HESI NCLEX-RN Comprehensive Review (Maternity) Test Questions and
Answers Graded A+
The nurse is counseling a couple who has sought infor-
A
mation about conceiving. The couple asks the nurse to
Rationale:
explain when ovulation usually occurs. Which statement
Ovulation occurs 14 days before the first day of the men-
by the nurse is correct?
strual period. Although ovulation can occur in the middle
of the cycle or 2 weeks after menstruation, this is only true
A. Two weeks before menstruation
for a woman who has a perfect 28-day cycle. For many
B. Immediately after menstruation
women, the length of the menstrual cycle varies. Options
C. Immediately before menstruation
B, C, and D are incorrect.
D. Three weeks before menstruation
A client in active labor is becoming increasingly fearful
because her contractions are occurring more often than
she had expected. Her partner is also becoming anxious.
C
Which of the following should be the focus of the nurse's
Rationale:
response?
Ottering to remain with the client and her partner otters
support without providing false reassurance. The length
A. Telling the client and her partner that the labor process
of labor is not always predictable, but options A and B do
is often unpredictable
not otter the client the support that is needed at this time.
B. Informing the client that this means she will give birth
Option D may be reassuring regarding the fetal heart rate
sooner than expected
but does not provide the client the emotional support she
C. Asking the client and her partner if they would like the
needs at this time during the labor process.
nurse to stay in the room
D. Aflrming that the fetal heart rate is remaining within
normal limits
A
A newborn infant, diagnosed with developmental dyspla-
Rationale:
sia of the hip (DDH), is being prepared for discharge.
It is important that the hips of infants with hip dysplasia
Which nursing intervention should be included in this
are maintained in an abducted position, which can be
infant's discharge teaching plan?
accomplished by using the Pavlik harness; this keeps the
hips and knees flexed, the hips abducted, and the femoral
A. Observe the parents applying a Pavlik harness.
head in the acetabulum. Early treatment often negates
B. Provide a referral for an orthopedic surgeon.
the need for surgery, and option B is not indicated until
,HESI NCLEX-RN Comprehensive Review (Maternity) Test Questions and
Answers Graded A+
approximately 6 months of age. Option C is not indicated
C. Schedule a physical therapy follow-up home visit. for hip dysplasia. It is best for the pediatrician to monitor
D. Teach the parents to check for hip joint mobility. hip joint mobility, and teaching the parents to perform this
technique is likely to increase their anxiety.
A new mother asks the nurse, "How do I know that my
daughter is getting enough breast milk?" Which explana- B
tion is appropriate? Rationale:
The urine will be dilute (straw-colored) and frequent (>6
A. "Weigh the baby daily, and if she is gaining weight, she to 10 times/day), if the infant is adequately hydrated.
is getting enough to eat." Although a weight gain of 30 g/day is indicative of ad-
B. "Your milk is suflcient if the baby is voiding pale, equate nutrition, most home scales do not measure this
straw-colored urine six to ten times a day." accurately, and the suggestion will likely make the mother
C. "Otter the baby extra bottled milk after her feeding and anxious. Option C causes nipple confusion and diminishes
see if she still seems hungry." the mother's milk production. Option D does not address
D. "If you're concerned, you might consider bottle feeding the client's question.
so that you can monitor intake."
Which maternal behavior is the nurse most likely to see
when a new mother receives her infant for the first time?
B
Rationale:
A. She eagerly reaches for the infant, undresses the infant,
Attachment and bonding theory indicates that most moth-
and examines the infant completely.
ers will demonstrate behaviors described in option B dur-
B. Her arms and hands receive the infant and she then
ing the first visit with the newborn, which may be at de-
traces the infant's profile with her fingertips.
livery or later. After the first visit, the mother may exhibit
C. Her arms and hands receive the infant and she then
ditterent touching behaviors such as eagerly reaching for
cuddles the infant to her own body.
the infant and cuddling the infant close to her.
D. She eagerly reaches for the infant and then holds the
infant close to her own body.
A breastfeeding postpartum client is diagnosed with mas-
A
titis, and antibiotic therapy is prescribed. Which instruc-
Rationale:
tion should the nurse provide to this client?
