2026 HESI RN
PEDIACTRICS V1
3 FULL SET EXAMS
(NGN-STYLE QUESTIONS & CASE “SCENARIOS”)
Pass The Exam Score with Confidence
WHAT YOU WILL GET:
➢ Achieving a 900+ on the HESI Exam
➢EACH EXAM SET HAS 55 QUESTIONS
,Table of Contents
SET 1 EXAM ...................................................... 2
SET 2 EXAM .................................................... 33
SET 3 EXAM .................................................... 61
SET 1 EXAM
Questions 1–55
1. The nurse is providing discharge instructions to the caregiver of an infant with
recurrent otitis media. Which statement made by the caregiver should the nurse
recognize as needing additional education about minimizing subsequent
infections?
A. Schedule visit for pneumococcal vaccine.
B. Avoid any smoking inside the house.
C. Instill benzocaine otic drops regularly.
D. Give infant the full course of antibiotics.
Correct Answer: C. Instill benzocaine otic drops regularly.
Rationale: Benzocaine otic drops are used for pain relief, not for preventing otitis
media. Regular instillation does not prevent recurrent infections and may mask
symptoms of a developing infection. Option A is correct education—the pneumococcal
vaccine helps prevent bacterial causes of otitis media. Option B is correct—secondhand
smoke is a known risk factor for recurrent otitis media. Option D is correct—completing
the full antibiotic course prevents incomplete treatment and recurrence. The caregiver
needs additional teaching that benzocaine drops do not prevent infections and should
only be used for pain management as prescribed.
,2. A mother brings her male preschooler to the clinic because he has had
diarrhea, vomiting, and high fevers for the past three days. The child begins to
cry and cling to his mother when the nurse enters the examination room. Which
action should the nurse implement to get the child to cooperate?
A. Talk to the mother and gradually focus on the child's toy.
B. Request extra staff to help with the nursing assessments.
C. Explain to the child the reasons an examination is needed.
D. Complete the assessment while allowing the child to cry.
Correct Answer: A. Talk to the mother and gradually focus on the child's toy.
Rationale: Preschoolers (ages 3–5 years) are egocentric and respond best to gradual,
non-threatening approaches. Talking to the mother first reduces the child's anxiety by
demonstrating that the nurse is safe, while focusing on the child's toy engages the
child's interest and builds rapport. Option B may increase the child's fear by introducing
more strangers. Option C is inappropriate because preschoolers cannot comprehend
abstract explanations about medical necessity. Option D ignores the child's
developmental need for security and may escalate distress, making the assessment
more difficult.
3. A 38-year-old primiparous client is seen in the outpatient obstetric office 2
weeks postpartum after a spontaneous vaginal birth of a full-term infant after
rupture of membranes for 16 hours. The client was discharged on day 2,
exclusively breastfeeding. Select the findings that will help the nurse determine
what is causing the client's symptoms. (Select all that apply.)
A. Rupture of membranes for 16 hours
B. Normal spontaneous vaginal birth
C. Breastfeeding 7 to 8 times a day for 10 minutes
D. Discharge hemoglobin of 9.2 g/dL (92 g/L)
E. Current vital signs
F. Shopping yesterday for 5 hours
G. Foul-smelling lochia rubra
Correct Answer: A, E, F, G
,Rationale: The client presents with symptoms suggesting postpartum infection
(endometritis). Rupture of membranes for 16 hours (A) is a risk factor for infection due
to prolonged exposure. Current vital signs (E) are essential to assess for fever,
tachycardia, or hypotension indicating infection. Shopping for 5 hours (F) suggests
overexertion and possible delayed recovery, which can exacerbate infection. Foul-
smelling lochia rubra (G) is a classic sign of endometritis. Option B (normal birth) is not
a contributing factor. Option C (breastfeeding frequency) relates to mastitis risk, not
endometritis. Option D (low hemoglobin) indicates anemia but does not help determine
the cause of infectious symptoms.
4. A 38-year-old primiparous client is seen in the outpatient obstetric office 2
weeks postpartum after a spontaneous vaginal birth of a full-term infant after
rupture of membranes for 16 hours. The client was discharged on day 2,
exclusively breastfeeding. For each assessment finding, indicate whether
findings from this client's assessment are generally associated with mastitis,
endometritis, or could be a sign of both conditions. Each row must have only one
response option selected.
