HESI RN
Maternity HESI 2023 Quizlet
1. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
- A. Auscultate the lungs for respiratory pneumonia.
- B. Change to latex-free gloves when handling infant.
- C. Draw blood to analyze for streptococcal infection.
- D. Apply zinc oxide to perineum with each diaper change.
Correct answer: B
Rationale: Latex allergy is a concern in patients with myelomeningocele, so switching to latex-free gloves is important.
2. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased by 5 cm since birth, and observes that the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant’s head-to-heel length
- B. Observe the infant for sunsetting eyes
- C. Palpate the anterior fontanel for tension and bulging
- D. Plot the measurement on the infant’s growth chart
Correct answer: C
Rationale: Palpating the anterior fontanel for tension and bulging is essential to assess for increased intracranial pressure, which could be indicated by the enlarged head circumference. This assessment can help identify potential neurological issues that need prompt attention.
3. A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. What information should the nurse provide this client?
- A. Use an alternative form of contraception until a new diaphragm is obtained.
- B. After weaning, the diaphragm should be resized.
- C. Avoid intercourse during ovulation until the diaphragm size is reassessed.
- D. If weight gain during pregnancy was no more than 20 pounds, the diaphragm is safe to use.
Correct answer: A
Rationale: The nurse should advise the client to use an alternative form of contraception until a new diaphragm that fits correctly post-pregnancy is obtained. It is essential to ensure proper fit for effective contraception, making it crucial to use an alternative method until the diaphragm is resized.
4. How can a nurse make a blind 8-year-old girl admitted to the hospital more comfortable?
- A. Bring familiar toys from home, such as a bear or doll.
- B. Explain the surroundings to the child.
- C. Allow the child to explore the room.
- D. Provide audio books and music.
Correct answer: A
Rationale: The correct answer is to bring familiar toys from home, such as a bear or doll. This action provides comfort and a sense of security for the child, as it allows her to have familiar objects around her in an unfamiliar environment, which can help reduce anxiety and stress during her hospital stay.
5. A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated?
- A. Weak cry without tears.
- B. Bulging fontanel.
- C. Visible peristaltic wave.
- D. Palpable mass in the right upper quadrant.
Correct answer: A
Rationale: In infants, a weak cry without tears is a classic sign of dehydration. Tears are produced by the lacrimal glands, and reduced tear production is a result of dehydration. This assessment finding should alert the nurse to the infant's dehydration status, requiring prompt intervention to prevent further complications.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99