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 labor is being augmented with an oxytocin (Pitocin) infusion 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?
o- Determine current cervical dilation
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
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)
A four-year-old boy was recently diagnosis with Duchenne muscular dystrophy (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
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 labor is being augmented with an oxytocin (Pitocin) infusion 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?
o- Determine current cervical dilation
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
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)
A four-year-old boy was recently diagnosis with Duchenne muscular dystrophy (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
