HESI Exit Exam 202 Test Bank: The
Ultimate Study Guide with Questions and
Verified Answers for 2025/2026 to Ensure
You Pass on the First Try
Question 1
A nurse is assessing a client who is at 35 weeks of gestation
and reports a headache and blurred vision. The client's blood
pressure is 168/102 mm Hg, and urine dipstick reveals 3+
protein. Which action should the nurse take first?
A. Administer labetalol IV push
B. Place the client in a left lateral position
C. Assess deep tendon reflexes
D. Notify the provider immediately
Answer: B. Place the client in a left lateral position
Rationale: The client is showing signs of severe preeclampsia
(severe hypertension, proteinuria, headache, blurred vision). The
priority is to improve uteroplacental perfusion and reduce the risk
of seizures by positioning the client in a left lateral position. This
alleviates pressure on the vena cava, improving cardiac output
and placental blood flow. While administering antihypertensives,
assessing reflexes, and notifying the provider are all important,
positioning is the immediate nursing action to enhance perfusion
and safety.
,Question 2
A nurse is caring for a client in active labor. The client's cervix
is dilated to 7 cm, and the fetal heart rate (FHR) tracing shows
recurrent late decelerations. Which is the priority nursing
intervention?
A. Increase the rate of IV oxytocin
B. Position the client on her left side
C. Prepare for an immediate cesarean birth
D. Administer oxygen at 2 L/min via nasal cannula
Answer: B. Position the client on her left side
Rationale: Late decelerations indicate uteroplacental insufficiency.
The first-line interventions are to increase placental blood flow by
turning the client to the left lateral position, then administering
oxygen at 10 L/min via non-rebreather mask (not 2 L/min), and
increasing IV fluid rate. Oxytocin should be discontinued, not
increased. While a cesarean may be necessary if the pattern does
not resolve, it is not the immediate priority.
Question 3
A nurse is assessing a newborn who is 12 hours old. The nurse
notes jaundice on the face and chest. The mother is Rh-
negative and received Rho(D) immune globulin at 28 weeks.
Which action should the nurse take?
,A. Prepare the newborn for phototherapy
B. Obtain a direct Coombs test result
C. Encourage early and frequent breastfeeding
D. Notify the provider of possible hemolytic disease
Answer: C. Encourage early and frequent breastfeeding
Rationale: Jaundice within the first 24 hours is always abnormal,
but in this scenario, the mother received RhoGAM, which reduces
the risk of Rh incompatibility. Physiologic jaundice typically
appears after 24 hours. Early and frequent feeding helps promote
passage of meconium and reduces enterohepatic circulation,
which can help prevent worsening hyperbilirubinemia. While the
direct Coombs test may have been done at birth, the nurse's initial
action is to support feeding. Phototherapy may be indicated if
bilirubin levels rise, but it is not the first action.
Question 4
A nurse is assessing a client who is receiving magnesium
sulfate for severe preeclampsia. Which finding indicates
magnesium toxicity?
A. Respiratory rate of 14 breaths/min
B. Urinary output of 35 mL/hr
C. Deep tendon reflexes 2+
D. Decreased level of consciousness
Answer: D. Decreased level of consciousness
, Rationale: Magnesium sulfate toxicity affects the central nervous
system, causing decreased level of consciousness, respiratory
depression (less than 12 breaths/min), absent deep tendon
reflexes, and decreased urinary output (less than 30 mL/hr). A
respiratory rate of 14 is within normal limits; urinary output of 35
mL/hr is acceptable; and 2+ reflexes are normal. The earliest sign
of toxicity is often loss of patellar reflexes, followed by respiratory
depression and altered mental status.
Question 5
A nurse is assessing a newborn who was born 6 hours ago to a
client with gestational diabetes. Which finding should the
nurse report to the provider?
A. Blood glucose level of 48 mg/dL
B. Jitteriness and high-pitched cry
C. Apgar scores of 8 at 1 minute and 9 at 5 minutes
D. Birth weight of 8 lb (3,629 g)
Answer: B. Jitteriness and high-pitched cry
Rationale: Infants of diabetic mothers are at risk for
hypoglycemia due to fetal hyperinsulinism. Jitteriness and a high-
pitched cry are signs of neonatal hypoglycemia. A blood glucose
level below 40–45 mg/dL in the first 24 hours is typically
concerning (48 mg/dL is borderline but not critical). Apgar scores
are normal, and a birth weight of 8 lb is within normal range,
though LGA (large for gestational age) is common in infants of
diabetic mothers.
