HESI MATERNITY/PEDS EXAM QUESTIONS AND ANSWERS #1
1. A 3-month-old with myelomeningocele and atonic bladder is catheterized every four hours to
prevent urinary retention. The home health nurse notes that the child has developed episodes of
sneezing, urticaria,, watery eyes, ad a rash in the diaper area. What action is most important for the
nurse to take?: Change to latex - free gloves when handling infant
2. The 6-week-old infant diagnosed with pyloric stenosis has recently devel- oped projectile vomiting.
Which assessment finding indicates to the nurse that the infant is becoming dehydrated?: Crying
without tears
3. A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is
most important for the nurse to implement?: Assess bilateral lung sounds
4. A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500 ML with
magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should be the nurse
program into the infusion pump?: - 75ml/hour
5. A 36-week primigravida is admitted to labor and delivery with severe ab- dominal pain and bright
red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90
beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse
implement first?: Notify healthcare provider at patients' bedside
6. A 39 week gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR)
has remained non- reactive during the 30 minutes of evaluation. Based on this finding, which action
should the nurse implement?-
: Place an acoustic simulator on the abdomen.
7. Artificial rupture of the membranes of a laboring client reveals meconium- stained fluid. What
intervention has the greatest priority?: Have a meconium aspirator available at delivery
8. At 20 weeks gestation, a client who has gained 20 pounds during pregnant states that she is felling
fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her
breasts are leaking clear fluid. Which assessment finding warrants further evaluation?: Gestationa
weight gain.
9. A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment,
the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on
palpation. The nurse knows that these findings are indicative of what condition?: Chorioamnionitis
10.A client at 40-weeks gestation presents to the obstetrical floor and indi- cates that the amniotic
membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down
and push. What information is most important foe the nurse to obtain first?: Color and consistency
of fluid
, HESI MATERNITY/PEDS EXAM QUESTIONS AND ANSWERS #1
11.A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after
the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what
information is most important for the nurse to provide?: Maternal blood pressure
12. A client whose labor is being augmented with an oxytocin (Pitocin) infu- sion requests an
epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical
dilatation, 60% effacement, and a
-2 station. What action should the nurse implement first?: Determine current cervical dilation
13.A community health nurse visits a family in which a 16-year old unmarried daughter is pregnant
with her first child and is at 32 weeks gestation. The client tells the nurse that she has been
intermittent back pain since the night before. What is the priority nursing intervention?: ask the client
if she has experienced any recent changes in vaginal discharge
14.The current vital signs for a primipara who delivered vaginally during the previous shift are:
temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood
pressure 130/74. What action should the nurse implement?: Document vital signs in record (normal)
15.A four-year-old boy was recently diagnosis with Duchenne muscular dys- trophy (DMD). Which
characteristic of the disease is most important for the nurse to focus on during initial teaching?:
Lower legs become progressively weaker, causing a wedding, unsteady gait
16.A full-term 24 hour old infant in the nursery regurgitates and suddenly turns cyanotic. What
should the nurse do first?: Stimulate the infant to cry
17.The healthcare provider prescribes amoxicillin 500 mg PO every eight hours for a child who
weighs 77 pounds. The available suspension is labeled, amoxicillin suspension 250 mg/5 ml. The
recommended maximum does is 50 mg/kg/24 hour. How many ml should the nurse administer in a
single dose based on the child's weight? (enter the numerical value only. If rounding is required,
round to the whole number.): 10ml/dose
18.An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds
the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?:
Determine infants blood sugar level
19.An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. What action should
the nurse implement first?: Place the infant in a knee -chest position
20. Insulin therapy is initiated for a 12 year-old child who is admitted with diabetic ketoacidosis
(DKA). Which action is important for the nurse to include
1. A 3-month-old with myelomeningocele and atonic bladder is catheterized every four hours to
prevent urinary retention. The home health nurse notes that the child has developed episodes of
sneezing, urticaria,, watery eyes, ad a rash in the diaper area. What action is most important for the
nurse to take?: Change to latex - free gloves when handling infant
2. The 6-week-old infant diagnosed with pyloric stenosis has recently devel- oped projectile vomiting.
Which assessment finding indicates to the nurse that the infant is becoming dehydrated?: Crying
without tears
3. A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is
most important for the nurse to implement?: Assess bilateral lung sounds
4. A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500 ML with
magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should be the nurse
program into the infusion pump?: - 75ml/hour
5. A 36-week primigravida is admitted to labor and delivery with severe ab- dominal pain and bright
red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90
beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse
implement first?: Notify healthcare provider at patients' bedside
6. A 39 week gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR)
has remained non- reactive during the 30 minutes of evaluation. Based on this finding, which action
should the nurse implement?-
: Place an acoustic simulator on the abdomen.
7. Artificial rupture of the membranes of a laboring client reveals meconium- stained fluid. What
intervention has the greatest priority?: Have a meconium aspirator available at delivery
8. At 20 weeks gestation, a client who has gained 20 pounds during pregnant states that she is felling
fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her
breasts are leaking clear fluid. Which assessment finding warrants further evaluation?: Gestationa
weight gain.
9. A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment,
the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on
palpation. The nurse knows that these findings are indicative of what condition?: Chorioamnionitis
10.A client at 40-weeks gestation presents to the obstetrical floor and indi- cates that the amniotic
membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down
and push. What information is most important foe the nurse to obtain first?: Color and consistency
of fluid
, HESI MATERNITY/PEDS EXAM QUESTIONS AND ANSWERS #1
11.A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after
the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what
information is most important for the nurse to provide?: Maternal blood pressure
12. A client whose labor is being augmented with an oxytocin (Pitocin) infu- sion requests an
epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical
dilatation, 60% effacement, and a
-2 station. What action should the nurse implement first?: Determine current cervical dilation
13.A community health nurse visits a family in which a 16-year old unmarried daughter is pregnant
with her first child and is at 32 weeks gestation. The client tells the nurse that she has been
intermittent back pain since the night before. What is the priority nursing intervention?: ask the client
if she has experienced any recent changes in vaginal discharge
14.The current vital signs for a primipara who delivered vaginally during the previous shift are:
temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood
pressure 130/74. What action should the nurse implement?: Document vital signs in record (normal)
15.A four-year-old boy was recently diagnosis with Duchenne muscular dys- trophy (DMD). Which
characteristic of the disease is most important for the nurse to focus on during initial teaching?:
Lower legs become progressively weaker, causing a wedding, unsteady gait
16.A full-term 24 hour old infant in the nursery regurgitates and suddenly turns cyanotic. What
should the nurse do first?: Stimulate the infant to cry
17.The healthcare provider prescribes amoxicillin 500 mg PO every eight hours for a child who
weighs 77 pounds. The available suspension is labeled, amoxicillin suspension 250 mg/5 ml. The
recommended maximum does is 50 mg/kg/24 hour. How many ml should the nurse administer in a
single dose based on the child's weight? (enter the numerical value only. If rounding is required,
round to the whole number.): 10ml/dose
18.An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds
the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take?:
Determine infants blood sugar level
19.An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. What action should
the nurse implement first?: Place the infant in a knee -chest position
20. Insulin therapy is initiated for a 12 year-old child who is admitted with diabetic ketoacidosis
(DKA). Which action is important for the nurse to include
