RN HESI MATERNITY EXAM PREPARATION
QUESTIONS WITH FULL RATIONALES 2026
▶ An infant with tetralogy of Fallot becomes acutely cyanotic and hyper
apneic. Which action should the nurse implement first?A. Administer
morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask. Answer: C. Place the infant in a
knee-chest position
▶ A one-day-old neonate develops a cephalohematoma. The nurse should
closely assess this neonate for which common complication?
A. jaundice
B. poor appetite
C. brain damage
D. hypoglycemia Answer: A. jaundice
▶ The nurse is reviewing the serum laboratory finding for a 5-day-old infant
with congenital adrenal hyperplasia. Which laboratory results should be
reported to the healthcare provider immediatly?
A. Bilirubin of 1.5 mg/dl
B. Glucose of 80 mg/dl
C. Potassium of 4.5 mEq/L
D. Sodium of 119 mEq/L Answer: D. Sodium of 119 mEq/L
▶ At 39-weeks gestation, a multigravida is having a non-stress test (NST).
The fetal heart rate (FHR) has remained nonreactive during the 30 minutes
of evaluation. Based on this finding, which action should the nurse
implement?
A. Initiate an intravenous infusion
B. Observe the FHR pattern for 30 more minutes
C. Schedule a biophysical profile
D. Place an acoustic stimulator on the abdomen Answer: D. Place an
acoustic stimulator on the abdomen
,▶ A community health nurse visits a family in which a 16-year-old
unmarried daughter is pregnant with her first child and is at 32-weeks
gestation. The client tells the nurse that she has been having intermittent
back pain since the night before. What is the priority nursing intervention?
A. Ask the clients mother to call an ambulance for transport to the hospital
immediately.
B. Determine what physical activities the client has performed for the past
24 hours
C. Teach the client if she has experienced any recent changes in vaginal
discharge. Answer: C. Teach the client if she has experienced any recent
changes in vaginal discharge.
▶ Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which
assessment finding indicates to the nurse that the medication is having the
desired effect?
A. Weight gain
B. Reduction of fever
C. Improved caloric intake
D. Reduction of edema Answer: D. Reduction of edema
▶ The nurse is conducting postpartum teaching with a mother who is
breastfeeding here infant. When discussing birth control, which method
should the nurse recommend to this client as beneficial for her to use in
preventing an unwanted pregnancy?
A. Breastfeed exclusively at least every 3-4 hours
B. Condoms and contraceptive foam or gel
C. Rhythm method (natural family planning)
D. Combined estrogen progesterone oral contraceptives. Answer: B.
Condoms and contraceptive foam or gel
▶ One day after a vaginal delivery of a full-term baby, a postpartum client's
white blood cell count is 15,000/mm2. What action should the nurse take
first?
A. Check he differential, since the WBC is normal for this client.
B. Assess the clients temperature, pulse, and respirations q4h.
C. Notify the healthcare provider, since this finding is indicative of infection
D. Assess the clients perineal area for signs of a perineal hematoma.
Answer: A. Check he differential, since the WBC is normal for this client.
, ▶ The parents of a newborn tell the nurse that their baby is already trying
to walk. How should the nurse respond?
A. Encourage the parents to report this to the healthcare provider
B. Acknowledge the parents' observation.
C. Schedule the newborn for further neurological testing.
D. Explain the newborn's normal stepping reflex. Answer: D. Explain the
newborn's normal stepping reflex.
▶ A breastfeeding infant, screened for congenital hypothyroidism, is found
to have low levels of thyroxine (t4) and high levels of thyroid stimulating
hormone (TSH)/ What is the best explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for
several weeks after birth
D. The TSH is high because of the low production of T4 by the thyroid.
Answer: D. The TSH is high because of the low production of T4 by the
thyroid.
▶ The nurse is assessing a 2-hour-old infant born by cesarean delivery at
39-weeks gestation. Which assessment finding should receive the highest
priority when planning this infants care?
A. Blood pressure 76/42 mm/Hg
B. Faint heart murmur
C. Respiratory rate 76 breaths/min
D. Blood glucose 45 mg/dl Answer: C. Respiratory rate 76 breaths/min
▶ At 20-weeks gestation, a client who has gained 20 pounds during this
pregnancy tells the nurse that she is feeling fetal movement. Fundal height
measurement is 20 cm, and the clients only complaint is that her breasts
are leaking clear fluid. Which assessment finding warrants further
evaluation?