Mastitis, caused by plugged milk ducts, is related to breast
, HESI NCLEX-RN Comprehensive Review (Maternity) Test Questions and
Answers Graded A+
A. Breastfeed the infant, ensuring that both breasts are
engorgement, and breastfeeding during mastitis facili-
completely emptied.
tates the complete emptying of engorged breasts, elim-
B. Feed expressed breast milk to avoid the pain of the
inating the pressure on the inflamed breast tissue. Option
infant latching onto the infected breast.
B is less painful but does not facilitate complete emptying
C. Breastfeed on the unattected breast only until the mas-
of the breast tissue. Option C will not relieve the engorge-
titis subsides.
ment on the attected side. Option D will not decrease
D. Dilute expressed breast milk with sterile water to reduce
antibiotic ettects on the infant.
the antibiotic ettect on the infant.
An expectant father tells the nurse he fears that his wife "is
losing her mind." He states that she is constantly rubbing
her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which D
recommendation should the nurse make to this expectant Rationale:
father? These behaviors are positive signs of maternal-fetal bond-
ing and do not reflect ambivalence. No intervention is
A. Suggest that his wife seek professional counseling to needed. Quickening, the first perception of fetal move-
deal with her symptoms. ment, occurs at 17 to 20 weeks of gestation and be-
B. Explain that his wife is exhibiting ambivalence about the gins a new phase of prenatal bonding during the second
pregnancy. trimester. Options A and C are not necessary because the
C. Ask him to report similar abnormal behaviors at the next behaviors displayed are normal.
prenatal visit.
D. Reassure him that normal maternal-fetal bonding is
occurring.
B
Rationale:
The nurse calls a client who is 4 days postpartum to follow During the postpartum period, when serum hormone lev-
up about her transition with her newborn son at home. els fall, women are emotionally labile, often crying easily
The woman tells the nurse, "I don't know what is wrong. for no apparent reason. This phase is commonly called
I love my son, but I feel so let down. I seem to cry for postpartum blues, which peaks around the fifth post-
partum day. The taking-in phase is the period following
birth when the mother focuses on her own psychological
Answers Graded A+
The nurse is counseling a couple who has sought infor-
A
mation about conceiving. The couple asks the nurse to
Rationale:
explain when ovulation usually occurs. Which statement
Ovulation occurs 14 days before the first day of the men-
by the nurse is correct?
strual period. Although ovulation can occur in the middle
of the cycle or 2 weeks after menstruation, this is only true
A. Two weeks before menstruation
for a woman who has a perfect 28-day cycle. For many
B. Immediately after menstruation
women, the length of the menstrual cycle varies. Options
C. Immediately before menstruation
B, C, and D are incorrect.
D. Three weeks before menstruation
A client in active labor is becoming increasingly fearful
because her contractions are occurring more often than
she had expected. Her partner is also becoming anxious.
C
Which of the following should be the focus of the nurse's
Rationale:
response?
Ottering to remain with the client and her partner otters
support without providing false reassurance. The length
A. Telling the client and her partner that the labor process
of labor is not always predictable, but options A and B do
is often unpredictable
not otter the client the support that is needed at this time.
B. Informing the client that this means she will give birth
Option D may be reassuring regarding the fetal heart rate
sooner than expected
but does not provide the client the emotional support she
C. Asking the client and her partner if they would like the
needs at this time during the labor process.
nurse to stay in the room
D. Aflrming that the fetal heart rate is remaining within
normal limits
A
A newborn infant, diagnosed with developmental dyspla-
Rationale:
sia of the hip (DDH), is being prepared for discharge.
It is important that the hips of infants with hip dysplasia
Which nursing intervention should be included in this
are maintained in an abducted position, which can be
infant's discharge teaching plan?
accomplished by using the Pavlik harness; this keeps the
hips and knees flexed, the hips abducted, and the femoral
A. Observe the parents applying a Pavlik harness.
head in the acetabulum. Early treatment often negates
B. Provide a referral for an orthopedic surgeon.
the need for surgery, and option B is not indicated until
,HESI NCLEX-RN Comprehensive Review (Maternity) Test Questions and
Answers Graded A+
approximately 6 months of age. Option C is not indicated
C. Schedule a physical therapy follow-up home visit. for hip dysplasia. It is best for the pediatrician to monitor
D. Teach the parents to check for hip joint mobility. hip joint mobility, and teaching the parents to perform this
technique is likely to increase their anxiety.
