Fortis PN Maternity HESI Exam Questions and
Answers | Complete Practical Nursing Maternity
Study Guide
Question 1: A practical nurse is caring for a client at 32 weeks gestation who reports experiencing
occasional Braxton Hicks contractions. Which statement by the client indicates understanding of the
teaching provided?
A. "I should go to the hospital if these contractions become regular and painful."
B. "These contractions mean I am going into preterm labor."
C. "I need to take medication to stop these contractions immediately."
D. "Braxton Hicks contractions cause cervical dilation and require intervention."
CORRECT ANSWER: A. "I should go to the hospital if these contractions become regular and painful."
RATIONALE: Braxton Hicks contractions are irregular, painless uterine contractions that are normal
during pregnancy. They do not cause cervical changes. However, if contractions become regular, painful,
or increase in frequency, this may indicate preterm labor, and the client should seek medical evaluation.
Options B, C, and D reflect misunderstandings about the nature of Braxton Hicks contractions.
Question 2: During a prenatal assessment, a client at 28 weeks gestation has a fundal height
measurement of 30 cm. What is the most appropriate action for the practical nurse to take?
A. Document the finding as normal and continue routine care.
B. Notify the registered nurse or provider immediately for possible fetal growth restriction.
C. Schedule an immediate ultrasound to assess fetal well-being.
D. Instruct the client to increase caloric intake to promote fetal growth.
CORRECT ANSWER: A. Document the finding as normal and continue routine care.
RATIONALE: Fundal height in centimeters typically corresponds to gestational age in weeks between
20-34 weeks, with a variation of ±2 cm considered normal. A measurement of 30 cm at 28 weeks
gestation falls within the expected range. No immediate intervention is required; the finding should be
documented and monitored at subsequent visits. Options B, C, and D represent unnecessary
interventions for a normal finding.
Question 3: A practical nurse is preparing to administer Rho(D) immune globulin to a Rh-negative
client at 28 weeks gestation. Which assessment finding is a priority before administration?
A. Client's blood type and Rh status confirmation
B. Client's history of allergies to immunizations
C. Results of the indirect Coombs test
D. Client's understanding of the medication purpose
CORRECT ANSWER: C. Results of the indirect Coombs test
RATIONALE: Rho(D) immune globulin is administered to Rh-negative clients who are not already
sensitized to Rh-positive blood. The indirect Coombs test detects the presence of anti-Rh antibodies. If
the test is positive, the client is already sensitized, and RhoGAM will not be effective. Confirming a
,negative indirect Coombs test is essential before administration. While options A, B, and D are
important, the Coombs test result is the priority assessment to determine eligibility for the medication.
Question 4: A client in the first trimester of pregnancy reports severe nausea and vomiting. Which
dietary recommendation should the practical nurse provide?
A. "Eat three large meals per day to maintain nutrition."
B. "Consume dry crackers or toast before getting out of bed in the morning."
C. "Avoid all carbohydrates to reduce nausea triggers."
D. "Drink large amounts of fluid with meals to stay hydrated."
CORRECT ANSWER: B. "Consume dry crackers or toast before getting out of bed in the morning."
RATIONALE: Eating small, frequent meals and consuming dry, bland carbohydrates like crackers or
toast before rising can help alleviate morning sickness by stabilizing blood glucose and reducing gastric
acidity. Large meals (A) may worsen nausea. Avoiding all carbohydrates (C) is unnecessary and may limit
essential nutrients. Drinking large fluids with meals (D) can distend the stomach and increase nausea;
fluids are better tolerated between meals.
Question 5: A practical nurse is caring for a client who is 39 weeks gestation and reports a sudden
gush of fluid from the vagina. What is the priority nursing action?
A. Assess the color, odor, and amount of fluid.
B. Place the client in a Trendelenburg position.
C. Immediately notify the provider of possible rupture of membranes.
D. Perform a sterile vaginal examination to assess cervical dilation.
CORRECT ANSWER: A. Assess the color, odor, and amount of fluid.