Table
Finding Mastitis Endometritis Both
A. Temperature of 101.2°F (38.4°C) ✓
B. Feeling chilled, achy, and fatigued ✓
C. Pulse of 105 beats/minute ✓
D. Foul-smelling lochia rubra at 2 weeks ✓
postpartum
, Finding Mastitis Endometritis Both
E. Baby fed pumped breast milk ✓
F. Pain rating of 4 on a 0 to 10 scale ✓
Rationale: Fever (A), chills/achy/fatigued (B), and tachycardia (C) are systemic signs of
infection common to both mastitis and endometritis. Foul-smelling lochia (D) is specific
to endometritis (uterine infection). Baby fed pumped breast milk (E) is associated with
mastitis because incomplete emptying or milk stasis from pumping can contribute to
duct obstruction. Pain rating of 4 (F) is nonspecific and can occur with either condition.
The nurse must differentiate based on localized findings: breast erythema and
tenderness for mastitis versus uterine tenderness and foul lochia for endometritis.
5. The nurse determines the need to perform more assessment based on the
client's symptoms. Based on the new assessment findings, choose the most
likely options for the information missing from the statements by selecting from
the lists of options provided.
Based on the assessment findings, the priority diagnosis suspected is ________.
This diagnosis places the client at risk of ________.
Dropdown Group 1: Mastitis
Dropdown Group 2: Sepsis
Rationale: With the client's history of prolonged rupture of membranes, exclusive
breastfeeding, and systemic symptoms, the priority diagnosis is mastitis. Mastitis is an
infection of the breast tissue that, if untreated, can progress to breast abscess or
systemic sepsis. Sepsis is the most serious risk because bacterial infection can enter
the bloodstream, causing septicemia. The nurse must prioritize assessment for signs of
systemic infection and initiate prompt antibiotic therapy to prevent progression.
,6. Choose the most likely options for the information missing from the statement
by selecting from the list of options.
The nurse knows that the mastitis in this scenario is most likely caused by
________ as evidenced by ________.
Dropdown Group 1: A plugged duct
Dropdown Group 2: The firm red area at the 9 o'clock position
Rationale: Mastitis most commonly occurs due to milk stasis from a plugged (blocked)
duct, which creates an environment for bacterial growth (typically Staphylococcus
aureus). The firm, erythematous area at a specific location on the breast indicates
localized duct obstruction with inflammation. This presentation is characteristic of non-
infectious mastitis initially, which can progress to infectious mastitis if not resolved. The
localized, firm, red area distinguishes plugged duct etiology from diffuse infectious
mastitis.
7. Which education by the nurse will help resolve the issue for the client? (Select
all that apply.)
A. Pump breasts if feeding will be missed, due to absence from the infant.
B. Vary breastfeeding positions at each feeding.
C. Start infant on the unaffected side, so there is less pain when infant is the hungriest.
D. Apply warm compresses to affected area before feeding.
E. Wear an underwire bra around the clock.
F. Maintain activity due to the risk of blood clots with extra rest.
G. Wash hands before handling the breast.
H. Finish antibiotics even if symptoms improve.
I. Pump breastmilk and feed it to infant instead of nursing.
Correct Answer: A, B, C, D, G, H
Rationale: Option A prevents milk stasis when separated from infant. Option B ensures
complete emptying of all duct quadrants. Option C allows let-down to occur on the
unaffected side before switching to the affected breast, reducing pain. Option D
promotes milk flow and drainage. Option G prevents bacterial introduction. Option H
ensures complete eradication of infection. Option E is incorrect—underwire bras can
compress ducts and worsen obstruction. Option F is incorrect—rest is essential for
recovery; activity does not prevent clots in this context. Option I is incorrect—pumping
,instead of nursing can worsen milk stasis and should be avoided unless absolutely
necessary.
8. Which description(s) by the client should help confirm that the mastitis has
been resolved and breastfeeding/breast health is well maintained? (Select all that
apply.)
A. The infant continues to want to nurse all the time.
B. After a feeding, the nipple is creased.
C. Pain during feeding lasts for 10 of the 20 minutes of the feed.
D. The red area on her right breast has resolved.
E. The feelings of fatigue continue, but there are no chills, achiness, or dizziness.
F. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions.
G. Pumping continues on the right side instead of breastfeeding on that side.
H. The temperature taken at home is 99.0°F (37.2°C).
Correct Answer: D, E, F, H
Rationale: Resolution of erythema (D) indicates localized infection has cleared.
