HESI RN
HESI Maternity Test Bank
1. Upon arrival in the nursery, a newborn infant is breathing satisfactorily but appears dusky. What action should the LPN/LVN take first?
- A. Notify the healthcare provider immediately.
- B. Suction the infant's nares, then the oral cavity.
- C. Check the infant's oxygen saturation rate.
- D. Position the infant on the right side.
Correct answer: C
Rationale: The priority action in this scenario is to check the infant's oxygen saturation rate. This will provide crucial information on the infant's oxygen levels and the need for immediate oxygen therapy. Assessing oxygen saturation is essential in determining the severity of hypoxia and guiding further interventions to ensure adequate oxygenation. Option A is not the priority as immediate intervention related to oxygenation is needed before notifying the healthcare provider. Suctioning (Option B) may be necessary but should come after assessing oxygen saturation. Positioning the infant (Option D) does not address the immediate need to evaluate oxygen levels.
2. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?
- A. Monitor urinary output
- B. Auscultate bowel sounds
- C. Observe appearance of stool
- D. Record percent of diet consumed
Correct answer: A
Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.
3. During a newborn assessment, which symptom would indicate respiratory distress if present in a newborn?
- A. Flaring of the nares.
- B. Shallow and irregular respirations.
- C. Respiratory rate of 50 breaths per minute.
- D. Abdominal breathing with synchronous chest movement.
Correct answer: A
Rationale: Flaring of the nares is a classic sign of respiratory distress in newborns. It indicates that the newborn is working hard to breathe, and immediate attention should be given to assess and address the respiratory status of the infant.
4. The healthcare provider is providing preconception counseling. Which supplement should the provider recommend to help prevent the occurrence of anencephaly?
- A. Folic Acid.
- B. Calcium.
- C. Iron.
- D. Vitamin D.
Correct answer: A
Rationale: Folic acid supplementation before and during early pregnancy is crucial for reducing the risk of neural tube defects, including anencephaly. Anencephaly is a severe birth defect in which a baby is born without parts of the brain and skull. Folic acid plays a key role in neural tube development and can significantly lower the chances of such defects when taken prior to conception and in early pregnancy.
5. What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?
- A. Body temperature.
- B. Level of pain.
- C. Time of first void.
- D. Number of vessels in the cord.
Correct answer: D
Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.
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