HESI Practice Exam

The father of a newborn tells the nurse, "My son just died." How should the nurse respond? a. "I am sorry for your loss." b. "There is an angel in heaven." c. "I understand how you feel." d. "You can have other children."

"I am sorry for your loss."

Which statement by a client who is pregnant indicates to the nurse an understanding of the role of protein during pregnancy? a. "Protein helps the fetus grow while I am pregnant." b. "Gestational diabetes is prevented by eating protein." c. "Anemia is averted by consuming enough protein." d. "My baby will develop strong teeth after he is born."

"Protein helps the fetus grow while I am pregnant."

An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours old and appears large for gestational age, flushed, and tremulous. What procedure should the nurse follow to implement a glucose screening? (Arrange the examination process from first on top to last on the bottom.) 1. Collecting a spring-loaded automatic puncture device 2. Cleanse puncture site on the lateral aspect of the heel. 3. Restrain the newborn's foot with your free hand. 4. Wrap the infant's foot with a heel warmer for 5 minutes.

1. Wrap infant's foot with heel warmer for 5 minutes 2. Cleanse puncture site on the lateral aspect of the heel 3. Restrain the newborns foot with your free hand 4. Collect a spring-loaded automatic puncture device

What nursing action should be implemented when intermittently gavage-feeding a preterm infant? a. Allow formula to flow by gravity. b. Avoid letting infant suck on tube. c. Insert feeding tube through nares. d. Apply steady pressure to syringe.

Allow formula to flow by gravity.

A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? a. Bruising. b. Oral intake. c. Hemoglobin. d. Bilirubin.

Bilirubin.

A multigravida client at 35-weeks gestation is diagnosed with pregnancy-induced hypertension (PIH). Which symptom should the nurse instruct the client to report immediately? a. Backache. b. Constipation. c. Blurred vision. d. Increased urine output.

Blurred vision.

A client at 35-weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? a. Periodic abdominal pain. b. Ankle edema in the afternoon. c. Backache with prolonged standing. d. Shortness of breath when climbing stairs.

Periodic abdominal pain.

Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? a. Pregnancy induced hypertension. b. Placenta previa. c. Gestational diabetes. d. Postpartum hemorrhage.

A Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension (A) is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. (B, C, and D) are not contraindications for the use of Methergine.

The mother of a neonate asks the nurse why it is so important to keep the infant warm. What information should the nurse provide? A) The kidneys and renal function are not fully developed B) A large body surface area favors heat loss to the environment C) Warmth promotes sleep so the infant will grow quickly D) The thick layer of subQ fat is inadequate for insulin

A large body surface area favors heat loss to the environment

The nurse on the postpartum unit receives report for 4 clients during change of shift. Which client should the nurse assess for risk of postpartum hemorrhage (PPH)? a. A primigravida who had a spontaneous birth of preterm twins. b. A multigravida who delivered a 8 pound 2 ounce infant after an 8-hour labor. c. A multiparous client receiving magnesium sulfate during induction for severe preeclampsia. d. A primiparous client who had an emergency cesarean birth due to fetal distress.

A multiparous client receiving magnesium sulfate during induction for severe preeclampsia

A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? a. Contraction stress test. b. Internal fetal monitoring. c. Abdominal ultrasound. d. Lecithin-sphingomyelin ratio.

Abdominal ultrasound.

The nurse is teaching a primigravida at 10-weeks gestation about the need to increase her intake of folic acid. Which explanation should the nurse provide that supports preventative perinatal care? a. The risk for neonatal cerebral palsy increases with folic acid deficiencies during pregnancy. b. Folic acid can significantly reduce the incidence of mental retardation. c. Adequate folic acid during embryogenesis reduces the incidence of neural tube defects. d. The incidence of congenital heart defects is related to folic acid intake deficiencies.

Adequate folic acid during embryogenesis reduces the incidence of neural tube defects

A client is experiencing "back" labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement? a. Perform effleurage on the abdomen. b. Encourage pant-blow breathing techniques. c. Apply counter pressure against the sacrum. d. Assist the client in guided imagery.

