HESI Peds & Maternity Exam Questions with 100% Correct Answers | Verified | Latest Update

The nurse is caring for a 3 year old child who is 2 hours postop from a cardiac catheritization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? - Correct answer-Right foot is cool to the touch and appears pale and blanched During fundal massage, place one hand at the fundus, what is the second hand used for - Correct answer-to anchor fundus Following a motor vehicle collision, a 3 year old girl has a spica cast applied. Which toy is best for the nurse for this 3 year old child? - Correct answer-Set of cloth and hand puppets There is a question that has to be put in order - Correct answer-*isolate the baby, move mom to private room, collect u/a, start iv* An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? - Correct answer-Place the infant in a knee-chest position How do you measure the frequency of contractions - Correct answer-from the beginning of one to the beginning of the next A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? - Correct answer-Metabolic Acidoses Mothers Hemoglobin A1C - Correct answer-give her a consultation to a nutritionist A 7 year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? - Correct answer-Serum potassium of 3.0 mg/dL Baby shows cyanosis in hands and feet and has elevated respirations - Correct answergradually warm the baby Cyanotic 3 hour old infant temperature 96.5, 40 breaths/min, 165 beats/minute. Intervention best to implement? - Correct answer-gradually warm under heat source The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective? - Correct answer-*Creamed corn* Baby is showing signs of mottling - Correct answer-check temperature During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? - Correct answer-Object Permanence Mom is at 20 week gestation and has gained 20 lbs, what is of most concern out of the data of mom - Correct answer-increased weight gain The nurse is measuring he frontal occipital circumference (FOC) of a 3 month old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next? - Correct answer-Palpate the anterior fontanel for tension and bulging Mom asks why her baby is being screened for T4 and TSH levels - Correct answer-it is state protocol to monitor for metabolic abnormalities The nurse is preparing a 10 year old with a lacerated forehead for suturing. Both parents and 12 years old sibling are at the child's bedside. Which instruction best supports family? - Correct answer-Please decide who will stay when the healthcare provider begins suturing Patient is having labor back pain - Correct answer-counter pressure on lower back (sacrum) The nurse is planning for a 5 month old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother? - Correct answer-Thicken formula with cereal for each feeding Woman had cleft lip, dads uncle had cleft lip - Correct answer-send them for genetic testing While teaching a parenting class to new parents the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors? - Correct answer-They provide the child with a sense of security Woman in labor and they look at vagina and see cord - Correct answer-put woman in Trendelenburg position The parents of a newborn infant with hypospadia are concerned about when the surgical correction should occur. What information should the nurse provide? - Correct answer-Repairs typically should be done before the child is potty trained Pregnant woman has a diaphragm - Correct answer-she needs to have it refitted for another diaphragm Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary considerations related to the disease? - Correct answerLemonade Baby starts showing signs of respiratory difficulty (nasal flaring, expiratory grunt, cyanosis) - Correct answer-check O2 saturation levels The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? - Correct answer-Tachycardia Baby progressing in extrauterine life would show what signs - Correct answer-good vigorous cry with stimulation While auscultating the lung sounds of a 5 year old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take? - Correct answerInquire about the use of alternative methods of treatment Baby has peri-oral cyanosis - Correct answer-assess the oral mucosa A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion, has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement? - Correct answer-Obtain specimen for blood cultures Before surgery mom is given an anticholinergic/atropine with anesthesia. What is the therapeutic response of the anticholinergic? - Correct answer-*increased pulse & decrease oral secretions/dry oral membranes* A child who weighs 25 kg is receiving IV ampicillin 300mg/kg/24 hours in equally divided doses every 4 hours. How many mg should the nurse administer to the child for each dose? - Correct answer-1875 mg Question about cytotec - Correct answer-answer is you are at an increased risk for abortion The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedures the infant passes a soft-formed brown stool. Which intervention should the nurse implement? - Correct answer-Notify the healthcare provider of the passage of brown stool Patients uterus is above the umbilicus and to the right during postpartum, what do you do first - Correct answer-palpate the bladder for distention The mother of a 4 month old asks the nurse to advice in preventing diaper rash. What suggestion should the nurse provide? - Correct answer-Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change Mom feels the urge to defecate during labor - Correct answer-do a vagina exam Which statement by a school aged client going o summer camp indicates the best understanding of the mode of transmission of Lyme disease? - Correct answer-I have to wear long sleeves and pants when we're hiking around the pond What is the reason to do an ultrasound on a mother at 20 weeks gestation - - Correct answer-- ultrasound for gestation and fetal growth The nurse is evaluating the effects of thyroid therapy used to treat a 5 month old with hypothyroidism. Which behavior indicates hat the treatment has been effective? - Correct answer-Laughs readily, turns from back to side Patient is taking mag sulfate and urine output is 25 mL/hr, respirations 14/min, pulse is 116/min, what should the nurse do first - Correct answer-discontinue mag sulfate (signs of mag tox) The HR for a 3 year old with CHF has steadily decreased over the last few hours, now is 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider? - Correct answer-BP 70/40 Postpartum with bathroom privileges, what possible condition would the nurse place the patient on temporary bed rest for - Correct answer-possible thrombus in the leg if positive Homan's sign is present 2 year old is admitted to the hospital with possible encehalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure? - Correct