All 2026 Maternal/Child HESI V1 (id: 4496935)

Free preview · Original latest version

Sample questions from All 2026 Maternal/Child HESI V1 (id: 4496935)

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift in a mother-baby unit, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 2-day-old newborn with a bilirubin level of 9 mg/dL who is feeding every 3 hours
   • B.A 34-year-old client requesting help with breastfeeding before discharge
   • C.A 41-year-old client 8 hours after cesarean birth reporting incisional pain of 6 on a 0-to-10 scale
   • D.A 19-year-old client 1 hour after vaginal birth with a boggy uterus and a saturated perineal pad

   Rationale: The client with a boggy uterus and a saturated pad may be experiencing postpartum hemorrhage and requires immediate assessment and intervention. The newborn's bilirubin level and feeding pattern require monitoring but do not indicate an immediate threat. Breastfeeding assistance and pain management are important, but neither takes priority over possible active hemorrhage. Prioritize instability and risk of rapid deterioration.

2. 2.In a pediatric clinic, a 3-year-old client with a mild upper respiratory infection has a temperature of 37.8 C, HR 108, RR 24, and SpO2 98% on room air. Which task is appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Obtain and document the child's routine temperature
   • B.Evaluate whether the child's cough has improved after a prescribed medication
   • C.Assess the child's breath sounds and work of breathing
   • D.Teach the caregiver how to use a humidifier safely

   Rationale: Obtaining a routine temperature for a stable child is a predictable task that can be delegated to trained UAP, with the nurse responsible for reviewing the result. Assessment of respiratory status and evaluation of treatment response require nursing judgment. Teaching also remains the registered nurse's responsibility. Delegate tasks, not assessment, teaching, or evaluation.

3. 3.Refer to the client's chart. Which actions should the nurse take now to address the client's condition? Select all that apply.

   • A.Notify the obstetric provider and activate the unit's hemorrhage response
   • B.Assist the client to ambulate to the bathroom to empty the bladder
   • C.Massage the fundus and reassess uterine tone
   • D.Reassess the lochia and vital signs after completing other routine postpartum care
   • E.Maintain or establish large-bore intravenous access and prepare to administer prescribed fluids

   Rationale: Fundal massage is indicated because the chart shows a boggy uterus, increasing lochia, and a rising pulse; the documented pad saturation also warrants prompt provider notification and the hemorrhage response. The nurse should maintain or obtain large-bore access to support rapid fluid administration as prescribed. Ambulating a client with active bleeding and dizziness creates a fall risk, and delaying reassessment for routine care is unsafe. Prompt recognition and coordinated action are essential in postpartum hemorrhage.

4. 4.A 16-year-old client in the emergency department is accompanied by a parent and needs an urgent procedure. The client says, "I want to understand what will happen before I agree." Which action should the nurse take?

   • A.Ask the parent to sign the consent form because the client is a minor
   • B.Explain the procedure within the nurse's scope and support the client's questions before consent is obtained
   • C.Tell the client that the provider has already obtained consent and the procedure cannot be delayed
   • D.Ask the parent to explain the procedure so the nurse can prepare the client

   Answer and rationale are in the full material.

5. 5.During a home visit, a nurse finds a 5-year-old client with bruises of different ages on the back and upper arms. The caregiver says the child "falls a lot," while the child becomes quiet when the caregiver enters the room. What should the nurse do first?

   • A.Confront the caregiver and demand an explanation for the bruises
   • B.Arrange a routine clinic appointment and continue monitoring the family
   • C.Document objective findings and follow the required child-protection reporting process
   • D.Wait for the child to disclose abuse before taking further action

   Answer and rationale are in the full material.