Apply counter pressure against sacrum

A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should the nurse give? a. Apply ice to the breasts. b. Wear a loose-fitting bra. c. Run warm water on the breasts during a shower. d. Express small amounts of milk from the breasts.

Apply ice to the breasts.

A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement? a. Emphasize that food and fluid intake should stop. b. Tell the woman to stay home until her membranes rupture. c. Ask the client to describe why she thinks she is in labor. d. Suggest the client to come to the hospital for labor evaluation. Submit

Ask the client to describe why she thinks she is in labor.

The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? a. Check the infant's arterial blood gases. b. Notify the pediatrician of the infant's vital signs. c. Assess the infant's blood glucose level. d. Encourage the infant to take the breast or sugar water.

Assess the infant's glucose level

The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? a. Avoid alcohol because it is excreted in breast milk. b. Avoid spicy foods to prevent infant colic. c. Increase caloric intake by approximately 500 calories/day. d. Double prenatal milk intake to improve Vitamin D transfer to the infant.

Avoid alcohol because it is excreted in breast milk.

A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? a. Recheck the client's vital signs. b. Notify the healthcare provider. c. Insert an indwelling urinary catheter. d. Massage the fundus in 30 minutes.

B. Treatment of excessive bleeding requires the collaboration of the healthcare provider. Based on the findings, the healthcare provider should be notified (B) for additional treatment. The nurse should ask another nurse to rechecks the vital signs (A) while the healthcare provider is being called. (C) maybe needed if the client is unable to void. (D) may be implemented to prevent immediate uterine overstimulation by massage, which can lead to uterine atony and rebound hemorrhage.

A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?

B. Help her breathe into a paper bag. Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness, tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around the mouth and nose enables the client to rebreathe carbon dioxide, which reduces depletion of carbonic acid and compensates for the respiratory alkalosis.

An infant in respiratory distress is placed on pulse oximetry. The oxygen saturation indicates 85%. What is the priority nursing intervention? a. Evaluate the blood pH. b. Begin humidified oxygen via hood. c. Stimulate infant crying. d. Place the infant under a radiant warmer.

Begin humidified oxygen via hood.

The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) a. Shallow with an irregular rhythm. b. Chest breathing with nasal flaring. c. Diaphragmatic with chest retraction. d. Abdominal with synchronous chest movements. e. Heart rate of 158 beats per minute. f. Grunting heard with a stethoscope.

Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant.

A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? a. Ask to meet with the client and infant without family members present. b. Do a brief assessment for only the infant while family members are present. c. Observe interactions of family members with the newborn and each other. d. Reschedule the visit so that the mother and infant can be assessed privately.

C An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members (C). Although family members can remain during the assessment of the newborn (B), the mother should be assessed also. Privacy to assess the mother should be assured (A and D), but evaluation of the family dynamics provides essential data about mother-child bonding and should be determined at this time.

A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? a. Vaginal bleeding. b. Complaints of abdominal pain. c. Changes in fetal heart rate patterns. d. Alteration in maternal blood pressure.

C Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in the mother. (A, B, and D) are not the first findings of internal hemorrhage in the pregnant client.

The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The infant expels a bloody stool. What nursing action should the nurse implement? a. Institute contact precautions. b. Obtain a rectal temperature. c. Assess for abdominal distention. d. Decrease the amount of the feeding.

C. Etiological factors playing an important role in the development of necrotizing enterocolitis (NEC), a complication common in premature infants, include intestinal ischemia, colonization by pathogenic bacteria, and substrate (formula feeding) in the intestinal lumen. Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of NEC. Nursing responsibilities include measuring the abdomen (C) and listening for bowel sounds. Contact precautions (A) are necessary if a contagious gastrointestinal infection is suspected. Rectal temperatures are contraindicated (B) because of the risk for perforation of the bowel. Oral or gavage feeding is stopped, not (D), until necrotizing enterocolitis is ruled out.

A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which food should the nurse recommend to increase the client's calcium intake? a. Canned clams. b. Fresh apricots. c. Canned sardines. d. Spaghetti with meat sauce.

