Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
1. An expectant father tells the nurse D) Reassure him that normal maternal-fetal bond-
he fears that his wife is "losing her ing is occurring.
mind." He states that she is constant-
ly rubbing her abdomen and talk- Rationale:
ing to the baby and that she actuallyThese behaviors are positive signs of maternal-fetal
reprimands the baby when it moves bonding and do not reflect ambivalence. No inter-
too much. Which recommendation vention is needed. Quickening, the first perception
should the nurse make to this expec- of fetal movement, occurs at 17 to 20 weeks of ges-
tant father? tation and begins a new phase of prenatal bonding
during the second trimester. Options A and C are
A.Suggest that his wife seek profes- not necessary because the behaviors displayed are
sional counseling to deal with her normal.
symptoms.
B.Explain that his wife is exhibiting
ambivalence about the pregnancy.
C. Ask him to report similar abnormal
behaviors at the next prenatal visit.
D.Reassure him that normal mater-
nal-fetal bonding is occurring.
2. The nurse is preparing a laboring C. Fetal heart rate (FHR)
client for an amniotomy. Immediate-
ly after the procedure is completed, Rationale:
it is most important for the nurse to The FHR should be assessed before and after the
obtain which information? procedure to detect changes that may indicate the
presence of cord compression or prolapse. An am-
A.Maternal blood pressure niotomy (artificial rupture of membranes [AROM])
is used to stimulate labor when the condition of
B.Maternal temperature the cervix is favorable. The fluid should be assessed
for color, odor, and consistency. Option A should
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
C.Fetal heart rate (FHR) be assessed every 15 to 20 minutes during labor
but is not specific for AROM. Option B is monitored
D.White blood cell count (WBC) hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be
determined for all clients in labor.
3. A nurse receives a shift change re- B. Skin color that is slightly jaundiced
port for a newborn who is 12 hours
post-vaginal delivery. In developing a Rationale: Jaundice, a yellow skin coloration, is
plan of care, the nurse should give caused by elevated levels of bilirubin, which should
the highest priority to which finding? be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet)
A.Cyanosis of the hands and feet is a common finding in newborns; it occurs be-
cause the capillary system is immature. Milia are
B.Skin color that is slightly jaundiced small white papules present on the nose and chin
that are caused by sebaceous gland blockage and
C.Tiny white papules on the nose or
disappear in a few weeks. Small red patches on
chin
the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
D.Red patches on the cheeks and
trunk
4. A breastfeeding postpartum client is A.Breastfeed the infant, ensuring that both breasts
diagnosed with mastitis, and antibi- are completely emptied.
otic therapy is prescribed. Which in-
struction should the nurse provide to Rationale:Mastitis, caused by plugged milk ducts, is
this client? related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of
A.Breastfeed the infant, ensuring engorged breasts, eliminating the pressure on the
that both breasts are completely inflamed breast tissue. Option B is less painful but
emptied. does not facilitate complete emptying of the breast
tissue. Option C will not relieve the engorgement
B.Feed expressed breast milk to
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
avoid the pain of the infant latching on the affected side. Option D will not decrease
onto the infected breast. antibiotic effects on the infant.
C.Breastfeed on the unaffected
breast only until the mastitis sub-
sides.
D.Dilute expressed breast milk with
sterile water to reduce the antibiotic
effect on the infant.
5. A 38-week primigravida who works C.Move about every hour.
as a secretary and sits at a computer
8 hours each day tells the nurse that Rationale:
her feet have begun to swell. Which Pooling of blood in the lower extremities results
instruction will aid in the prevention from the enlarged uterus exerting pressure on the
of pooling of blood in the lower ex- pelvic veins. Moving about every hour will relieve
tremities? pressure on the pelvic veins and increase venous
return. Option A would increase venous return from
A.Wear support stockings. varicose veins in the lower extremities but would
be of little help with swelling. Option B might be
B.Reduce salt in the diet. helpful with generalized edema but is not specific
for edematous lower extremities. Option D does not
C.Move about every hour.
address venous return, and there is no indication in
the question that constrictive clothing is a problem.
D.Avoid constrictive clothing.
6. Twenty-four hours after admis- A.Cephalhematoma, which is caused by forceps
sion to the newborn nursery, a trauma
full-term male infant develops local-
ized swelling on the right side of his Rationale: Cephalhematoma, a slight abnormal vari-
head. In a newborn, what is the most ation of the newborn, usually arises within the first
likely cause of this accumulation of 24 hours after delivery. Trauma from delivery caus-
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
blood between the periosteum and es capillary bleeding between the periosteum and
skull that does not cross the suture skull. Option C is a cranial distortion lasting 5 to 7
line? days, caused by pressure on the cranium during
vaginal delivery, and is a common variation of the
A.Cephalhematoma, which is caused newborn. Options B and D both involve intracranial
by forceps trauma bleeding and could not be detected by physical
assessment alone.
B.Subarachnoid hematoma, which
requires immediate drainage
C.Molding, which is caused by pres-
sure during labor
D.Subdural hematoma, which can re-
sult in lifelong damage
7. Prior to discharge, what instructions C.Allow the cord to air-dry as much as possible.
should the nurse give to parents re-
garding the newborn's umbilical cord Rationale:Recent studies have indicated that air dry-
care at home? ing or plain water application may be equal to
or more effective than alcohol in the cord healing
A.Wash the cord frequently with mild process. Options A, B, and D are incorrect because
soap and water. they promote moisture and increase the potential
for infection.
B.Cover the cord with a sterile dress-
ing.
C.Allow the cord to air-dry as much
as possible.