RATIONALE: When a client reports rupture of membranes, the priority is to assess the fluid
characteristics to determine if it is amniotic fluid and to identify signs of complications such as
meconium (green/brown color) or infection (foul odor). This assessment guides subsequent
interventions. Notifying the provider (C) is important but follows initial assessment. Trendelenburg
position (B) is not indicated unless cord prolapse is suspected. Sterile vaginal examination (D) should be
avoided until rupture is confirmed and provider evaluation occurs to reduce infection risk.
Question 6: During active labor, a client's fetal heart rate monitoring shows late decelerations. Which
intervention should the practical nurse implement first?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Reposition the client to the left lateral position.
C. Increase the rate of IV fluids.
D. Prepare for immediate cesarean delivery.
CORRECT ANSWER: B. Reposition the client to the left lateral position.
RATIONALE: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. The first
intervention is to improve placental perfusion by repositioning the client to the left lateral position,
which relieves pressure on the vena cava and enhances blood flow to the uterus. Oxygen administration
,(A) and IV fluid increase (C) are appropriate subsequent interventions. Preparing for cesarean delivery
(D) may be necessary if interventions fail, but repositioning is the immediate first step.
Question 7: A practical nurse is providing postpartum care to a client who delivered vaginally 2 hours
ago. Which assessment finding requires immediate intervention?
A. Fundus firm and at the level of the umbilicus.
B. Lochia rubra with small clots.
C. Perineal edema and mild discomfort.
D. Saturated perineal pad in 15 minutes.
CORRECT ANSWER: D. Saturated perineal pad in 15 minutes.
RATIONALE: Saturating a perineal pad in 15 minutes indicates excessive bleeding (postpartum
hemorrhage), which is a medical emergency requiring immediate intervention such as fundal massage,
notification of the provider, and preparation for additional treatments. A firm fundus at the umbilicus
(A), lochia rubra with small clots (B), and mild perineal edema (C) are normal findings in the immediate
postpartum period.
Question 8: A newborn is assessed 1 minute after birth with a heart rate of 90 bpm, slow irregular
respirations, some flexion of extremities, grimace response to stimulation, and pink body with blue
extremities. What is the newborn's Apgar score?
A. 4
B. 5
C. 6
D. 7
CORRECT ANSWER: B. 5
RATIONALE: Apgar scoring: Heart rate 90 bpm = 1 point (below 100); slow irregular respirations = 1
point; some flexion = 1 point (activity); grimace = 1 point (grimace); pink body/blue extremities = 1 point
(appearance). Total = 5. This score indicates the newborn requires some resuscitative assistance. A score
of 4 (A) would be too low; 6 (C) or 7 (D) would require stronger scores in one or more categories.
Question 9: A practical nurse is teaching a postpartum client about signs of infection. Which
statement by the client indicates a need for further teaching?
A. "I should report a fever above 100.4°F (38°C)."
B. "Foul-smelling lochia is normal for the first week."
C. "Increased pain or redness at my incision site needs evaluation."
D. "Painful urination could indicate a urinary tract infection."
CORRECT ANSWER: B. "Foul-smelling lochia is normal for the first week."
RATIONALE: Foul-smelling lochia is NOT normal and may indicate endometritis or infection, requiring
prompt medical evaluation. The other statements reflect accurate understanding: fever >100.4°F (A),
incision changes (C), and dysuria (D) are all signs of potential postpartum complications that should be
reported.
, Question 10: A client at 36 weeks gestation is diagnosed with preeclampsia. Which assessment finding
should the practical nurse report to the registered nurse immediately?
A. Blood pressure 148/92 mmHg
B. 1+ proteinuria on dipstick
C. Reports of severe headache and visual changes
D. 2+ pitting edema in lower extremities
CORRECT ANSWER: C. Reports of severe headache and visual changes
RATIONALE: Severe headache and visual changes are signs of cerebral involvement and may indicate
progression to eclampsia (seizures), which is a life-threatening emergency requiring immediate
intervention. While elevated BP (A), proteinuria (B), and edema (D) are expected findings in
preeclampsia, neurological symptoms represent a critical change requiring urgent notification.