Canned sardines

While inspecting a newborn's head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document? a. Molding. b. Cephalohematoma. c. Caput succedaneum. d. Bulging fontanel.

Cephalohematoma

A client who is breastfeeding develops engorged breasts on the third postpartum day. Which action should the nurse recommend to relieve breast engorgement? a. Avoid pumping her breasts. b. Continue breastfeeding every 2 hours. c. Skip a feeding to rest the breasts. d. Decrease fluid intake for at least 24 hours.

Continue to breast feed every two hours

The apnea monitor alarm sounds for the third time during one shift for a neonate who was delivered at 37-weeks gestation. What nursing action should be implemented first? a. Provide tactile stimulation. b. Administer flow by 100% oxygen. c. Asses the functionality of the monitoring device. d. Evaluate the newborn's color and respirations.

Evaluate the newborns color and respiration

The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to make? a. Inform the mother that the injection was prescribed by the healthcare provider. b. Explore the mother's concerns about the infant receiving an injection of vitamin K. c. Explain that vitamin K is required by state law and compliance is mandatory. d. Remind the mother that all babies receive this shot and it is relatively painless.

Explore the mother's concerns about the infant receiving an injection of vitamin K.

Which client finding should the nurse document as a positive sign of pregnancy? a. Last menstrual cycle occurred 2 months ago. b. A urine sample with a positive pregnancy test. c. Presence of Braxton Hicks contractions. d. Fetal heart tones (FHT) heard with a doppler.

Fetal heart tones (FHT) heard with a doppler.

During an assessment of a multiparous client who delivered an 8-lb 7-oz infant 4 hours ago, the nurse notes the client's perineal pad is completely saturated within 15 minutes. What action should the nurse implement next? a. Perform fundal massage. b. Assess blood pressure. c. Notify the healthcare provider. d. Encourage the client to void.

Fundus displacement commonly occurs in the early hours of the postpartum period due to urinary retention, so assisting the client to the bathroom (C) to void should be implement next. (A and B) can be completed after the client's bladder is emptied. (D) should only be implemented if the fundus does not become firm or lochial bleeding continues after the bladder is emptied.

A preterm infant with an apnea monitor experiences an apneic episode. Which action should the nurse implement first? a. Ventilate with an Ambu bag. b. Perform nasal and airway suctioning. c. Administer supplemental oxygen. d. Gently rub the infant's feet or back.

Gently rub the infants feet or back

The nurse notes a pattern of the fetal heart rate decreasing after each contraction. What action should the nurse implement? a. Give 10 liters of oxygen via face mask. b. Prepare for an emergency cesarean section. c. Continue to monitor the fetal heart rate pattern. d. Obtain an oral maternal temperature.

Give 10 liters of oxygen via face mask. Rationale: Late decelerations occur when there is reduced placental and fetal perfusion. Administering oxygen increases the oxygen saturation in the blood thus increasing oxygen to the fetus.

The nurse observes a male newborn who is displaying a rigid posture with his eyes tightly closed and grimacing as he is crying after an invasive procedure. The baby's blood pressure is elevated on the Dinamap display. What action should the nurse implement? a. Obtain a serum glucose level. b. c. Feed the newborn 1 ounce of formula. d. Request a genetic consultation.

Give the infant medication for pain.

A client delivers twins, one is stillborn and the other is recovering in intensive care nursery. As the nurse provides assistance to the bathroom, the client softly crying, states, "I wish my baby could have lived." Which response is best for the nurse to provide? a. "Don't be sad. You'll need to be strong to care for your healthy baby." b. "Do you want to go to the nursery and see your baby?" c. "I am sorry for your loss. Do you want to talk about it?" d. "It is always sad to lose a baby. Would you like me to call your minister?"

I am sorry for your loss. Do you want to talk about it?

What assessment finding should the nurse report to the healthcare provider that is consistent with concealed hemorrhage in an abruptio placenta? A) decrease in abdominal pain B) Hard board like abdomen C) Decrease in fundal height D) Maternal bradycardia

Hard Board like abdomen Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the blood manifests as a firm, board-like abdomen (B), which should be reported immediately to the healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised leading to fetal and maternal tachycardia, not (A). With abruptio placenta, fundal height and abdominal pain increase, not (C and D).

