Maternity HESI questions and answers 2026\2027
A+ Grade
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet:
- correct answer Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further
evaluation?
- correct answer Too much weight gain, gestational weight gain should only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"?
- correct answer Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say...
- correct answer If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate
- correct answer Inspect perineal and rectal area.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx?
- correct answer Fluid volume excess.
RATIONALE: 3rd spacing.
Cesarean - hemorrhage risk assessment?
- correct answer Check for fundal firmness Q15 min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min
checks stimulate fundus to contract and prevents bleeding.
,Water broke, umbilical cord is on perineum, what does nurse do?
- correct answer Place pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the
presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s?
- correct answer To evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority?
- correct answer Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What
would be a therapeutic response to the injection?
- correct answer Increased HR and decrease in oral secretions.
Newborn assessment that indicates a cardiac problem?
- correct answer RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give?
- correct answer Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding.
- correct answer Assess infants position while feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery.
- correct answer Rhogam prevents maternal antibody formation for future Rh positive babies.
24 hours after birth, cephalohematoma, what intervention?
- correct answer Examine jaundice Q8 hours.
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
,. Patient had twins born to multigravida, 12 hours ago. Nursing Dx?
- correct answer Assess fundal tone and lochia flow.
. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex
presentation, greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last
4 contraction peaks. What to do FIRST?
- correct answer 02 via facemask.
Terbutaline (Brethine) injections for preterm labor. When do you hold and call the MD?
- correct answer Bilateral crackles in lungs on auscultation (critical complication).
RATIONALE: Could indicate pulmonary edema.
APGAR 3. Intervention?
- correct answer Continue resuscitation efforts.
In PACU, the most important assessment for first 8 hours after cesarean:
- correct answer Uterine atony.
RATIONALE: Uterine atony can lead to hemorrhage.
Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse response?
- correct answer Increased risk for spontaneous miscarriage.
RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in miscarriage.
Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station.
- correct answer Apply counter pressure to sacral area.
RATIONALE: Caused by malposition of the fetus.
Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine be given?
- correct answer Give early postpartum within 72 hours.
HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing congenital heart
disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a
, woman's titers are low, she should receive the vaccine after delivery and be instructed not to get
pregnant within 3 months. Breast-feeding mothers may take the vaccine" (p. 288).
Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and nausea. Nurse Dx?
- correct answer Pain r/t transitional phase of labor.
Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse do?
- correct answer Tell mother it is normal.
RATIONALE: Newborns can lose 10% of their wt and regain it later.
Receiving report on laboring pt from ER. Water broke and didn't know it. First thing the nurse does?
- correct answer Take temperature.
RATIONALE: Length of time membranes ruptured is important to monitor for infection.
Postpartum temporary bed-rest should be placed if?
- correct answer Positive Homan's sign.
. Fundus hand placement: 1 massages the fundus the other is for...
- correct answer The other hand anchors the lower uterine section.
DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do?
- correct answer Contact MD for BPP (BioPhysical Profile).
Symptoms of hemorrhage/bleeding out:
- correct answer LR 200 mL/hr using 18 gauge needle.
Most accurate way to determine fetal position at 29 weeks gestation.
- correct answer Ultrasound.
RATIONALE: Provides direct view of the fetus.
To measure contractions...
- correct answer From beginning of a contraction, to the beginning of the next contractions.
A+ Grade
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet:
- correct answer Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further
evaluation?
- correct answer Too much weight gain, gestational weight gain should only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"?
- correct answer Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say...
- correct answer If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate
- correct answer Inspect perineal and rectal area.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx?
- correct answer Fluid volume excess.
RATIONALE: 3rd spacing.
Cesarean - hemorrhage risk assessment?
- correct answer Check for fundal firmness Q15 min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min
checks stimulate fundus to contract and prevents bleeding.
,Water broke, umbilical cord is on perineum, what does nurse do?
- correct answer Place pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the
presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s?
- correct answer To evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority?
- correct answer Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What
would be a therapeutic response to the injection?
- correct answer Increased HR and decrease in oral secretions.
Newborn assessment that indicates a cardiac problem?
- correct answer RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give?
- correct answer Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding.
- correct answer Assess infants position while feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery.
- correct answer Rhogam prevents maternal antibody formation for future Rh positive babies.
24 hours after birth, cephalohematoma, what intervention?
- correct answer Examine jaundice Q8 hours.
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
,. Patient had twins born to multigravida, 12 hours ago. Nursing Dx?
- correct answer Assess fundal tone and lochia flow.
. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station, vertex
presentation, greenish colored amniotic fluid, contractions Q3-5 min with deceased in FHR after the last
4 contraction peaks. What to do FIRST?
- correct answer 02 via facemask.
Terbutaline (Brethine) injections for preterm labor. When do you hold and call the MD?
- correct answer Bilateral crackles in lungs on auscultation (critical complication).
RATIONALE: Could indicate pulmonary edema.
APGAR 3. Intervention?
- correct answer Continue resuscitation efforts.
In PACU, the most important assessment for first 8 hours after cesarean:
- correct answer Uterine atony.
RATIONALE: Uterine atony can lead to hemorrhage.
Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse response?
- correct answer Increased risk for spontaneous miscarriage.
RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in miscarriage.
Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station.
- correct answer Apply counter pressure to sacral area.
RATIONALE: Caused by malposition of the fetus.
Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine be given?
- correct answer Give early postpartum within 72 hours.
HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing congenital heart
disease, congenital cataracts, or both. All women should have their titers checked during pregnancy. If a
, woman's titers are low, she should receive the vaccine after delivery and be instructed not to get
pregnant within 3 months. Breast-feeding mothers may take the vaccine" (p. 288).
Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and nausea. Nurse Dx?
- correct answer Pain r/t transitional phase of labor.
Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse do?
- correct answer Tell mother it is normal.
RATIONALE: Newborns can lose 10% of their wt and regain it later.
Receiving report on laboring pt from ER. Water broke and didn't know it. First thing the nurse does?
- correct answer Take temperature.
RATIONALE: Length of time membranes ruptured is important to monitor for infection.
Postpartum temporary bed-rest should be placed if?
- correct answer Positive Homan's sign.
. Fundus hand placement: 1 massages the fundus the other is for...
- correct answer The other hand anchors the lower uterine section.
DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do?
- correct answer Contact MD for BPP (BioPhysical Profile).
Symptoms of hemorrhage/bleeding out:
- correct answer LR 200 mL/hr using 18 gauge needle.
Most accurate way to determine fetal position at 29 weeks gestation.
- correct answer Ultrasound.
RATIONALE: Provides direct view of the fetus.
To measure contractions...
- correct answer From beginning of a contraction, to the beginning of the next contractions.