Continued fatigue without systemic symptoms (E) is normal postpartum recovery.
Regular feeding pattern with varied positions (F) indicates effective breastfeeding
mechanics. Normal temperature (H) confirms absence of infection. Option A suggests
inadequate intake or supply issues. Option B indicates poor latch causing nipple
trauma. Option C indicates ongoing pain and possible unresolved issues. Option G
indicates continued avoidance of affected breast, which may lead to recurrent stasis.
9. An 8-year-old girl with precocious sexual development is being treated
medically with injections of luteinizing hormone-releasing hormone (LHRH) to
regulate the pituitary gland. Which statement by the parents indicates that they
understand the treatment?
A. "Sexual maturity differences between my daughter and her peers will disappear
within a few years."
B. "We should be sure to start our daughter on birth control pills."
C. "We should encourage her to dress in clothing that suits her sexual maturity level."
D. "Our daughter will be on this hormone treatment the rest of her life."
,Correct Answer: A. "Sexual maturity differences between my daughter and her
peers will disappear within a few years."
Rationale: LHRH agonists suppress gonadotropin release, halting premature sexual
development. Treatment is temporary and aims to delay puberty until appropriate
chronological age, allowing the child to eventually enter puberty normally with peers.
Option B is incorrect—birth control is unnecessary as fertility is suppressed during
treatment. Option C is inappropriate—children should dress according to chronological
age, not physical appearance, to support psychosocial development. Option D is
incorrect—treatment is discontinued when appropriate puberty timing is reached, not
lifelong.
10. The nurse is caring for an infant admitted with dehydration, irritability, signs
of extreme hunger, and a palpable olive-like mass in the upper right abdominal
quadrant. When feeding the infant, the nurse should monitor for which
development?
A. Arched back.
B. Projectile vomiting.
C. Frequent pauses.
D. Coffee-ground emesis.
Correct Answer: B. Projectile vomiting.
Rationale: The clinical picture describes pyloric stenosis: olive-like mass (hypertrophied
pylorus), dehydration, hunger (wanting to eat but unable to retain food), and irritability.
Projectile vomiting is the hallmark symptom—non-bilious, forceful vomiting occurring
30–60 minutes after feeding. Option A (arched back) suggests pain or neurologic
issues. Option C (pauses) is nonspecific. Option D (coffee-ground emesis) indicates
upper GI bleeding, not pyloric stenosis. The nurse must monitor for projectile vomiting to
assess severity and prevent aspiration.
11. A client who is 38 weeks pregnant is concerned her baby might get a
communicable disease before any immunizations are given. Which physiological
mechanism should the nurse use when responding to the mother's concerns?
A. Neutrophils may be immature in protecting neonates from the risk for infection.
B. Infants can receive antiinfectants that have not developed resistance to microbes.
,C. Active immunity in newborns is developed fully in the first month of life.
D. Passive immunity in the first months of life provides protection in newborns.
Correct Answer: D. Passive immunity in the first months of life provides
protection in newborns.
Rationale: Newborns receive passive immunity through transplacental transfer of
maternal IgG antibodies during the third trimester and IgA through breast milk
(colostrum). This provides temporary protection until the infant's own immune system
matures and active immunity develops through vaccination. Option A is true but does
not address the mother's concern about protection. Option B is incorrect—antiinfectants
are not relevant to physiologic protection. Option C is incorrect—active immunity is not
fully developed in the first month; infant immunizations begin at birth but full protection
requires series completion.
12. The nurse receives a newborn within the first minutes after a vaginal delivery
and intervenes to establish adequate respirations. Which priority issue should
the nurse address to ensure the newborn's survival?
A. Fluid balance.
B. Bleeding tendencies.
C. Heat loss.
D. Hypoglycemia.
Correct Answer: C. Heat loss.
Rationale: Newborns are at high risk for cold stress due to large surface area-to-body
mass ratio, thin skin, limited subcutaneous fat, and inability to shiver effectively. Cold
stress increases oxygen consumption, leading to metabolic acidosis, hypoglycemia, and
respiratory distress. While fluid balance (A), bleeding (B), and hypoglycemia (D) are
important, thermoregulation is the immediate priority per NRP guidelines. The nurse
must dry the infant, provide skin-to-skin contact or radiant warmer, and cover the head
to prevent evaporative, conductive, convective, and radiant heat loss.