When discussing birth in a home setting with a group of pregnant women, which situation should the nurse include about the safety of a home birth? a. Only the woman and her midwife should be present during the delivery. b. The woman should live no more than 15 minutes from the hospital. c. The woman's extended family should be allowed to attend the home birth. d. Medical backup should be available quickly in case of complications.

Medical backup should be available quickly in case of complications.

Which nonpharmacologic interventions should the nurse implement to provide the most effective response in decreasing procedural pain in a neonate? a. Tactile stimulation. b. Commercial warm packs. c. Skin-to-skin contact with parent. d. Oral sucrose and nonnutritive sucking.

Oral sucrose and nonnutritive sucking.

The nurse observes a new mother avoiding eye contact with her newborn. Which action should the nurse take? a. Ask the mother why she won't look at the infant. b. Observe the mother for other attachment behaviors. c. Examine the newborn's eyes for the ability to focus. d. Recognize this as a common reaction in new mothers.

Observe the mother for other attachment behaviors.

A macrosomic infant is in stable condition after a difficult forceps-assisted delivery. After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the priority nursing action? a. Assess newborn reflexes for signs of neurological impairment. b. Leave the infant in the room with the mother to foster attachment. c. Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia. d. Perform a gestational age assessment to determine if the infant is large-for-gestational-age.

Obtain serum glucose levels frequently while observing closely for signs of hypoglycemia.

What action should the nurse implement when caring for a newborn receiving phototherapy? a. Reposition every 6 hours. b. Place an eyeshield over the eyes. c. Limit the intake of formula. d. Apply an oil-based lotion to the skin.

Phototherapy converts unconjugated bilirubin, which is deposited in the skin, to a water-soluble form that is more easily excreted by the liver. Exposure to the light source can increase the risk for ocular damage, so an eyeshield (B) is placed while the infant is under the light source. To ensure all body surfaces are exposed to the lights, the newborn should be reposition every 2 to 4 hours, not every 6 hours (A). Phototherapy can increase insensible water loss, and to prevent dehydration, fluid intake should be encouraged, not restricted (C). Lotions (D) absorb heat and can potentially cause burns and should not be used on the skin while phototherapy is in progress.

The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? a. Notify the healthcare provider of fetal status. b. Give oxygen at 10 L per nasal cannula. c. Place the client in a side-lying position. d. Increase the flow rate of intravenous fluids.

Place the client in a side-lying position. Rationale: Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance,characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position.

What action should the nurse implement with the family when an infant is born with anencephaly? a. Ensure that measures to facilitate the attachment process are offered. b. Prepare the family to explore ways to cope with the imminent death of the infant. c. Inform the family about multiple corrective surgical procedures that will be needed. d. Provide emotional support to facilitate the consideration of fetal organ donation.

Prepare the family to explore ways to cope with the imminent death of the infant.

What action should the nurse implement to prevent conductive heat loss in a newborn? a. Place the infant under a radiant warming system. b. Put a blanket on the scale when weighing the infant. c. Dry the newborn with a warmed blanket. d. Position the crib away from the windows.

Put a blanket on the scale when weighing the infant.

The nurse is providing discharge teaching for a gravid client who is being released from the hospital after placement of cerclage. Which instruction is the most important for the client to understand? a. Plan for a possible cesarean birth. b. Arrange for home uterine monitoring. c. Make arrangements for care at home. d. Report uterine cramping or low backache

Report uterine cramping or low backache

A 36-week gestation client with pregnancy-induced hypertension (PIH) is receiving an IV infusion of magnesium sulfate. Which assessment finding should the nurse report to the healthcare provider? a. Blood pressure of 100/60 mm Hg. b. Fetal heart rate of 120 to 125 beats/minute. c. Contractions occurring every 30 minutes. d. Respiratory rate of 11 breaths/minute.

Respiratory rate of 11 breaths/minute. Rationale: A sign of magnesium toxicity is respiratory depression, so the client's respiration rate of 11 breaths/minute should be reported to the healthcare provider.

