*NURSING > EXAM > 2022 HESI Maternity/Pediatrics (PEDS) Exam, Answered (All)

2022 HESI Maternity/Pediatrics (PEDS) Exam, Answered

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2022 HESI Maternity/Pediatrics (PEDS) Exam, Answered-A 3-month-old with myelomeningocele and atonic bladder is catheterized every four hours to prevent urinary retention. The home health nurse notes t... hat the child has developed episodes of sneezing, urticaria,, watery eyes, ad a rash in the diaper area. What action is most important for the nurse to take? - Change to latex - free gloves when handling infant The 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? - Crying without tears A 6-year old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is most important for the nurse to implement? - Assess bilateral lung sounds A 34-week primigravida with preeclampsia is receiving Lactated Ringer's 500 ML with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many mL/hour should be the nurse program into the infusion pump? - 75mL/hour A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? - Notify healthcare provider at patients' bedside A 39 week gestation, a multigravida is having a non-stress test (NST). The fetal heart rate (FHR) has remained non- reactive during the 30 minutes of evaluation. Based on this finding, which action should the nurse implement? - Place an acoustic simulator on the abdomen. Artificial rupture of the membranes of a laboring client reveals meconium- stained fluid. What intervention has the greatest priority? - Have a meconium aspirator available at delivery At 20 weeks gestation, a client who has gained 20 pounds during pregnant states that she is felling fetal movement. Fundal height measurement is 20 cm, and the clients only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? - Gestational weight gain. A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2 F, with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? - Chorioamnionitis A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. What information is most important foe the nurse to obtain first? - Color and consistency of fluid A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client's condition, what information is most important for the nurse to provide? - Maternal blood pressure A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilatation, 60% effacement, and a -2 station. What action should the nurse implement first? o- Determine current cervical dilation A community health nurse visits a family in which a 16-year old unmarried daughter is pregnant with her first child and is at 32 weeks gestation. The client tells the nurse that she has been intermittent back pain since the night before. What is the priority nursing intervention? - ask the client if she has experienced any recent changes in vaginal discharge The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? - Document vital signs in record (normal) A four-year-old boy was recently diagnosis with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during initial teaching? - Lower legs become progressively weaker, causing a wedding, unsteady gait A full-term 24 hour old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? - Stimulate the infant to cry The healthcare provider prescribes amoxicillin 500 mg PO every eight hours for a child who weighs 77 pounds. The available suspension is labeled, amoxicillin suspension 250 mg/5 ml. The recommended maximum does is 50 mg/kg/24 hour. How many mL should the nurse administer in a single dose based on the child's weight? (enter the numerical value only. If rounding is required, round to the whole number.) - 10mL/dose An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take? - Determine infants blood sugar level An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. What action should the nurse implement first? - Place the infant in a knee -chest position Insulin therapy is initiated for a 12 year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is important for the nurse to include in the child plan of care? - Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R). A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? - Report to HCP A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. What prescription is most important to implement? - Infuse normal saline intravenously A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "why is my baby sister eating my mommy's breast?" How should the nurse responds? (Select all that apply.) - -Remind him that his mother breastfed him too -Reassure the older brother that it does not hurt -Explain that newborns get milk mothers this way A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? - Advice the mother to wait at least another month before starting any solid foods. The nurse is assessing a 2 hour-old infant born by cesarean delivery at 39-weeks gestation. Which finding should receive the highest priority when planning the infants care? - Respiratory rate of 76 breaths per min The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life? - Cries vigorously when stimulated The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complains of blurry vision and a severe frontal headache. Which medication should the nurse anticipate for this client? [Show More]

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