Question 11: A practical nurse is caring for a client receiving oxytocin for labor induction. Which
finding requires the nurse to stop the oxytocin infusion?
A. Contractions every 3 minutes lasting 60 seconds
B. Fetal heart rate baseline of 150 bpm with moderate variability
C. Uterine contractions lasting longer than 90 seconds
D. Maternal heart rate of 100 bpm
CORRECT ANSWER: C. Uterine contractions lasting longer than 90 seconds
RATIONALE: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation, which can
compromise fetal oxygenation and requires immediate discontinuation of oxytocin. Contractions every 3
minutes lasting 60 seconds (A) represent adequate labor progress. A fetal heart rate of 150 bpm with
moderate variability (B) is reassuring. Maternal tachycardia of 100 bpm (D) may be normal in labor but
does not require stopping oxytocin.
Question 12: A practical nurse is providing newborn care education to a first-time parent. Which
statement about umbilical cord care is correct?
A. "Apply alcohol to the cord stump three times daily until it falls off."
B. "Keep the cord stump covered with the diaper to prevent contamination."
C. "Clean the cord stump with soap and water during each diaper change."
D. "Fold the diaper below the cord stump to keep it exposed to air."
CORRECT ANSWER: D. "Fold the diaper below the cord stump to keep it exposed to air."
RATIONALE: Current evidence-based practice recommends keeping the umbilical cord stump clean and
dry, exposed to air to promote healing and prevent infection. Folding the diaper below the stump
achieves this. Alcohol application (A) is no longer routinely recommended as it may delay separation.
Covering with the diaper (B) traps moisture and increases infection risk. Soap and water cleaning (C) is
unnecessary and may irritate the area; gentle cleaning with water if soiled is sufficient.
Answers | Complete Practical Nursing Maternity
Study Guide
Question 1: A practical nurse is caring for a client at 32 weeks gestation who reports experiencing
occasional Braxton Hicks contractions. Which statement by the client indicates understanding of the
teaching provided?
A. "I should go to the hospital if these contractions become regular and painful."
B. "These contractions mean I am going into preterm labor."
C. "I need to take medication to stop these contractions immediately."
D. "Braxton Hicks contractions cause cervical dilation and require intervention."
CORRECT ANSWER: A. "I should go to the hospital if these contractions become regular and painful."
RATIONALE: Braxton Hicks contractions are irregular, painless uterine contractions that are normal
during pregnancy. They do not cause cervical changes. However, if contractions become regular, painful,
or increase in frequency, this may indicate preterm labor, and the client should seek medical evaluation.
Options B, C, and D reflect misunderstandings about the nature of Braxton Hicks contractions.
Question 2: During a prenatal assessment, a client at 28 weeks gestation has a fundal height
measurement of 30 cm. What is the most appropriate action for the practical nurse to take?
A. Document the finding as normal and continue routine care.
B. Notify the registered nurse or provider immediately for possible fetal growth restriction.
C. Schedule an immediate ultrasound to assess fetal well-being.
D. Instruct the client to increase caloric intake to promote fetal growth.
CORRECT ANSWER: A. Document the finding as normal and continue routine care.
RATIONALE: Fundal height in centimeters typically corresponds to gestational age in weeks between
20-34 weeks, with a variation of ±2 cm considered normal. A measurement of 30 cm at 28 weeks
gestation falls within the expected range. No immediate intervention is required; the finding should be
documented and monitored at subsequent visits. Options B, C, and D represent unnecessary
interventions for a normal finding.
Question 3: A practical nurse is preparing to administer Rho(D) immune globulin to a Rh-negative
client at 28 weeks gestation. Which assessment finding is a priority before administration?