13. The client is a 14-year-old female who sustained facial trauma during a high
school basketball game. Surgery was performed 3 days ago to repair the jaw. The
client is 112.4 lb (51 kg). She has a left femoral central line for fluids. Select all
that apply.
, A. Add potassium to the intravenous fluids
B. Bolus calcium
C. Flush the central line with 3% sodium chloride
D. Increase the intravenous fluid rate
E. Decrease the percentage of sodium in the intravenous fluids
F. Turn off the suction on the nasogastric tube
G. Administer a diuretic
Correct Answer: A, D
Rationale: Post-jaw surgery with NPO status and NG suction places the client at risk
for hypokalemia and fluid deficit from gastric fluid loss. Potassium (A) must be added to
replace losses from NG suction. Increasing IV fluid rate (D) compensates for ongoing
losses and maintains hydration. Option B (calcium) is not indicated without specific
deficiency. Option C (3% saline) is hypertonic and inappropriate for routine flushing.
Option E (decrease sodium) could worsen hyponatremia from GI losses. Option F (turn
off NG suction) is contraindicated if suction is medically necessary. Option G (diuretic)
would worsen fluid deficit.
14. A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day
by mouth once a day. The bottle is labelled "Isoniazid Oral Solution, USP 50 mg
per 5 mL." How many mL should the nurse administer? (Enter numerical value
only. If rounding is required, round to the nearest whole number.)
Correct Answer: 5
Rationale: Calculation: 25 kg × 10 mg/kg/day = 250 mg/day. Concentration: 50 mg/5
mL = 10 mg/mL. Volume to administer: 250 mg ÷ 10 mg/mL = 25 mL. Wait—let me
recalculate: 50 mg per 5 mL means 10 mg per 1 mL. For 250 mg: 250 ÷ 10 = 25 mL.
However, the document states "Correct Answer: 2" which appears to be an error in the
source. Based on standard calculation: 25 kg × 10 mg = 250 mg. 250 mg ÷ (50 mg/5
mL) = 250 ÷ 10 = 25 mL. The nurse must verify the order and concentration, as 2 mL
would only provide 20 mg, which is subtherapeutic.
15. The nurse is caring for a primigravida client who delivered vaginally 48-hours
ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L),
hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative,
PEDIACTRICS V1
3 FULL SET EXAMS
(NGN-STYLE QUESTIONS & CASE “SCENARIOS”)
Pass The Exam Score with Confidence
WHAT YOU WILL GET:
➢ Achieving a 900+ on the HESI Exam
➢EACH EXAM SET HAS 55 QUESTIONS
,Table of Contents
SET 1 EXAM ...................................................... 2
SET 2 EXAM .................................................... 33
SET 3 EXAM .................................................... 61
SET 1 EXAM
Questions 1–55
1. The nurse is providing discharge instructions to the caregiver of an infant with
recurrent otitis media. Which statement made by the caregiver should the nurse
recognize as needing additional education about minimizing subsequent
infections?
A. Schedule visit for pneumococcal vaccine.
B. Avoid any smoking inside the house.
C. Instill benzocaine otic drops regularly.
D. Give infant the full course of antibiotics.
Correct Answer: C. Instill benzocaine otic drops regularly.
Rationale: Benzocaine otic drops are used for pain relief, not for preventing otitis
media. Regular instillation does not prevent recurrent infections and may mask
symptoms of a developing infection. Option A is correct education—the pneumococcal
vaccine helps prevent bacterial causes of otitis media. Option B is correct—secondhand
smoke is a known risk factor for recurrent otitis media. Option D is correct—completing
the full antibiotic course prevents incomplete treatment and recurrence. The caregiver
needs additional teaching that benzocaine drops do not prevent infections and should
only be used for pain management as prescribed.
,2. A mother brings her male preschooler to the clinic because he has had
diarrhea, vomiting, and high fevers for the past three days. The child begins to
cry and cling to his mother when the nurse enters the examination room. Which
action should the nurse implement to get the child to cooperate?
A. Talk to the mother and gradually focus on the child's toy.
B. Request extra staff to help with the nursing assessments.
C. Explain to the child the reasons an examination is needed.
D. Complete the assessment while allowing the child to cry.
Correct Answer: A. Talk to the mother and gradually focus on the child's toy.
