HESI Exit Exam 202 Test Bank: The
Ultimate Study Guide with Questions
and Verified Answers for 2025/2026 to
Ensure You Pass on the First Try
Question 1
A nurse is assessing a client who is at 35 weeks of gestation and reports a headache and
blurred vision. The client’s blood pressure is 168/102 mm Hg, and urine dipstick reveals
3+ protein. Which of the following actions should the nurse take first?
A. Administer labetalol IV push
B. Place the client in a left lateral position
C. Assess deep tendon reflexes
D. Notify the provider immediately
Answer: B. Place the client in a left lateral position
Rationale:
The client is showing signs of severe preeclampsia (severe hypertension, proteinuria,
headache, blurred vision). The priority is to improve uteroplacental perfusion and
reduce the risk of seizures by positioning the client in a left lateral position. This
alleviates pressure on the vena cava, improving cardiac output and placental blood flow.
While administering antihypertensives, assessing reflexes, and notifying the provider are
all important, positioning is the immediate nursing action to enhance perfusion and
safety.
Question 2
A nurse is caring for a client in active labor. The client’s cervix is dilated to 7 cm, and the
fetal heart rate (FHR) tracing shows recurrent late decelerations. Which of the following
is the priority nursing intervention?
,A. Increase the rate of IV oxytocin
B. Position the client on her left side
C. Prepare for an immediate cesarean birth
D. Administer oxygen at 2 L/min via nasal cannula
Answer: B. Position the client on her left side
Rationale:
Late decelerations indicate uteroplacental insufficiency. The first-line interventions are
to increase placental blood flow by turning the client to the left lateral position, then
administering oxygen at 10 L/min via non-rebreather mask, and increasing IV fluid
rate. Oxytocin should be discontinued, not increased. While a cesarean may be
necessary if the pattern does not resolve, it is not the immediate priority.
Question 3
A nurse is assessing a newborn who is 12 hours old. The nurse notes jaundice on the
face and chest. The mother is Rh-negative and received Rho(D) immune globulin at 28
weeks. Which of the following actions should the nurse take?
A. Prepare the newborn for phototherapy
B. Obtain a direct Coombs test result
C. Encourage early and frequent breastfeeding
D. Notify the provider of possible hemolytic disease
Answer: C. Encourage early and frequent breastfeeding
Rationale:
Jaundice within the first 24 hours is always abnormal, but in this scenario, the mother
received RhoGAM, which reduces the risk of Rh incompatibility. Physiologic jaundice
typically appears after 24 hours. Early and frequent feeding helps promote passage of
meconium and reduces enterohepatic circulation, which can help prevent worsening
hyperbilirubinemia. While the direct Coombs test may have been done at birth, the
nurse’s initial action is to support feeding. Phototherapy may be indicated if bilirubin
levels rise, but it is not the first action.
,Question 4
A nurse is providing discharge teaching to a client who is 24 hours postpartum and is
breastfeeding. Which of the following statements by the client indicates a need for
further teaching?
A. “I should feel my uterus as a firm mass at my belly button for the next few days.”
B. “If I feel a hard lump in my breast, I should apply warm compresses and feed
frequently.”
C. “It’s normal for my baby to have at least 6 to 8 wet diapers a day after my milk comes
in.”
D. “I can use ibuprofen for afterpains while breastfeeding.”
Answer: A. “I should feel my uterus as a firm mass at my belly button for the next
few days.”
Rationale:
By 24 hours postpartum, the fundus should be approximately 1 cm below the
umbilicus and should continue to descend about 1 cm per day. By day 2, it is typically
at or below the umbilicus. A fundus at the umbilicus several days after birth could
indicate subinvolution. The other statements are correct: warm compresses and feeding
help relieve plugged ducts; adequate wet diapers indicate hydration; ibuprofen is safe
for afterpains in breastfeeding mothers.
Question 5
A nurse is caring for a client who is receiving IV magnesium sulfate for severe
preeclampsia. Which of the following findings indicates magnesium toxicity?
A. Respiratory rate of 14 breaths per minute
B. Urinary output of 35 mL per hour
C. Deep tendon reflexes 2+
D. Decreased level of consciousness
Answer: D. Decreased level of consciousness
Rationale:
Signs of magnesium toxicity include decreased level of consciousness, respiratory
, depression (less than 12 breaths/min), absent deep tendon reflexes, and decreased
urinary output (less than 30 mL/hr) . A respiratory rate of 14 is within normal limits;
urinary output of 35 mL/hr is acceptable; and 2+ reflexes are normal. The earliest sign of
toxicity is often loss of patellar reflexes, followed by respiratory depression and altered
mental status.
Question 6
A nurse is assessing a newborn who was born 6 hours ago to a client with gestational
diabetes. Which of the following findings should the nurse report to the provider?
A. Blood glucose level of 48 mg/dL
B. Jitteriness and high-pitched cry
C. Apgar scores of 8 at 1 minute and 9 at 5 minutes
D. Birth weight of 8 lb (3,629 g)
Answer: B. Jitteriness and high-pitched cry
Rationale:
Infants of diabetic mothers are at risk for hypoglycemia due to fetal hyperinsulinism.
Jitteriness and a high-pitched cry are signs of neonatal hypoglycemia. A blood glucose
level below 40–45 mg/dL in the first 24 hours is typically concerning (48 mg/dL is
borderline but not critical). Apgar scores are normal, and a birth weight of 8 lb is within
normal range, though LGA (large for gestational age) is common in infants of diabetic
mothers.