A. Client's blood type and Rh status confirmation
B. Client's history of allergies to immunizations
C. Results of the indirect Coombs test
D. Client's understanding of the medication purpose
CORRECT ANSWER: C. Results of the indirect Coombs test
RATIONALE: Rho(D) immune globulin is administered to Rh-negative clients who are not already
sensitized to Rh-positive blood. The indirect Coombs test detects the presence of anti-Rh antibodies. If
the test is positive, the client is already sensitized, and RhoGAM will not be effective. Confirming a
,negative indirect Coombs test is essential before administration. While options A, B, and D are
important, the Coombs test result is the priority assessment to determine eligibility for the medication.
Question 4: A client in the first trimester of pregnancy reports severe nausea and vomiting. Which
dietary recommendation should the practical nurse provide?
A. "Eat three large meals per day to maintain nutrition."
B. "Consume dry crackers or toast before getting out of bed in the morning."
C. "Avoid all carbohydrates to reduce nausea triggers."
D. "Drink large amounts of fluid with meals to stay hydrated."
CORRECT ANSWER: B. "Consume dry crackers or toast before getting out of bed in the morning."
RATIONALE: Eating small, frequent meals and consuming dry, bland carbohydrates like crackers or
toast before rising can help alleviate morning sickness by stabilizing blood glucose and reducing gastric
acidity. Large meals (A) may worsen nausea. Avoiding all carbohydrates (C) is unnecessary and may limit
essential nutrients. Drinking large fluids with meals (D) can distend the stomach and increase nausea;
fluids are better tolerated between meals.
Question 5: A practical nurse is caring for a client who is 39 weeks gestation and reports a sudden
gush of fluid from the vagina. What is the priority nursing action?
A. Assess the color, odor, and amount of fluid.
B. Place the client in a Trendelenburg position.
C. Immediately notify the provider of possible rupture of membranes.
D. Perform a sterile vaginal examination to assess cervical dilation.
CORRECT ANSWER: A. Assess the color, odor, and amount of fluid.
RATIONALE: When a client reports rupture of membranes, the priority is to assess the fluid
characteristics to determine if it is amniotic fluid and to identify signs of complications such as
meconium (green/brown color) or infection (foul odor). This assessment guides subsequent
interventions. Notifying the provider (C) is important but follows initial assessment. Trendelenburg
position (B) is not indicated unless cord prolapse is suspected. Sterile vaginal examination (D) should be
avoided until rupture is confirmed and provider evaluation occurs to reduce infection risk.
Question 6: During active labor, a client's fetal heart rate monitoring shows late decelerations. Which
intervention should the practical nurse implement first?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Reposition the client to the left lateral position.
C. Increase the rate of IV fluids.
D. Prepare for immediate cesarean delivery.
CORRECT ANSWER: B. Reposition the client to the left lateral position.
RATIONALE: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. The first
intervention is to improve placental perfusion by repositioning the client to the left lateral position,
which relieves pressure on the vena cava and enhances blood flow to the uterus. Oxygen administration
,(A) and IV fluid increase (C) are appropriate subsequent interventions. Preparing for cesarean delivery
(D) may be necessary if interventions fail, but repositioning is the immediate first step.
Question 7: A practical nurse is providing postpartum care to a client who delivered vaginally 2 hours
ago. Which assessment finding requires immediate intervention?
A. Fundus firm and at the level of the umbilicus.
B. Lochia rubra with small clots.
C. Perineal edema and mild discomfort.
D. Saturated perineal pad in 15 minutes.
CORRECT ANSWER: D. Saturated perineal pad in 15 minutes.
RATIONALE: Saturating a perineal pad in 15 minutes indicates excessive bleeding (postpartum
hemorrhage), which is a medical emergency requiring immediate intervention such as fundal massage,
notification of the provider, and preparation for additional treatments. A firm fundus at the umbilicus
(A), lochia rubra with small clots (B), and mild perineal edema (C) are normal findings in the immediate
postpartum period.