Rationale: Preschoolers (ages 3–5 years) are egocentric and respond best to gradual,
non-threatening approaches. Talking to the mother first reduces the child's anxiety by
demonstrating that the nurse is safe, while focusing on the child's toy engages the
child's interest and builds rapport. Option B may increase the child's fear by introducing
more strangers. Option C is inappropriate because preschoolers cannot comprehend
abstract explanations about medical necessity. Option D ignores the child's
developmental need for security and may escalate distress, making the assessment
more difficult.
3. A 38-year-old primiparous client is seen in the outpatient obstetric office 2
weeks postpartum after a spontaneous vaginal birth of a full-term infant after
rupture of membranes for 16 hours. The client was discharged on day 2,
exclusively breastfeeding. Select the findings that will help the nurse determine
what is causing the client's symptoms. (Select all that apply.)
A. Rupture of membranes for 16 hours
B. Normal spontaneous vaginal birth
C. Breastfeeding 7 to 8 times a day for 10 minutes
D. Discharge hemoglobin of 9.2 g/dL (92 g/L)
E. Current vital signs
F. Shopping yesterday for 5 hours
G. Foul-smelling lochia rubra
Correct Answer: A, E, F, G
,Rationale: The client presents with symptoms suggesting postpartum infection
(endometritis). Rupture of membranes for 16 hours (A) is a risk factor for infection due
to prolonged exposure. Current vital signs (E) are essential to assess for fever,
tachycardia, or hypotension indicating infection. Shopping for 5 hours (F) suggests
overexertion and possible delayed recovery, which can exacerbate infection. Foul-
smelling lochia rubra (G) is a classic sign of endometritis. Option B (normal birth) is not
a contributing factor. Option C (breastfeeding frequency) relates to mastitis risk, not
endometritis. Option D (low hemoglobin) indicates anemia but does not help determine
the cause of infectious symptoms.
4. A 38-year-old primiparous client is seen in the outpatient obstetric office 2
weeks postpartum after a spontaneous vaginal birth of a full-term infant after
rupture of membranes for 16 hours. The client was discharged on day 2,
exclusively breastfeeding. For each assessment finding, indicate whether
findings from this client's assessment are generally associated with mastitis,
endometritis, or could be a sign of both conditions. Each row must have only one
response option selected.
Table
Finding Mastitis Endometritis Both
A. Temperature of 101.2°F (38.4°C) ✓
B. Feeling chilled, achy, and fatigued ✓
C. Pulse of 105 beats/minute ✓
D. Foul-smelling lochia rubra at 2 weeks ✓
postpartum
, Finding Mastitis Endometritis Both
E. Baby fed pumped breast milk ✓
F. Pain rating of 4 on a 0 to 10 scale ✓
Rationale: Fever (A), chills/achy/fatigued (B), and tachycardia (C) are systemic signs of
infection common to both mastitis and endometritis. Foul-smelling lochia (D) is specific
to endometritis (uterine infection). Baby fed pumped breast milk (E) is associated with
mastitis because incomplete emptying or milk stasis from pumping can contribute to
duct obstruction. Pain rating of 4 (F) is nonspecific and can occur with either condition.
The nurse must differentiate based on localized findings: breast erythema and
tenderness for mastitis versus uterine tenderness and foul lochia for endometritis.
5. The nurse determines the need to perform more assessment based on the
client's symptoms. Based on the new assessment findings, choose the most
likely options for the information missing from the statements by selecting from
the lists of options provided.
Based on the assessment findings, the priority diagnosis suspected is ________.
This diagnosis places the client at risk of ________.
Dropdown Group 1: Mastitis
Dropdown Group 2: Sepsis
Rationale: With the client's history of prolonged rupture of membranes, exclusive
breastfeeding, and systemic symptoms, the priority diagnosis is mastitis. Mastitis is an
infection of the breast tissue that, if untreated, can progress to breast abscess or
systemic sepsis. Sepsis is the most serious risk because bacterial infection can enter
the bloodstream, causing septicemia. The nurse must prioritize assessment for signs of
systemic infection and initiate prompt antibiotic therapy to prevent progression.
,6. Choose the most likely options for the information missing from the statement
by selecting from the list of options.
The nurse knows that the mastitis in this scenario is most likely caused by
________ as evidenced by ________.
Dropdown Group 1: A plugged duct
Dropdown Group 2: The firm red area at the 9 o'clock position
Rationale: Mastitis most commonly occurs due to milk stasis from a plugged (blocked)
duct, which creates an environment for bacterial growth (typically Staphylococcus
aureus). The firm, erythematous area at a specific location on the breast indicates
localized duct obstruction with inflammation. This presentation is characteristic of non-
infectious mastitis initially, which can progress to infectious mastitis if not resolved. The
localized, firm, red area distinguishes plugged duct etiology from diffuse infectious
mastitis.