A. Presence of fetal movements.
B. Gestational weight gain
C. Fundal height measurement
D. Leakage from breasts Answer: B. Gestational weight gain
▶ The nurse is planning discharge teaching for a client who had an
evacuation of gestational
QUESTIONS WITH FULL RATIONALES 2026
▶ An infant with tetralogy of Fallot becomes acutely cyanotic and hyper
apneic. Which action should the nurse implement first?A. Administer
morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask. Answer: C. Place the infant in a
knee-chest position
▶ A one-day-old neonate develops a cephalohematoma. The nurse should
closely assess this neonate for which common complication?
A. jaundice
B. poor appetite
C. brain damage
D. hypoglycemia Answer: A. jaundice
▶ The nurse is reviewing the serum laboratory finding for a 5-day-old infant
with congenital adrenal hyperplasia. Which laboratory results should be
reported to the healthcare provider immediatly?
A. Bilirubin of 1.5 mg/dl
B. Glucose of 80 mg/dl
C. Potassium of 4.5 mEq/L
D. Sodium of 119 mEq/L Answer: D. Sodium of 119 mEq/L
▶ At 39-weeks gestation, a multigravida is having a non-stress test (NST).
The fetal heart rate (FHR) has remained nonreactive during the 30 minutes
of evaluation. Based on this finding, which action should the nurse
implement?
A. Initiate an intravenous infusion
B. Observe the FHR pattern for 30 more minutes
C. Schedule a biophysical profile
D. Place an acoustic stimulator on the abdomen Answer: D. Place an
acoustic stimulator on the abdomen
,▶ A community health nurse visits a family in which a 16-year-old
unmarried daughter is pregnant with her first child and is at 32-weeks
gestation. The client tells the nurse that she has been having intermittent
back pain since the night before. What is the priority nursing intervention?
A. Ask the clients mother to call an ambulance for transport to the hospital
immediately.
B. Determine what physical activities the client has performed for the past
24 hours
C. Teach the client if she has experienced any recent changes in vaginal
discharge. Answer: C. Teach the client if she has experienced any recent
changes in vaginal discharge.
▶ Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which
assessment finding indicates to the nurse that the medication is having the
desired effect?
A. Weight gain
B. Reduction of fever
C. Improved caloric intake
D. Reduction of edema Answer: D. Reduction of edema
▶ The nurse is conducting postpartum teaching with a mother who is
breastfeeding here infant. When discussing birth control, which method
should the nurse recommend to this client as beneficial for her to use in
preventing an unwanted pregnancy?
A. Breastfeed exclusively at least every 3-4 hours
B. Condoms and contraceptive foam or gel
C. Rhythm method (natural family planning)
D. Combined estrogen progesterone oral contraceptives. Answer: B.
Condoms and contraceptive foam or gel
▶ One day after a vaginal delivery of a full-term baby, a postpartum client's
white blood cell count is 15,000/mm2. What action should the nurse take
first?
A. Check he differential, since the WBC is normal for this client.
B. Assess the clients temperature, pulse, and respirations q4h.
C. Notify the healthcare provider, since this finding is indicative of infection
D. Assess the clients perineal area for signs of a perineal hematoma.
Answer: A. Check he differential, since the WBC is normal for this client.
, ▶ The parents of a newborn tell the nurse that their baby is already trying
to walk. How should the nurse respond?
A. Encourage the parents to report this to the healthcare provider
B. Acknowledge the parents' observation.
C. Schedule the newborn for further neurological testing.
D. Explain the newborn's normal stepping reflex. Answer: D. Explain the
newborn's normal stepping reflex.
▶ A breastfeeding infant, screened for congenital hypothyroidism, is found
to have low levels of thyroxine (t4) and high levels of thyroid stimulating
hormone (TSH)/ What is the best explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for
several weeks after birth
D. The TSH is high because of the low production of T4 by the thyroid.
Answer: D. The TSH is high because of the low production of T4 by the
thyroid.
▶ The nurse is assessing a 2-hour-old infant born by cesarean delivery at
39-weeks gestation. Which assessment finding should receive the highest
priority when planning this infants care?
A. Blood pressure 76/42 mm/Hg
B. Faint heart murmur
C. Respiratory rate 76 breaths/min
D. Blood glucose 45 mg/dl Answer: C. Respiratory rate 76 breaths/min
▶ At 20-weeks gestation, a client who has gained 20 pounds during this
pregnancy tells the nurse that she is feeling fetal movement. Fundal height
measurement is 20 cm, and the clients only complaint is that her breasts
are leaking clear fluid. Which assessment finding warrants further
evaluation?
A. Presence of fetal movements.
B. Gestational weight gain
C. Fundal height measurement
D. Leakage from breasts Answer: B. Gestational weight gain
▶ The nurse is planning discharge teaching for a client who had an
evacuation of gestational
