HESI EXAM 4 FOR PEDIATRIC CARE IN NURSING. 100%
SUCCESS WITH GRADE A+ ANSERS AND RATIONALE
PROVIDED. 2024/2025 STUDY MATERIAL
1. A nurse identifies a right cephalohematoma on an
otherwise healthy 1 -day-old newborn. What should the nurse
teach the parents at the time of discharge?
A. To space feedings at every 3 hours
B. How to assess the fontanels for tenseness
C. How to monitor their child for signs of jaundice
D. To record the number of wet diapers during the first 24
hours: C. How to monitor their child for signs of jaundice
Rationale: Bilirubin is a yellow pigment derived from the hemoglobin
released with the breakdown of red blood cells as the hematoma
resolves. Signs of jaundice should be reported
2. During the physical assessment of a recently born neonate, the
nurse palpates the infant's femoral pulses. For which cardiac
defect is the nurse looking?
A. Atrial septa' defect
B. Coarctation of the aorta
C. Patent ductus arteriosus
D. Ventricular septa' defect: B. Coarctation of the aorta
Rationale: Coarctation of the aorta results in diminished or absent
femoral pulses.
3. One minute after birth a nurse assesses a newborn &
auscultates a heart rate of 90 beats/min. The newborn has a
strong, loud cry, moves all extremities well, and has acrocyanosis
but is otherwise pink. What is the neonate's Apgar score?
22
,Rationale: Heart rate less than 100 beats/min receives 1 point, color
(acrocyanosis body pink, blue extremities) receives 1 point, RR
(strong, loud cry), muscle tone, and reflex irritability each get a score
of 2, for a total of 8
4. The nurse is caring for the newborn of a mother with
diabetes. For which signs of hypoglycemia should the nurse
assess the newborn? Select all that apply
A. Pallor
B. Irritability
C. Hypotonia
1/
D. Ineffective sucking
E. Excessive birth weight: A. Pallor
B. Irritability
C. Hypotonia
D. Ineffective sucking
Rationale: Excessive birthweight is common in neonates whose
mother has diabetes but this does not indicate hypoglycemia
5. A neonate weighing 5 1b 6 oz (2438 g) is born in a cesarean
birth & admitted to the newborn nursery. What range of resting
respiratory rate should the nurse anticipate?
22
,HESI EXAM 4 FOR PEDIATRIC CARE IN NURSING. 100%
SUCCESS WITH GRADE A+ ANSERS AND RATIONALE
PROVIDED. 2024/2025 STUDY MATERIAL
A. 20-40
breaths/mi
n B. 30-60
breaths/mi
n
C. 60-80 breaths/min
D. 70-90 breaths/min: B. 30-60 breaths/min
6. A nurse who is observing a sleeping newborn at 2 hours of age
identifies periods of irregular breathing and occasional twitching
movements of the arms and legs. The neonate's heart rate is 150
beats/min; the respiratory rate is 50 breaths/min; and the
glucose strip reading is 60 mg/dL (3.3 mmoI/L). What does the
nurse conclude that these findings indicate?
A. Hypoglycemia
B. Seizure activity
C. Expected adaptations
D. Respiratory distress syndrome: C. Expected adaptations
Rationale: During periods of active or irregular sleep, healthy newborns
have some twitching movements & irregular respirations; the heart rate,
respirations, & blood glucose level are within expected limits.
7. A new mother is feeding her baby girl, who was born 36 hours
ago in a spontaneous vaginal delivery. The nurse notices that the
mother is crying and points to the top of her baby's head. She
cries, "I don't know what's wrong with my baby! She didn't have
22
, this big lump on the right side of her head before now. I haven't
dropped her! What happened to her?" What is the best response
once the nurse has assessed the infant's head?
A. "Your baby's head is just slightly elongated, and that's
nothing to be concerned about."
B. "She'll be examined again by the pediatrician before you
leave later today, so there's no need to worry right now."
C. "Your baby may have a condition called cephalohematoma.
It's common,
2/
but I'll make a note to have the pediatrician assess it."
D. "Your baby may have a condition called caput succedaneum,
which is common. I'll make a note to have the pediatrician assess
it.": C. "Your baby may have a condition called
cephalohematoma. It's common, but I'll make a note to have the
pediatrician assess it."
Rationale: A cephalohematoma usually develops on one side of the
head over the parietal bones. The swelling is not generally present at
birth; rather it develops over the first 24-48 hours of life.
8. While changing her baby girls diaper, a client expresses
concern about small spot of red vaginal discharge on the
diaper. How should the nurse respond to this concern.
A. Explain that this is an expected finding
B. Obtain a prescription for vaginal cultures
C. Assess the infant for other signs of bleeding
22
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