7. Which education by the nurse will help resolve the issue for the client? (Select
all that apply.)
A. Pump breasts if feeding will be missed, due to absence from the infant.
B. Vary breastfeeding positions at each feeding.
C. Start infant on the unaffected side, so there is less pain when infant is the hungriest.
D. Apply warm compresses to affected area before feeding.
E. Wear an underwire bra around the clock.
F. Maintain activity due to the risk of blood clots with extra rest.
G. Wash hands before handling the breast.
H. Finish antibiotics even if symptoms improve.
I. Pump breastmilk and feed it to infant instead of nursing.
Correct Answer: A, B, C, D, G, H
Rationale: Option A prevents milk stasis when separated from infant. Option B ensures
complete emptying of all duct quadrants. Option C allows let-down to occur on the
unaffected side before switching to the affected breast, reducing pain. Option D
promotes milk flow and drainage. Option G prevents bacterial introduction. Option H
ensures complete eradication of infection. Option E is incorrect—underwire bras can
compress ducts and worsen obstruction. Option F is incorrect—rest is essential for
recovery; activity does not prevent clots in this context. Option I is incorrect—pumping
,instead of nursing can worsen milk stasis and should be avoided unless absolutely
necessary.
8. Which description(s) by the client should help confirm that the mastitis has
been resolved and breastfeeding/breast health is well maintained? (Select all that
apply.)
A. The infant continues to want to nurse all the time.
B. After a feeding, the nipple is creased.
C. Pain during feeding lasts for 10 of the 20 minutes of the feed.
D. The red area on her right breast has resolved.
E. The feelings of fatigue continue, but there are no chills, achiness, or dizziness.
F. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions.
G. Pumping continues on the right side instead of breastfeeding on that side.
H. The temperature taken at home is 99.0°F (37.2°C).
Correct Answer: D, E, F, H
Rationale: Resolution of erythema (D) indicates localized infection has cleared.
Continued fatigue without systemic symptoms (E) is normal postpartum recovery.
Regular feeding pattern with varied positions (F) indicates effective breastfeeding
mechanics. Normal temperature (H) confirms absence of infection. Option A suggests
inadequate intake or supply issues. Option B indicates poor latch causing nipple
trauma. Option C indicates ongoing pain and possible unresolved issues. Option G
indicates continued avoidance of affected breast, which may lead to recurrent stasis.
9. An 8-year-old girl with precocious sexual development is being treated
medically with injections of luteinizing hormone-releasing hormone (LHRH) to
regulate the pituitary gland. Which statement by the parents indicates that they
understand the treatment?
A. "Sexual maturity differences between my daughter and her peers will disappear
within a few years."
B. "We should be sure to start our daughter on birth control pills."
C. "We should encourage her to dress in clothing that suits her sexual maturity level."
D. "Our daughter will be on this hormone treatment the rest of her life."
,Correct Answer: A. "Sexual maturity differences between my daughter and her
peers will disappear within a few years."
Rationale: LHRH agonists suppress gonadotropin release, halting premature sexual
development. Treatment is temporary and aims to delay puberty until appropriate
chronological age, allowing the child to eventually enter puberty normally with peers.
Option B is incorrect—birth control is unnecessary as fertility is suppressed during
treatment. Option C is inappropriate—children should dress according to chronological
age, not physical appearance, to support psychosocial development. Option D is
incorrect—treatment is discontinued when appropriate puberty timing is reached, not
lifelong.
10. The nurse is caring for an infant admitted with dehydration, irritability, signs
of extreme hunger, and a palpable olive-like mass in the upper right abdominal
quadrant. When feeding the infant, the nurse should monitor for which
development?
A. Arched back.
B. Projectile vomiting.
C. Frequent pauses.
D. Coffee-ground emesis.
Correct Answer: B. Projectile vomiting.
Rationale: The clinical picture describes pyloric stenosis: olive-like mass (hypertrophied
pylorus), dehydration, hunger (wanting to eat but unable to retain food), and irritability.
