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. When preparing a class on newborn care for expectant parents, what content should be taught concerning the newborn infant born at term gestation?
- A. Milia are white marks caused by sebaceous glands and typically resolve within 2 to 4 weeks.
- B. Meconium is the first stool and is typically dark green or black in color.
- C. Vernix caseosa is a white, cheesy substance mainly found in skin folds, providing a protective layer.
- D. Pseudostrabismus in newborns usually self-resolves without the need for intervention.
Correct answer: C
Rationale: Vernix caseosa is a white, cheesy substance that acts as a protective barrier on the skin of newborns, particularly present in skin folds. It helps to prevent dehydration and protect the delicate skin of the newborn from the amniotic fluid in utero. Educating expectant parents about the presence and function of vernix caseosa can help them understand the importance of its preservation during the immediate postnatal period. Choices A, B, and D are incorrect as they do not directly relate to the protective function of vernix caseosa in newborns. Milia are small, white bumps on the skin due to blocked oil glands, meconium is the first stool of a newborn and is typically dark green or black in color, and pseudostrabismus refers to false appearance of misalignment of the eyes, which usually resolves on its own without intervention.
3. A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child’s plan of care?
- A. Allow the child to eat any food desired and tolerated.
- B. Provide small, frequent meals that are high in protein and calories.
- C. Offer the child preferred foods and avoid foods that are not well-tolerated.
- D. Consult with a dietitian to provide appropriate nutritional support.
Correct answer: B
Rationale: In children with leukemia undergoing chemotherapy, anorexia, nausea, and vomiting are common issues leading to altered nutrition. Providing small, frequent meals that are high in protein and calories is essential to address these symptoms and meet the child's nutritional needs effectively. This approach helps in managing the side effects of treatment and supporting the child's nutritional requirements during this challenging time.
4. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the postpartum unit. Which nursing plan is best in assisting this mother to bond with her newborn infant?
- A. Encourage the mother to provide total care for her infant.
- B. Provide privacy so the mother can develop a relationship with the infant.
- C. Encourage the father to provide most of the infant's care during hospitalization.
- D. Meet the mother's physical needs and demonstrate warmth toward the infant.
Correct answer: D
Rationale: Meeting the mother's physical needs and demonstrating warmth toward the infant is essential in creating a supportive environment that fosters bonding between the mother and the newborn. By ensuring the mother's comfort and well-being, the nurse can help promote a positive interaction between the mother and her infant, leading to a stronger emotional connection and bonding.
5. What is the best nursing intervention for a pregnant woman with hyperemesis gravidarum?
- A. Administer prescribed IV solution.
- B. Give oral rehydration solution.
- C. Encourage small, frequent meals.
- D. Offer ginger tea to reduce nausea.
Correct answer: A
Rationale: The best nursing intervention for a pregnant woman with hyperemesis gravidarum is to administer the prescribed IV solution. Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. Administering IV fluids helps in managing dehydration, replenishing electrolytes, and providing the necessary hydration for both the mother and the fetus. Giving oral rehydration solution (Choice B) may not be sufficient for severe cases of hyperemesis gravidarum where IV fluids are required. Encouraging small, frequent meals (Choice C) may not be effective as the woman may not be able to tolerate oral intake. Offering ginger tea (Choice D) is not the most appropriate intervention for hyperemesis gravidarum, as it may not provide adequate hydration or electrolyte balance needed in severe cases.
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