HESI RN
HESI Maternity Test Bank Questions
Question 1 of 5
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care?
Correct Answer: A
Rationale: In managing diabetic ketoacidosis (DKA), monitoring serum glucose levels is crucial to adjust the infusion rate of regular insulin effectively. This helps in controlling blood glucose levels and preventing complications associated with DKA. Close monitoring and adjustments based on glucose levels are essential for the successful management of DKA.
Question 2 of 5
At 35 weeks gestation, a client complains of 'pain whenever the baby moves.' The nurse notes a temperature of 101.2 F (38.4 C) with severe abdominal or uterine tenderness on palpation. What condition do these findings indicate?
Correct Answer: B
Rationale: The client's symptoms of fever and abdominal tenderness, along with the gestational age, are classic signs of chorioamnionitis, an infection of the amniotic fluid. This condition requires prompt recognition and treatment to prevent maternal and fetal complications.
Question 3 of 5
A new mother who is breastfeeding her 4-week-old infant and has type 1 diabetes reports that her insulin needs have decreased since the birth of her child. Which action should the nurse implement?
Correct Answer: A
Rationale: During breastfeeding, insulin needs often decrease due to the metabolic demands of milk production. Therefore, the nurse should inform the client that this decrease in insulin requirements is a normal response to breastfeeding. It is essential for healthcare providers to educate clients about this physiological change to prevent unnecessary concerns or adjustments to insulin therapy.
Question 4 of 5
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperneic. Which action should the nurse implement first?
Correct Answer: A
Rationale: In a tetralogy of Fallot situation, placing the infant in a knee-chest position is the initial priority to help increase systemic vascular resistance, which reduces the right-to-left shunt and improves oxygenation. This position can assist in optimizing oxygen levels before considering other interventions.
Question 5 of 5
When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes a yellow tint to the skin on the forehead, sternum, and abdomen. Which action should the nurse take?
Correct Answer: A
Rationale: The presence of a yellow tint on the skin of a newborn suggests jaundice. The initial step in managing jaundice in a newborn is to measure bilirubin levels, typically done using transcutaneous bilirubinometry. This measurement helps determine the severity of jaundice and guides appropriate treatment interventions. Evaluating cord blood Coombs test results or reviewing maternal medical records for blood type and Rh factor are not the immediate actions indicated when jaundice is suspected. Phototherapy may be considered after confirming elevated bilirubin levels and assessing the need for treatment.
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