D.Apply baby lotion after the baby's
daily bath
Study online at https://quizlet.com/_9fcccz
1. An expectant father tells the nurse D) Reassure him that normal maternal-fetal bond-
he fears that his wife is "losing her ing is occurring.
mind." He states that she is constant-
ly rubbing her abdomen and talk- Rationale:
ing to the baby and that she actuallyThese behaviors are positive signs of maternal-fetal
reprimands the baby when it moves bonding and do not reflect ambivalence. No inter-
too much. Which recommendation vention is needed. Quickening, the first perception
should the nurse make to this expec- of fetal movement, occurs at 17 to 20 weeks of ges-
tant father? tation and begins a new phase of prenatal bonding
during the second trimester. Options A and C are
A.Suggest that his wife seek profes- not necessary because the behaviors displayed are
sional counseling to deal with her normal.
symptoms.
B.Explain that his wife is exhibiting
ambivalence about the pregnancy.
C. Ask him to report similar abnormal
behaviors at the next prenatal visit.
D.Reassure him that normal mater-
nal-fetal bonding is occurring.
2. The nurse is preparing a laboring C. Fetal heart rate (FHR)
client for an amniotomy. Immediate-
ly after the procedure is completed, Rationale:
it is most important for the nurse to The FHR should be assessed before and after the
obtain which information? procedure to detect changes that may indicate the
presence of cord compression or prolapse. An am-
A.Maternal blood pressure niotomy (artificial rupture of membranes [AROM])
is used to stimulate labor when the condition of
B.Maternal temperature the cervix is favorable. The fluid should be assessed
for color, odor, and consistency. Option A should
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
C.Fetal heart rate (FHR) be assessed every 15 to 20 minutes during labor
but is not specific for AROM. Option B is monitored
D.White blood cell count (WBC) hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be
determined for all clients in labor.
3. A nurse receives a shift change re- B. Skin color that is slightly jaundiced
port for a newborn who is 12 hours
post-vaginal delivery. In developing a Rationale: Jaundice, a yellow skin coloration, is
plan of care, the nurse should give caused by elevated levels of bilirubin, which should
the highest priority to which finding? be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet)
A.Cyanosis of the hands and feet is a common finding in newborns; it occurs be-
cause the capillary system is immature. Milia are
B.Skin color that is slightly jaundiced small white papules present on the nose and chin
that are caused by sebaceous gland blockage and
C.Tiny white papules on the nose or
disappear in a few weeks. Small red patches on
chin
the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
D.Red patches on the cheeks and
trunk
4. A breastfeeding postpartum client is A.Breastfeed the infant, ensuring that both breasts
diagnosed with mastitis, and antibi- are completely emptied.
otic therapy is prescribed. Which in-
struction should the nurse provide to Rationale:Mastitis, caused by plugged milk ducts, is
this client? related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of
A.Breastfeed the infant, ensuring engorged breasts, eliminating the pressure on the
that both breasts are completely inflamed breast tissue. Option B is less painful but
emptied. does not facilitate complete emptying of the breast
tissue. Option C will not relieve the engorgement
B.Feed expressed breast milk to
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
avoid the pain of the infant latching on the affected side. Option D will not decrease
onto the infected breast. antibiotic effects on the infant.
C.Breastfeed on the unaffected
breast only until the mastitis sub-
sides.
D.Dilute expressed breast milk with
sterile water to reduce the antibiotic
effect on the infant.
5. A 38-week primigravida who works C.Move about every hour.
as a secretary and sits at a computer
8 hours each day tells the nurse that Rationale:
her feet have begun to swell. Which Pooling of blood in the lower extremities results
instruction will aid in the prevention from the enlarged uterus exerting pressure on the
of pooling of blood in the lower ex- pelvic veins. Moving about every hour will relieve
tremities? pressure on the pelvic veins and increase venous
return. Option A would increase venous return from
A.Wear support stockings. varicose veins in the lower extremities but would
be of little help with swelling. Option B might be
B.Reduce salt in the diet. helpful with generalized edema but is not specific
for edematous lower extremities. Option D does not
C.Move about every hour.
address venous return, and there is no indication in
the question that constrictive clothing is a problem.
D.Avoid constrictive clothing.
6. Twenty-four hours after admis- A.Cephalhematoma, which is caused by forceps
sion to the newborn nursery, a trauma
full-term male infant develops local-
ized swelling on the right side of his Rationale: Cephalhematoma, a slight abnormal vari-
head. In a newborn, what is the most ation of the newborn, usually arises within the first
likely cause of this accumulation of 24 hours after delivery. Trauma from delivery caus-
, Maternity HESI Test bank (combined red hesi and other sources)
Study online at https://quizlet.com/_9fcccz
blood between the periosteum and es capillary bleeding between the periosteum and
skull that does not cross the suture skull. Option C is a cranial distortion lasting 5 to 7
line? days, caused by pressure on the cranium during
vaginal delivery, and is a common variation of the
A.Cephalhematoma, which is caused newborn. Options B and D both involve intracranial
by forceps trauma bleeding and could not be detected by physical
assessment alone.
B.Subarachnoid hematoma, which
requires immediate drainage
C.Molding, which is caused by pres-
sure during labor
D.Subdural hematoma, which can re-
sult in lifelong damage
7. Prior to discharge, what instructions C.Allow the cord to air-dry as much as possible.
should the nurse give to parents re-
garding the newborn's umbilical cord Rationale:Recent studies have indicated that air dry-
care at home? ing or plain water application may be equal to
or more effective than alcohol in the cord healing
A.Wash the cord frequently with mild process. Options A, B, and D are incorrect because
soap and water. they promote moisture and increase the potential
for infection.
B.Cover the cord with a sterile dress-
ing.
C.Allow the cord to air-dry as much
as possible.
D.Apply baby lotion after the baby's
daily bath
