Med Surge HESI Real Exam
NUR 230 Exam – Galen OB/Peds (2026) Actual
Questions & Correct Answers | Guarantee Pass
Test Bank Exam 2026/2027 –Verified | Detailed
Rationales – Pass Guaranteed – A+ Graded
During the transition phase of labor, a client complains of tingling and numbness in her fingers
and tells the nurse that she feels like she is going to pass out. What action should the nurse
take?
A.Encourage her to pant between contractions and blow with contractions.
B.Coach her to take a deep cleansing breath and then refocus.
C.Instruct her to pant three times and then exhale through pursed lips.
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, Med Surge HESI Real Exam
D.Have her cup both hands over her nose and mouth while breathing. –
Correct Answer :D.Have her cup both hands over her nose and mouth while breathing.
Rationale:
Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes
transient respiratory alkalosis, so the client should cup both her hands over her mouth and
nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore
carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper
bag.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is
96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands
shake. Which intervention should the nurse implement first?
A.Stimulate the infant to cry.
B.Wrap the infant in warm blankets.
C.Feed the infant formula.
D.Obtain a serum glucose level. –
Correct Answer :D.Obtain a serum glucose level.
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, Med Surge HESI Real Exam
Rationale:
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body
temperature. The nurse should first determine the serum glucose level. Option A is an
intervention for a lethargic infant. Option B should be done based on the temperature, but
first the glucose level should be obtained. Option C helps raise the blood sugar, but first the
nurse should determine the glucose level.
During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client.
Which statement is most characteristic of an infant whose mother smoked during pregnancy
compared with the infant of a nonsmoking mother?
A.Lower Apgar score recorded at delivery
B.Lower initial weight documented at birth
C.Higher oxygen use to stimulate breathing
D.Higher prevalence of congenital anomalies –
Correct Answer :
B.Lower initial weight documented at birth
Rationale:
Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not
to smoke during pregnancy. Options A, C, and D have not been clearly associated with
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, Med Surge HESI Real Exam
smoking during pregnancy, but there is a strong correlation between smoking and lower birth
weights.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress
and determines that the infant is demonstrating marked nasal flaring, an audible expiratory
grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should
the nurse assign?
A.3
B.4
C.5
D.8 –
Correct Answer :C.5
Rationale:
The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory
status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and
abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0,
and a total of 10 indicates maximum respiratory distress. This infant is demonstrating
respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring,
grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a
total score of 5. Options A, B, and D are not accurate.
The nurse observes that an antepartum client who is on bed rest for preterm labor is eating
ice rather than the food on her breakfast tray. The client states that she has a craving for ice
and then feels too full to eat anything else. Which is the best response by the nurse?
P a g e 4 | 116
NUR 230 Exam – Galen OB/Peds (2026) Actual
Questions & Correct Answers | Guarantee Pass
Test Bank Exam 2026/2027 –Verified | Detailed
Rationales – Pass Guaranteed – A+ Graded
During the transition phase of labor, a client complains of tingling and numbness in her fingers
and tells the nurse that she feels like she is going to pass out. What action should the nurse
take?
A.Encourage her to pant between contractions and blow with contractions.
B.Coach her to take a deep cleansing breath and then refocus.
C.Instruct her to pant three times and then exhale through pursed lips.
P a g e 1 | 116
, Med Surge HESI Real Exam
D.Have her cup both hands over her nose and mouth while breathing. –
Correct Answer :D.Have her cup both hands over her nose and mouth while breathing.
Rationale:
Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes
transient respiratory alkalosis, so the client should cup both her hands over her mouth and
nose so that she can rebreathe carbon dioxide. Options A, B, and C do not help restore
carbon dioxide levels as effectively as rebreathing air in the cupped hands or from a paper
bag.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is
96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands
shake. Which intervention should the nurse implement first?
A.Stimulate the infant to cry.
B.Wrap the infant in warm blankets.
C.Feed the infant formula.
D.Obtain a serum glucose level. –
Correct Answer :D.Obtain a serum glucose level.
P a g e 2 | 116
, Med Surge HESI Real Exam
Rationale:
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body
temperature. The nurse should first determine the serum glucose level. Option A is an
intervention for a lethargic infant. Option B should be done based on the temperature, but
first the glucose level should be obtained. Option C helps raise the blood sugar, but first the
nurse should determine the glucose level.
During a prenatal visit, the nurse discusses the effects of smoking on the fetus with a client.
Which statement is most characteristic of an infant whose mother smoked during pregnancy
compared with the infant of a nonsmoking mother?
A.Lower Apgar score recorded at delivery
B.Lower initial weight documented at birth
C.Higher oxygen use to stimulate breathing
D.Higher prevalence of congenital anomalies –
Correct Answer :
B.Lower initial weight documented at birth
Rationale:
Smoking is associated with low-birth-weight infants. Therefore, mothers are encouraged not
to smoke during pregnancy. Options A, C, and D have not been clearly associated with
P a g e 3 | 116
, Med Surge HESI Real Exam
smoking during pregnancy, but there is a strong correlation between smoking and lower birth
weights.
The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress
and determines that the infant is demonstrating marked nasal flaring, an audible expiratory
grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should
the nurse assign?
A.3
B.4
C.5
D.8 –
Correct Answer :C.5
Rationale:
The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory
status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and
abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0,
and a total of 10 indicates maximum respiratory distress. This infant is demonstrating
respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring,
grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a
total score of 5. Options A, B, and D are not accurate.
The nurse observes that an antepartum client who is on bed rest for preterm labor is eating
ice rather than the food on her breakfast tray. The client states that she has a craving for ice
and then feels too full to eat anything else. Which is the best response by the nurse?
P a g e 4 | 116