Question 8: A newborn is assessed 1 minute after birth with a heart rate of 90 bpm, slow irregular
respirations, some flexion of extremities, grimace response to stimulation, and pink body with blue
extremities. What is the newborn's Apgar score?
A. 4
B. 5
C. 6
D. 7
CORRECT ANSWER: B. 5
RATIONALE: Apgar scoring: Heart rate 90 bpm = 1 point (below 100); slow irregular respirations = 1
point; some flexion = 1 point (activity); grimace = 1 point (grimace); pink body/blue extremities = 1 point
(appearance). Total = 5. This score indicates the newborn requires some resuscitative assistance. A score
of 4 (A) would be too low; 6 (C) or 7 (D) would require stronger scores in one or more categories.
Question 9: A practical nurse is teaching a postpartum client about signs of infection. Which
statement by the client indicates a need for further teaching?
A. "I should report a fever above 100.4°F (38°C)."
B. "Foul-smelling lochia is normal for the first week."
C. "Increased pain or redness at my incision site needs evaluation."
D. "Painful urination could indicate a urinary tract infection."
CORRECT ANSWER: B. "Foul-smelling lochia is normal for the first week."
RATIONALE: Foul-smelling lochia is NOT normal and may indicate endometritis or infection, requiring
prompt medical evaluation. The other statements reflect accurate understanding: fever >100.4°F (A),
incision changes (C), and dysuria (D) are all signs of potential postpartum complications that should be
reported.
, Question 10: A client at 36 weeks gestation is diagnosed with preeclampsia. Which assessment finding
should the practical nurse report to the registered nurse immediately?
A. Blood pressure 148/92 mmHg
B. 1+ proteinuria on dipstick
C. Reports of severe headache and visual changes
D. 2+ pitting edema in lower extremities
CORRECT ANSWER: C. Reports of severe headache and visual changes
RATIONALE: Severe headache and visual changes are signs of cerebral involvement and may indicate
progression to eclampsia (seizures), which is a life-threatening emergency requiring immediate
intervention. While elevated BP (A), proteinuria (B), and edema (D) are expected findings in
preeclampsia, neurological symptoms represent a critical change requiring urgent notification.
Question 11: A practical nurse is caring for a client receiving oxytocin for labor induction. Which
finding requires the nurse to stop the oxytocin infusion?
A. Contractions every 3 minutes lasting 60 seconds
B. Fetal heart rate baseline of 150 bpm with moderate variability
C. Uterine contractions lasting longer than 90 seconds
D. Maternal heart rate of 100 bpm
CORRECT ANSWER: C. Uterine contractions lasting longer than 90 seconds
RATIONALE: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation, which can
compromise fetal oxygenation and requires immediate discontinuation of oxytocin. Contractions every 3
minutes lasting 60 seconds (A) represent adequate labor progress. A fetal heart rate of 150 bpm with
moderate variability (B) is reassuring. Maternal tachycardia of 100 bpm (D) may be normal in labor but
does not require stopping oxytocin.
Question 12: A practical nurse is providing newborn care education to a first-time parent. Which
statement about umbilical cord care is correct?
A. "Apply alcohol to the cord stump three times daily until it falls off."
B. "Keep the cord stump covered with the diaper to prevent contamination."
C. "Clean the cord stump with soap and water during each diaper change."
D. "Fold the diaper below the cord stump to keep it exposed to air."
CORRECT ANSWER: D. "Fold the diaper below the cord stump to keep it exposed to air."
RATIONALE: Current evidence-based practice recommends keeping the umbilical cord stump clean and
dry, exposed to air to promote healing and prevent infection. Folding the diaper below the stump
achieves this. Alcohol application (A) is no longer routinely recommended as it may delay separation.
Covering with the diaper (B) traps moisture and increases infection risk. Soap and water cleaning (C) is
unnecessary and may irritate the area; gentle cleaning with water if soiled is sufficient.