answer-Describe he side-lying, knees to chest position that must be assumed during the proceudure Pregnant woman has an increased costal angle and diaphragm is elevated , how does the nurse document this - Correct answer-as a normal finding The parents of a 3 year old boy who has Duschenne muscular dystrophy ask "how can our son have this disease? We are wondering if we should have any more children" What information should the nurse provide these parents? - Correct answer-This is an inherited X-linked recessive disorder, which primarily affects male children in the family Moms Hgb and Hct is low, what food to tell her to eat that contains the most iron? - Correct answer-chicken (other sources: liver, meats, whole grains, enriched bread, cereal, dried fruits) The nurse finds a 6 month old infant unresponsive and calls for help. After opening the airway and finding the XXXX the infant is still not breathing. Which action should the nurse take? - Correct answer-Give two breaths that makes the chest rise Mom wakes up in a pool of blood and comes to emergency room. What to check first - Correct answer-blood pressure A 3 year old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks then nurse what she should do. Which action should the nurse take first? - Correct answer-Review the immunizaiton documentation of the child who has HIV Nurse anticipates that the prenatal lab will be performed at 28 weeks - Correct answer-- 1 hr glucose (140 between 24-28 weeks) A 16 year old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Provenfil) metre-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is "beating a mile per minute" Which information is most important for the nurse to obtain? - Correct answer-How often the MDI is used daily What medication to give mom to prevent RDS in fetus - Correct answer-betamethasone The nurse is assessing a child for neurological soft signs, which finding is most likely demonstrated in the child's behavior? - Correct answer-Poor coordinatin and sense of position Pt is induced for labor contractions begin occurring 1 ½ to 2 min apart with no resting in between contractions, what to do first - Correct answer-stop Pitocin infusion The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture? - Correct answer-Metabolic Alkalosis Mom has been on mag sulfate and is now postpartum, what is she at increased risk for - Correct answer-uterine atony (hemorrhage) A month old girl is brought to the clinic by her mother because she has had a cold for 2 to 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? - Correct answer-Flaring of the nares Mom is prescribed hemabate - Correct answer-give antiemetic before hemabate due to s/e (also cause diarrhea so give antidiarrheal) A 2 year old boy begins to cry when the mother starts to leave. What is the nurse's best response to the situation? - Correct answer-let me read this book to you Mom says baby is trying to walk, what do you say - Correct answer-stepping reflex is normal reflex for babies A 2 year old child with HF is admitted for replacement of a graft for coarcion of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains and apical heart rate at 128 bpm. What action should the nurse implement? - Correct answer-Administer the scheduled dose Functions of placenta in early pregnancy - Correct answer-estrogen and progesterone production A child with leukemia is admited to chemotherapy and the nursing diagnosis "alered nutrition, less than boy requirements related to anorexia, nausea, and vomiting" is identified. Which intervention the nurse included in this childs plan of care? - Correct answer-Allow the child to eat any food desired and tolerated What does nurse do prior to administering RhoGAM injection - Correct answer-get second nurse to confirm med and patient A 6 year old with asthma is demonstrating a prolonged expiratory phase and wheezing and has a 35% of personal best peak expiratory flow rate (PEFR) based on these findings, what action should the nurse take first? - Correct answer-Administer a prescribed bronchodilator Mom is having third baby at home, her two previous babies were rH negative, does she have to come get a direct coombs test dine on baby - Correct answer-yes The nurse plans to administer 10 mcg/kg of digoxin elixir as a loading dose to a child who weighs 55 pounds. Digoxin is available as elixer of 50 mcg/ml. How many ml of the digoxin elixer should the nurse administer to this child? - Correct answer-5 ml Patient has been breastfeeding for 15 months and 6 weeks pregnant now, what is major assessment - Correct answer-nutritional intake The nurse observes a mother giving her 11 month old ferrous sulfate, followed by two ounces of orange juice. What should the nurse do next? - Correct answer-Give positive feedback about the way she administered the sulfate Signs of fetal alcohol syndrome - Correct answer-flat nose bridge Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis? - Correct answer-Weigh the child daily Patient is showing signs of mag toxicity (nausea, feeling of warmth, flushing) - Correct answer-stop infusion During a well baby visit the parents explain that the soft bulge appears in the groin of their 4 month old son when he cries or strains with stool. The infant is scheduled for surgical repair of the inguinal hernia in 2 weeks. The parent should be instructed to take which measure if the hernia becomes incarceraed prior to surgery? - Correct answerGently manipulate the hernia for reducion What is the best method to get hemoglobin and hematocrit on baby - Correct answerheel stick A 16 year old male who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission he begins to have a Grand Mal seizure. Which action should the nurse take? - Correct answer-observe him carefully Patient is diagnosed with eclampsia, what do you do - Correct answer-- keep airway at bedside (immediate goal of care when during convulsion is to maintain a patent airway. When seizures do occur, turn woman on her side to prevent aspiration) The mother of a 9 month old who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friends child the following day. What response should the nurse provide this mother? - Correct answer-Do not expose other children to RSV, it is very contagious even without direct contact Postpartum after c-section, pt is nauseated and abdominal distention, what to do first - Correct answer-auscultate for bowel sounds When screening a 5 year old for strabism, what action should the nurse take? - Correct answer-Direct the child through the 6 cardinal position of glaze Patient is noted to have positive homan sign, what do you do - Correct answer-tell the patient to stay in the bed and notify the dr The nurse is assessing a 6 month old infant. Which response requires further evaluation by the nurse? - Correct answer-demonstrate startle reflux