HESI
MATERNITY/
PEDIATRICS
(PEDS) EXAM,
ANSWERED
,HESI Maternity/Pediatrics (PEDS) Exam,
Answered
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
The 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile
vomiting. Which assessment finding indicates to the nurse that the infant is becoming
dehydrated?
- Crying without tears
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
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
A 36-week primigravida is admitted to labor and delivery with severe abdominal 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
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.
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
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?
- Gestational weight gain.
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
A client at 40-weeks gestation presents to the obstetrical floor and indicates 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
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
A client whose alabor ais abeing aaugmented awith aan aoxytocin a(Pitocin) ainfusion
arequests aan aepidural afor apain acontrol. aFindings aof athe alast avaginal aexam, aperformed
a1 ahour aago, awere a3 acm acervical adilatation, a60% aeffacement, aand aa a-2 astation. aWhat
aaction ashould athe anurse aimplement afirst?
o- aDetermine acurrent acervical adilation
A acommunity ahealth anurse avisits aa afamily ain awhich aa a16-year aold aunmarried
adaughter ais apregnant awith aher afirst achild aand ais aat a32 aweeks agestation. aThe aclient
atells athe anurse athat ashe ahas abeen aintermittent aback apain asince athe anight abefore.
aWhat ais athe apriority anursing aintervention?
- ask athe aclient aif ashe ahas aexperienced aany arecent achanges ain avaginal adischarge
The acurrent avital asigns afor aa aprimipara awho adelivered avaginally aduring athe aprevious
ashift aare: atemperature a100.4 aF, aheart arate a58 abeats/minute, arespiratory arate a16
abreaths/minute, aand ablood apressure a130/74. aWhat aaction ashould athe anurse
aimplement?
- Document avital asigns ain arecord a(normal)
A afour-year-old aboy awas arecently adiagnosis awith aDuchenne amuscular adystrophy
a(DMD). aWhich acharacteristic aof athe adisease ais amost aimportant afor athe anurse ato
afocus aon aduring ainitial ateaching?
- Lower alegs abecome aprogressively aweaker, acausing aa awedding, aunsteady agait
MATERNITY/
PEDIATRICS
(PEDS) EXAM,
ANSWERED
,HESI Maternity/Pediatrics (PEDS) Exam,
Answered
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
The 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile
vomiting. Which assessment finding indicates to the nurse that the infant is becoming
dehydrated?
- Crying without tears
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
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
A 36-week primigravida is admitted to labor and delivery with severe abdominal 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
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.
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
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?
- Gestational weight gain.
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
A client at 40-weeks gestation presents to the obstetrical floor and indicates 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
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
A client whose alabor ais abeing aaugmented awith aan aoxytocin a(Pitocin) ainfusion
arequests aan aepidural afor apain acontrol. aFindings aof athe alast avaginal aexam, aperformed
a1 ahour aago, awere a3 acm acervical adilatation, a60% aeffacement, aand aa a-2 astation. aWhat
aaction ashould athe anurse aimplement afirst?
o- aDetermine acurrent acervical adilation
A acommunity ahealth anurse avisits aa afamily ain awhich aa a16-year aold aunmarried
adaughter ais apregnant awith aher afirst achild aand ais aat a32 aweeks agestation. aThe aclient
atells athe anurse athat ashe ahas abeen aintermittent aback apain asince athe anight abefore.
aWhat ais athe apriority anursing aintervention?
- ask athe aclient aif ashe ahas aexperienced aany arecent achanges ain avaginal adischarge
The acurrent avital asigns afor aa aprimipara awho adelivered avaginally aduring athe aprevious
ashift aare: atemperature a100.4 aF, aheart arate a58 abeats/minute, arespiratory arate a16
abreaths/minute, aand ablood apressure a130/74. aWhat aaction ashould athe anurse
aimplement?
- Document avital asigns ain arecord a(normal)
A afour-year-old aboy awas arecently adiagnosis awith aDuchenne amuscular adystrophy
a(DMD). aWhich acharacteristic aof athe adisease ais amost aimportant afor athe anurse ato
afocus aon aduring ainitial ateaching?
- Lower alegs abecome aprogressively aweaker, acausing aa awedding, aunsteady agait
