HESI RN
HESI Maternity Test Bank Questions
Question 1 of 5
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage'. The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on the client's history, which nursing problem has the highest priority?
Correct Answer: D
Rationale: Fluid volume excess is a priority concern in this client, as heart damage from rheumatic fever can impair the heart's ability to manage increased blood volume postpartum, leading to potential heart failure. Monitoring and managing fluid volume status are crucial to prevent complications in this high-risk client.
Question 2 of 5
The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?
Correct Answer: D
Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver.
Question 3 of 5
At 40-weeks gestation, a client presents to the obstetrical floor with spontaneous rupture of amniotic membranes at home, in active labor, and feeling the urge to push. What information should the nurse prioritize obtaining?
Correct Answer: A
Rationale: Assessing the color and consistency of amniotic fluid is crucial as it can indicate the presence of meconium, which suggests potential fetal distress. This information guides the need for further assessments and interventions to ensure the well-being of the mother and fetus.
Question 4 of 5
A mother calls the school nurse to report that her preschool-aged child was bitten by a tick during a school outing last week. The mother removed the tick and flushed it down the toilet. What action should the school nurse take?
Correct Answer: D
Rationale: Scheduling a test for Lyme disease if a rash appears is the correct action to take in this situation. Lyme disease can be transmitted through tick bites, and a rash is a common early symptom. Testing for Lyme disease is essential for timely diagnosis and treatment to prevent complications.
Question 5 of 5
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the healthcare provider take?
Correct Answer: C
Rationale: Placing the woman in a lateral position is the appropriate action to improve venous return and cardiac output, helping to stabilize the blood pressure. This position can alleviate pressure on the inferior vena cava, reducing the risk of hypotension associated with epidural anesthesia.
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