A new mother asks the nurse, "How do I know that my
daughter is getting enough breast milk?" Which explana- B
tion is appropriate? Rationale:
The urine will be dilute (straw-colored) and frequent (>6
A. "Weigh the baby daily, and if she is gaining weight, she to 10 times/day), if the infant is adequately hydrated.
is getting enough to eat." Although a weight gain of 30 g/day is indicative of ad-
B. "Your milk is suflcient if the baby is voiding pale, equate nutrition, most home scales do not measure this
straw-colored urine six to ten times a day." accurately, and the suggestion will likely make the mother
C. "Otter the baby extra bottled milk after her feeding and anxious. Option C causes nipple confusion and diminishes
see if she still seems hungry." the mother's milk production. Option D does not address
D. "If you're concerned, you might consider bottle feeding the client's question.
so that you can monitor intake."
Which maternal behavior is the nurse most likely to see
when a new mother receives her infant for the first time?
B
Rationale:
A. She eagerly reaches for the infant, undresses the infant,
Attachment and bonding theory indicates that most moth-
and examines the infant completely.
ers will demonstrate behaviors described in option B dur-
B. Her arms and hands receive the infant and she then
ing the first visit with the newborn, which may be at de-
traces the infant's profile with her fingertips.
livery or later. After the first visit, the mother may exhibit
C. Her arms and hands receive the infant and she then
ditterent touching behaviors such as eagerly reaching for
cuddles the infant to her own body.
the infant and cuddling the infant close to her.
D. She eagerly reaches for the infant and then holds the
infant close to her own body.
A breastfeeding postpartum client is diagnosed with mas-
A
titis, and antibiotic therapy is prescribed. Which instruc-
Rationale:
tion should the nurse provide to this client?
Mastitis, caused by plugged milk ducts, is related to breast
, HESI NCLEX-RN Comprehensive Review (Maternity) Test Questions and
Answers Graded A+
A. Breastfeed the infant, ensuring that both breasts are
engorgement, and breastfeeding during mastitis facili-
completely emptied.
tates the complete emptying of engorged breasts, elim-
B. Feed expressed breast milk to avoid the pain of the
inating the pressure on the inflamed breast tissue. Option
infant latching onto the infected breast.
B is less painful but does not facilitate complete emptying
C. Breastfeed on the unattected breast only until the mas-
of the breast tissue. Option C will not relieve the engorge-
titis subsides.
ment on the attected side. Option D will not decrease
D. Dilute expressed breast milk with sterile water to reduce
antibiotic ettects on the infant.
the antibiotic ettect on the infant.
An expectant father tells the nurse he fears that his wife "is
losing her mind." He states that she is constantly rubbing
her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which D
recommendation should the nurse make to this expectant Rationale:
father? These behaviors are positive signs of maternal-fetal bond-
ing and do not reflect ambivalence. No intervention is
A. Suggest that his wife seek professional counseling to needed. Quickening, the first perception of fetal move-
deal with her symptoms. ment, occurs at 17 to 20 weeks of gestation and be-
B. Explain that his wife is exhibiting ambivalence about the gins a new phase of prenatal bonding during the second
pregnancy. trimester. Options A and C are not necessary because the
C. Ask him to report similar abnormal behaviors at the next behaviors displayed are normal.
prenatal visit.
D. Reassure him that normal maternal-fetal bonding is
occurring.
B
Rationale:
The nurse calls a client who is 4 days postpartum to follow During the postpartum period, when serum hormone lev-
up about her transition with her newborn son at home. els fall, women are emotionally labile, often crying easily
The woman tells the nurse, "I don't know what is wrong. for no apparent reason. This phase is commonly called
I love my son, but I feel so let down. I seem to cry for postpartum blues, which peaks around the fifth post-
partum day. The taking-in phase is the period following
birth when the mother focuses on her own psychological
