Maternal/Pediatric HESI practice
A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on
knowledge of the statistics related to infant mortality, which plan should the nurse implement
with this client?
a. refer to client to a social worker to arrange for home care.
b. recommend perinatal care for an obstetrician, not a nurse-midwife
c. teach the client why keeping prenatal care appointments is important. - ANS-C
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back,
and abdomen. What action should the nurse implement?
a. notify the healthcare provider
b. move the newborn to an isolation nursery
c. document the finding in the infant's record.
d. obtain a culture of the vesicles - ANS-C
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in
preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to
stop her labor contractions. The nurse plans to monitor for which primary side effect of
terbutaline sulfate?
a. drowsiness and bradycardia
b. depressed reflexes and increased respirations
c. tachycardia and a feeling of nervousness.
d. a flushed, warm feeling and a dry mouth - ANS-C
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in
preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is
the highest priority for the nurse to monitor during the administration of this drug?
a. maternal blood pressure and respirations
b. maternal and fetal heart rates
c. hourly urinary output
d. deep tendon reflexes - ANS-B
A 30-year-old multiparous woman who has a 3-year-old boy and a newborn girl tells the nurse,
"My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get
home." How should the nurse respond?
a. "Tell the older child that he is a big boy now and should love his new sister."
b. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to
spoil him."
c. "Let the older child stay with his grandparents for the first six weeks to allow him to adjust to
the newborn."
d. "Regression in behaviors in the older child is a typical reaction so he needs attention at this
time." - ANS-D
, A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data would indicate to the nurse that the client is
experiencing magnesium sulfate toxicity?
a. deep tendon reflexes 2+
b. blood pressure 140/90
c. respiratory rate 18/minute
d. urine output 90 mL/4 hours - ANS-D
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells
the nurse that her feet have begun to swell. Which instruction would be most effective in
preventing pooling of blood in the lower extremities?
a. wearing support stockings
b. reduce salt in her diet
c. move about every hour
d. avoid constrictive clothing - ANS-C
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) fro the last three
weeks. Which assessment finding indicates to the nurse that the drug is effective?
a. slowly increasing urinary output over the last week
b. respiratory rate changes from the 40s to the 60s
c. changes in apical heart rate from the 180s to the 140s
d. change in indirect bilirubin from 12 mg/dL to 8 mg/dL - ANS-C
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she
is not experiencing any uterine contractions or abdominal pain. What instruction should the
nurse provide?
a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops.
d. bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection -
ANS-A
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for
observation. She is contracting irregularly and demonstrates underlying uterine irritability.
Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data,
which intervention should the nurse implement first?
a. provide oral hydration
b. have a complete blood count drawn
c. obtain a specimen for urine analysis
d. place the client on strict bedrest - ANS-C
A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion?
a. 3+ deep tendon reflexes.
b. periorbital edema
c. epigastric pain
d. decreased urine output - ANS-C
A 23-year-old client who is receiving Medicaid benefits is pregnant with her first child. Based on
knowledge of the statistics related to infant mortality, which plan should the nurse implement
with this client?
a. refer to client to a social worker to arrange for home care.
b. recommend perinatal care for an obstetrician, not a nurse-midwife
c. teach the client why keeping prenatal care appointments is important. - ANS-C
A 24-hour-old newborn has a pink papular rash with vesicles superimposed on the thorax, back,
and abdomen. What action should the nurse implement?
a. notify the healthcare provider
b. move the newborn to an isolation nursery
c. document the finding in the infant's record.
d. obtain a culture of the vesicles - ANS-C
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in
preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to
stop her labor contractions. The nurse plans to monitor for which primary side effect of
terbutaline sulfate?
a. drowsiness and bradycardia
b. depressed reflexes and increased respirations
c. tachycardia and a feeling of nervousness.
d. a flushed, warm feeling and a dry mouth - ANS-C
A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks gestation in
preterm labor. She is started on an IV solution of terbutaline (Brethine). Which assessment is
the highest priority for the nurse to monitor during the administration of this drug?
a. maternal blood pressure and respirations
b. maternal and fetal heart rates
c. hourly urinary output
d. deep tendon reflexes - ANS-B
A 30-year-old multiparous woman who has a 3-year-old boy and a newborn girl tells the nurse,
"My son is so jealous of my daughter, I don't know how I'll ever manage both children when I get
home." How should the nurse respond?
a. "Tell the older child that he is a big boy now and should love his new sister."
b. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to
spoil him."
c. "Let the older child stay with his grandparents for the first six weeks to allow him to adjust to
the newborn."
d. "Regression in behaviors in the older child is a typical reaction so he needs attention at this
time." - ANS-D
, A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data would indicate to the nurse that the client is
experiencing magnesium sulfate toxicity?
a. deep tendon reflexes 2+
b. blood pressure 140/90
c. respiratory rate 18/minute
d. urine output 90 mL/4 hours - ANS-D
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells
the nurse that her feet have begun to swell. Which instruction would be most effective in
preventing pooling of blood in the lower extremities?
a. wearing support stockings
b. reduce salt in her diet
c. move about every hour
d. avoid constrictive clothing - ANS-C
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) fro the last three
weeks. Which assessment finding indicates to the nurse that the drug is effective?
a. slowly increasing urinary output over the last week
b. respiratory rate changes from the 40s to the 60s
c. changes in apical heart rate from the 180s to the 140s
d. change in indirect bilirubin from 12 mg/dL to 8 mg/dL - ANS-C
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she
is not experiencing any uterine contractions or abdominal pain. What instruction should the
nurse provide?
a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops.
d. bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection -
ANS-A
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for
observation. She is contracting irregularly and demonstrates underlying uterine irritability.
Vaginal examination reveals that her cervix is closed, thick, and high. Based on these data,
which intervention should the nurse implement first?
a. provide oral hydration
b. have a complete blood count drawn
c. obtain a specimen for urine analysis
d. place the client on strict bedrest - ANS-C
A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion?
a. 3+ deep tendon reflexes.
b. periorbital edema
c. epigastric pain
d. decreased urine output - ANS-C