A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? a. Excretes prolactin and insulin. b. Produces nutrients for fetal nutrition. c. Secretes both estrogen and progesterone. d. Forms a protective, impenetrable barrier.

Secretes both estrogen and progesterone

What information should the nurse include about perineal self-care for a client who is 24-hours post delivery? a. Use cool water to decrease swelling of the perineum. b. Perineal care should be done at least twice per day. c. Reapply ice packs to perineum after each voiding. d. Spray warm water from front to back using a squeeze bottle.

Spray warm water from front to back using a squeeze bottle. Rationale: A postpartum client should use a squeeze bottle after each void and clean from front to back.

The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding indicates that the nurse should discontinue the oxytocin infusion? a. The client needs to void. b. Amniotic membranes rupture. c. Uterine contractions occur every 8 to 10 minutes. d. The fetal heart rate is 180 bpm without variability.

The fetal heart rate is 180 bpm without variability.

A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby jumped in response to the noise. What information should the nurse provide? a. This is a demonstration of the fetus's acoustical reflex. b. The fetus can respond to sound by 24-weeks gestation. c. It is a coincidence the fetus responded at the same time. d. Report the fetus's behavior to the healthcare provider.

The fetus can respond to sound by 24-weeks gestation.

A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? a. Many women imagine what their baby is like by interpreting fetal movements. b. The fetus in utero is capable of hearing and does respond to the mother's voice. c. The healthcare provider should address her concerns about her baby's hearing function. d. The interaction between the mother's voice and the fetus's response ensures bonding.

The fetus in utero is capable of hearing and does respond to the mother's voice. Rationale: Fetal hearing and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound of the mother's voice.

A client states, "During the three months I've been pregnant, it seems like I have had to go to the bathroom every five minutes." Which explanation should the nurse provide to this client? a. The client may have a bladder or kidney infection. b. Bladder capacity increases during pregnancy. c. During pregnancy a woman is especially sensitive to body functions. d. The growing uterus is putting pressure on the bladder

The growing uterus is putting pressure on the bladder

A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? a. It depends on what the causative factors are for a CHD. b. We don't really know what or when CHDs occur. c. They usually occur in the first trimester of pregnancy. d. The heart develops in the third to fifth weeks after conception.

The heart develops in the third - fifth weeks after conception

A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife in providing obstetric care. What information should the nurse provide? a. Birth in the home setting is the preference for a using a midwife for delivery. b. The pregnancy should progress normally and be considered low risk. c. Natural child birth without analgesia is used to manage pain during labor. d. An obstetrician should also follow the client during pregnancy.

The pregnancy should progress normally and be considered low risk.

A client at 28-weeks gestation is concerned about her weight gain of 17 pounds. What information should the nurse provide this client? a. It is not necessary to keep such a close watch on weight gain. b. Try to exercise more because too much weight has been gained. c. Increase the calories in your diet to gain more weight per week. d. The weight gain is acceptable for the number of weeks pregnant.

The weight gain is acceptable for the number of weeks pregnant

A 31-year-old woman uses an over-the-counter (OTC) pregnancy test that is positive one week after a missed period. At the clinic, the client tells the nurse she takes phenytoin (Dilantin) for epilepsy, has a history of irregular periods, is under stress at work, and has not been sleeping well. The client's physical examination and ultrasound do not indicate that she is pregnant. How should the nurse explain the most likely cause for obtaining false-positive pregnancy test results? a. Having an irregular menstrual cycle. b. Using an anticonvulsant for epilepsy. c. Taking the pregnancy test too early. d. Being under too much stress at work.

Using an anticonvulsant for epilepsy

A multiparous client is bearing down with contractions and crying out, "The baby is coming!" Which immediate action should the nurse implement? a. Obtain a precipitous delivery tray. b. Visualize the perineum for bulging. c. Call the healthcare provider for a STAT delivery. d. Instruct the client's partner to stay for the delivery.

Visualize the perineum for bulging. Rationale: The perineum should be visualized for bulging or the presentation of the baby so assistance with the impending birth can be immediately rendered.