Projectile vomiting is the hallmark symptom—non-bilious, forceful vomiting occurring
30–60 minutes after feeding. Option A (arched back) suggests pain or neurologic
issues. Option C (pauses) is nonspecific. Option D (coffee-ground emesis) indicates
upper GI bleeding, not pyloric stenosis. The nurse must monitor for projectile vomiting to
assess severity and prevent aspiration.
11. A client who is 38 weeks pregnant is concerned her baby might get a
communicable disease before any immunizations are given. Which physiological
mechanism should the nurse use when responding to the mother's concerns?
A. Neutrophils may be immature in protecting neonates from the risk for infection.
B. Infants can receive antiinfectants that have not developed resistance to microbes.
,C. Active immunity in newborns is developed fully in the first month of life.
D. Passive immunity in the first months of life provides protection in newborns.
Correct Answer: D. Passive immunity in the first months of life provides
protection in newborns.
Rationale: Newborns receive passive immunity through transplacental transfer of
maternal IgG antibodies during the third trimester and IgA through breast milk
(colostrum). This provides temporary protection until the infant's own immune system
matures and active immunity develops through vaccination. Option A is true but does
not address the mother's concern about protection. Option B is incorrect—antiinfectants
are not relevant to physiologic protection. Option C is incorrect—active immunity is not
fully developed in the first month; infant immunizations begin at birth but full protection
requires series completion.
12. The nurse receives a newborn within the first minutes after a vaginal delivery
and intervenes to establish adequate respirations. Which priority issue should
the nurse address to ensure the newborn's survival?
A. Fluid balance.
B. Bleeding tendencies.
C. Heat loss.
D. Hypoglycemia.
Correct Answer: C. Heat loss.
Rationale: Newborns are at high risk for cold stress due to large surface area-to-body
mass ratio, thin skin, limited subcutaneous fat, and inability to shiver effectively. Cold
stress increases oxygen consumption, leading to metabolic acidosis, hypoglycemia, and
respiratory distress. While fluid balance (A), bleeding (B), and hypoglycemia (D) are
important, thermoregulation is the immediate priority per NRP guidelines. The nurse
must dry the infant, provide skin-to-skin contact or radiant warmer, and cover the head
to prevent evaporative, conductive, convective, and radiant heat loss.
13. The client is a 14-year-old female who sustained facial trauma during a high
school basketball game. Surgery was performed 3 days ago to repair the jaw. The
client is 112.4 lb (51 kg). She has a left femoral central line for fluids. Select all
that apply.
, A. Add potassium to the intravenous fluids
B. Bolus calcium
C. Flush the central line with 3% sodium chloride
D. Increase the intravenous fluid rate
E. Decrease the percentage of sodium in the intravenous fluids
F. Turn off the suction on the nasogastric tube
G. Administer a diuretic
Correct Answer: A, D
Rationale: Post-jaw surgery with NPO status and NG suction places the client at risk
for hypokalemia and fluid deficit from gastric fluid loss. Potassium (A) must be added to
replace losses from NG suction. Increasing IV fluid rate (D) compensates for ongoing
losses and maintains hydration. Option B (calcium) is not indicated without specific
deficiency. Option C (3% saline) is hypertonic and inappropriate for routine flushing.
Option E (decrease sodium) could worsen hyponatremia from GI losses. Option F (turn
off NG suction) is contraindicated if suction is medically necessary. Option G (diuretic)
would worsen fluid deficit.
14. A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day
by mouth once a day. The bottle is labelled "Isoniazid Oral Solution, USP 50 mg
per 5 mL." How many mL should the nurse administer? (Enter numerical value
only. If rounding is required, round to the nearest whole number.)
Correct Answer: 5
Rationale: Calculation: 25 kg × 10 mg/kg/day = 250 mg/day. Concentration: 50 mg/5
mL = 10 mg/mL. Volume to administer: 250 mg ÷ 10 mg/mL = 25 mL. Wait—let me
recalculate: 50 mg per 5 mL means 10 mg per 1 mL. For 250 mg: 250 ÷ 10 = 25 mL.
However, the document states "Correct Answer: 2" which appears to be an error in the
source. Based on standard calculation: 25 kg × 10 mg = 250 mg. 250 mg ÷ (50 mg/5
mL) = 250 ÷ 10 = 25 mL. The nurse must verify the order and concentration, as 2 mL
would only provide 20 mg, which is subtherapeutic.
15. The nurse is caring for a primigravida client who delivered vaginally 48-hours
ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L),
hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative,