Question 7
A nurse is assessing a client who is 2 hours postpartum after a vaginal delivery. The
nurse notes a large amount of lochia rubra with several clots and a boggy fundus
displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin IV as prescribed
B. Assist the client to void
Ultimate Study Guide with Questions
and Verified Answers for 2025/2026 to
Ensure You Pass on the First Try
Question 1
A nurse is assessing a client who is at 35 weeks of gestation and reports a headache and
blurred vision. The client’s blood pressure is 168/102 mm Hg, and urine dipstick reveals
3+ protein. Which of the following actions should the nurse take first?
A. Administer labetalol IV push
B. Place the client in a left lateral position
C. Assess deep tendon reflexes
D. Notify the provider immediately
Answer: B. Place the client in a left lateral position
Rationale:
The client is showing signs of severe preeclampsia (severe hypertension, proteinuria,
headache, blurred vision). The priority is to improve uteroplacental perfusion and
reduce the risk of seizures by positioning the client in a left lateral position. This
alleviates pressure on the vena cava, improving cardiac output and placental blood flow.
While administering antihypertensives, assessing reflexes, and notifying the provider are
all important, positioning is the immediate nursing action to enhance perfusion and
safety.
Question 2
A nurse is caring for a client in active labor. The client’s cervix is dilated to 7 cm, and the
fetal heart rate (FHR) tracing shows recurrent late decelerations. Which of the following
is the priority nursing intervention?
,A. Increase the rate of IV oxytocin
B. Position the client on her left side
C. Prepare for an immediate cesarean birth
D. Administer oxygen at 2 L/min via nasal cannula
Answer: B. Position the client on her left side
Rationale:
Late decelerations indicate uteroplacental insufficiency. The first-line interventions are
to increase placental blood flow by turning the client to the left lateral position, then
administering oxygen at 10 L/min via non-rebreather mask, and increasing IV fluid
rate. Oxytocin should be discontinued, not increased. While a cesarean may be
necessary if the pattern does not resolve, it is not the immediate priority.
Question 3
A nurse is assessing a newborn who is 12 hours old. The nurse notes jaundice on the
face and chest. The mother is Rh-negative and received Rho(D) immune globulin at 28
weeks. Which of the following actions should the nurse take?
A. Prepare the newborn for phototherapy
B. Obtain a direct Coombs test result
C. Encourage early and frequent breastfeeding
D. Notify the provider of possible hemolytic disease
Answer: C. Encourage early and frequent breastfeeding
Rationale:
Jaundice within the first 24 hours is always abnormal, but in this scenario, the mother
received RhoGAM, which reduces the risk of Rh incompatibility. Physiologic jaundice
typically appears after 24 hours. Early and frequent feeding helps promote passage of
meconium and reduces enterohepatic circulation, which can help prevent worsening
hyperbilirubinemia. While the direct Coombs test may have been done at birth, the
nurse’s initial action is to support feeding. Phototherapy may be indicated if bilirubin
levels rise, but it is not the first action.
,Question 4
A nurse is providing discharge teaching to a client who is 24 hours postpartum and is
breastfeeding. Which of the following statements by the client indicates a need for
further teaching?
A. “I should feel my uterus as a firm mass at my belly button for the next few days.”
B. “If I feel a hard lump in my breast, I should apply warm compresses and feed
frequently.”
C. “It’s normal for my baby to have at least 6 to 8 wet diapers a day after my milk comes
in.”
D. “I can use ibuprofen for afterpains while breastfeeding.”
Answer: A. “I should feel my uterus as a firm mass at my belly button for the next
few days.”
Rationale:
By 24 hours postpartum, the fundus should be approximately 1 cm below the
umbilicus and should continue to descend about 1 cm per day. By day 2, it is typically
at or below the umbilicus. A fundus at the umbilicus several days after birth could
indicate subinvolution. The other statements are correct: warm compresses and feeding
help relieve plugged ducts; adequate wet diapers indicate hydration; ibuprofen is safe
for afterpains in breastfeeding mothers.
Question 5
A nurse is caring for a client who is receiving IV magnesium sulfate for severe
preeclampsia. Which of the following findings indicates magnesium toxicity?
A. Respiratory rate of 14 breaths per minute
B. Urinary output of 35 mL per hour
C. Deep tendon reflexes 2+
D. Decreased level of consciousness
Answer: D. Decreased level of consciousness
Rationale:
Signs of magnesium toxicity include decreased level of consciousness, respiratory
, depression (less than 12 breaths/min), absent deep tendon reflexes, and decreased
urinary output (less than 30 mL/hr) . A respiratory rate of 14 is within normal limits;
urinary output of 35 mL/hr is acceptable; and 2+ reflexes are normal. The earliest sign of
toxicity is often loss of patellar reflexes, followed by respiratory depression and altered
mental status.
Question 6
A nurse is assessing a newborn who was born 6 hours ago to a client with gestational
diabetes. Which of the following findings should the nurse report to the provider?
A. Blood glucose level of 48 mg/dL
B. Jitteriness and high-pitched cry
C. Apgar scores of 8 at 1 minute and 9 at 5 minutes
D. Birth weight of 8 lb (3,629 g)
Answer: B. Jitteriness and high-pitched cry
Rationale:
Infants of diabetic mothers are at risk for hypoglycemia due to fetal hyperinsulinism.
Jitteriness and a high-pitched cry are signs of neonatal hypoglycemia. A blood glucose
level below 40–45 mg/dL in the first 24 hours is typically concerning (48 mg/dL is
borderline but not critical). Apgar scores are normal, and a birth weight of 8 lb is within
normal range, though LGA (large for gestational age) is common in infants of diabetic
mothers.
Question 7
A nurse is assessing a client who is 2 hours postpartum after a vaginal delivery. The
nurse notes a large amount of lochia rubra with several clots and a boggy fundus
displaced to the right. Which of the following actions should the nurse take first?
A. Administer oxytocin IV as prescribed
B. Assist the client to void