Ultimate Study Guide with Questions and
Verified Answers for 2025/2026 to Ensure
You Pass on the First Try
Question 1
A nurse is assessing a client who is at 35 weeks of gestation
and reports a headache and blurred vision. The client's blood
pressure is 168/102 mm Hg, and urine dipstick reveals 3+
protein. Which action should the nurse take first?
A. Administer labetalol IV push
B. Place the client in a left lateral position
C. Assess deep tendon reflexes
D. Notify the provider immediately
Answer: B. Place the client in a left lateral position
Rationale: The client is showing signs of severe preeclampsia
(severe hypertension, proteinuria, headache, blurred vision). The
priority is to improve uteroplacental perfusion and reduce the risk
of seizures by positioning the client in a left lateral position. This
alleviates pressure on the vena cava, improving cardiac output
and placental blood flow. While administering antihypertensives,
assessing reflexes, and notifying the provider are all important,
positioning is the immediate nursing action to enhance perfusion
and safety.
,Question 2
A nurse is caring for a client in active labor. The client's cervix
is dilated to 7 cm, and the fetal heart rate (FHR) tracing shows
recurrent late decelerations. Which is the priority nursing
intervention?
A. Increase the rate of IV oxytocin
B. Position the client on her left side
C. Prepare for an immediate cesarean birth
D. Administer oxygen at 2 L/min via nasal cannula
Answer: B. Position the client on her left side
Rationale: Late decelerations indicate uteroplacental insufficiency.
The first-line interventions are to increase placental blood flow by
turning the client to the left lateral position, then administering
oxygen at 10 L/min via non-rebreather mask (not 2 L/min), and
increasing IV fluid rate. Oxytocin should be discontinued, not
increased. While a cesarean may be necessary if the pattern does
not resolve, it is not the immediate priority.
Question 3
A nurse is assessing a newborn who is 12 hours old. The nurse
notes jaundice on the face and chest. The mother is Rh-
negative and received Rho(D) immune globulin at 28 weeks.
Which action should the nurse take?
,A. Prepare the newborn for phototherapy
B. Obtain a direct Coombs test result
C. Encourage early and frequent breastfeeding
D. Notify the provider of possible hemolytic disease
Answer: C. Encourage early and frequent breastfeeding
Rationale: Jaundice within the first 24 hours is always abnormal,
but in this scenario, the mother received RhoGAM, which reduces
the risk of Rh incompatibility. Physiologic jaundice typically
appears after 24 hours. Early and frequent feeding helps promote
passage of meconium and reduces enterohepatic circulation,
which can help prevent worsening hyperbilirubinemia. While the
direct Coombs test may have been done at birth, the nurse's initial
action is to support feeding. Phototherapy may be indicated if
bilirubin levels rise, but it is not the first action.
Question 4
A nurse is assessing a client who is receiving magnesium
sulfate for severe preeclampsia. Which finding indicates
magnesium toxicity?
A. Respiratory rate of 14 breaths/min
B. Urinary output of 35 mL/hr
C. Deep tendon reflexes 2+
D. Decreased level of consciousness
Answer: D. Decreased level of consciousness
, Rationale: Magnesium sulfate toxicity affects the central nervous
system, causing decreased level of consciousness, respiratory
depression (less than 12 breaths/min), absent deep tendon
reflexes, and decreased urinary output (less than 30 mL/hr). A
respiratory rate of 14 is within normal limits; urinary output of 35
mL/hr is acceptable; and 2+ reflexes are normal. The earliest sign
of toxicity is often loss of patellar reflexes, followed by respiratory
depression and altered mental status.
Question 5
A nurse is assessing a newborn who was born 6 hours ago to a
client with gestational diabetes. Which finding should the
nurse report to the provider?
A. Blood glucose level of 48 mg/dL
B. Jitteriness and high-pitched cry
C. Apgar scores of 8 at 1 minute and 9 at 5 minutes
D. Birth weight of 8 lb (3,629 g)
Answer: B. Jitteriness and high-pitched cry
Rationale: Infants of diabetic mothers are at risk for
hypoglycemia due to fetal hyperinsulinism. Jitteriness and a high-
pitched cry are signs of neonatal hypoglycemia. A blood glucose
level below 40–45 mg/dL in the first 24 hours is typically
concerning (48 mg/dL is borderline but not critical). Apgar scores
are normal, and a birth weight of 8 lb is within normal range,
though LGA (large for gestational age) is common in infants of
diabetic mothers.
