiet environment for homework, is helpful but does not directly involve parents in supporting the child's academic progress.
4. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child?
- A. Reduce cerebral edema and lower intracranial pressure
- B. Avert hypotension and septic shock
- C. Prevent cardiac arrhythmias and heart failure
- D. Promote kidney perfusion and normal blood pressure
Correct answer: A
Rationale: Reducing cerebral edema and lowering intracranial pressure is the primary goal of treatment for Reye’s syndrome.
5. What action should be implemented when preparing to measure the fundal height of a pregnant client?
- A. Have the client empty her bladder.
- B. Request the client lie on her left side.
- C. Perform Leopold's maneuvers first.
- D. Give the client some cold juice to drink.
Correct answer: A
Rationale: The correct action when preparing to measure the fundal height of a pregnant client is to have the client empty her bladder. This is essential to ensure an accurate measurement because a full bladder can displace the uterus and affect the accuracy of the assessment. Choice B is incorrect because the client should lie flat on her back, not on her left side, to measure fundal height accurately. Choice C is incorrect because Leopold's maneuvers are used to determine the position of the fetus, not to measure fundal height. Choice D is incorrect as giving the client cold juice is not necessary for measuring fundal height.
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