RN HESI Maternity EXAM (Latest Update 2026)
|Questions & Correct Detailed Answers with Rationales|
Latest Version!!! Already Graded A+
A nurse receives a shift change report for a newborn who is 12 hours
post-vaginal delivery. In developing a plan of care, the nurse should
give the highest priority to which finding?
A. Cyanosis of the hands and feet
B. Skin color that is slightly jaundiced
C. Tiny white papules on the nose or chin
D. Red patches on the cheeks and trunk
B. Skin color that is slightly jaundiced
Rationale:
Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis
(blue color of the hands and feet) is a common finding in newborns; it occurs
because the capillary system is immature. Milia are small white papules present
on the nose and chin that are caused by sebaceous gland blockage and disappear
in a few weeks. Small red patches on the cheeks and trunk are called erythema
toxicum neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and
antibiotic therapy is prescribed. Which instruction should the nurse
provide to this client?
A .Breastfeed the infant, ensuring that both breasts are completely
emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching
onto the infected breast.
C. Breastfeed on the unaffected breast only until the mastitis subsides.
D .Dilute expressed breast milk with sterile water to reduce the
antibiotic effect on the infant.
pg. 1
,A. Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale:
Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged
breasts, eliminating the pressure on the inflamed breast tissue. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C
will not relieve the engorgement on the affected side. Option D will not
decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a
computer 8 hours each day tells the nurse that her feet have begun to
swell. Which instruction will aid in the prevention of pooling of blood
in the lower extremities?
A. Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing.
C. Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve
pressure on the pelvic veins and increase venous return. Option A would
increase venous return from varicose veins in the lower extremities but would
be of little help with swelling. Option B might be helpful with generalized
edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive
clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term
male infant develops localized swelling on the right side of his head.
pg. 2
,In a newborn, what is the most likely cause of this accumulation of
blood between the periosteum and skull that does not cross the suture
line?
A. Cephalhematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage
A. Cephalhematoma, which is caused by forceps trauma
Rationale:
Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary
bleeding between the periosteum and skull. Option C is a cranial distortion
lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery,
and is a common variation of the newborn. Options B and D both involve
intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents
regarding the newborn's umbilical cord care at home?
A. Wash the cord frequently with mild soap and water.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
D. Apply baby lotion after the baby's daily bath
C. Allow the cord to air-dry as much as possible.
Rationale:
Recent studies have indicated that air drying or plain water application may be
equal to or more effective than alcohol in the cord healing process. Options A,
B, and D are incorrect because they promote moisture and increase the potential
for infection.
pg. 3
, 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 recommendation should the nurse make to
this expectant father?
A. Suggest that his wife seek professional counseling to deal with her
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 maternal-fetal bonding is occurring.
D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy.
Immediately after the procedure is completed, it is most important for
the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC)
C. Fetal heart rate (FHR)
Rationale:
pg. 4
|Questions & Correct Detailed Answers with Rationales|
Latest Version!!! Already Graded A+
A nurse receives a shift change report for a newborn who is 12 hours
post-vaginal delivery. In developing a plan of care, the nurse should
give the highest priority to which finding?
A. Cyanosis of the hands and feet
B. Skin color that is slightly jaundiced
C. Tiny white papules on the nose or chin
D. Red patches on the cheeks and trunk
B. Skin color that is slightly jaundiced
Rationale:
Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis
(blue color of the hands and feet) is a common finding in newborns; it occurs
because the capillary system is immature. Milia are small white papules present
on the nose and chin that are caused by sebaceous gland blockage and disappear
in a few weeks. Small red patches on the cheeks and trunk are called erythema
toxicum neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and
antibiotic therapy is prescribed. Which instruction should the nurse
provide to this client?
A .Breastfeed the infant, ensuring that both breasts are completely
emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching
onto the infected breast.
C. Breastfeed on the unaffected breast only until the mastitis subsides.
D .Dilute expressed breast milk with sterile water to reduce the
antibiotic effect on the infant.
pg. 1
,A. Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale:
Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged
breasts, eliminating the pressure on the inflamed breast tissue. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C
will not relieve the engorgement on the affected side. Option D will not
decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a
computer 8 hours each day tells the nurse that her feet have begun to
swell. Which instruction will aid in the prevention of pooling of blood
in the lower extremities?
A. Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing.
C. Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve
pressure on the pelvic veins and increase venous return. Option A would
increase venous return from varicose veins in the lower extremities but would
be of little help with swelling. Option B might be helpful with generalized
edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive
clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term
male infant develops localized swelling on the right side of his head.
pg. 2
,In a newborn, what is the most likely cause of this accumulation of
blood between the periosteum and skull that does not cross the suture
line?
A. Cephalhematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage
A. Cephalhematoma, which is caused by forceps trauma
Rationale:
Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary
bleeding between the periosteum and skull. Option C is a cranial distortion
lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery,
and is a common variation of the newborn. Options B and D both involve
intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents
regarding the newborn's umbilical cord care at home?
A. Wash the cord frequently with mild soap and water.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
D. Apply baby lotion after the baby's daily bath
C. Allow the cord to air-dry as much as possible.
Rationale:
Recent studies have indicated that air drying or plain water application may be
equal to or more effective than alcohol in the cord healing process. Options A,
B, and D are incorrect because they promote moisture and increase the potential
for infection.
pg. 3
, 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 recommendation should the nurse make to
this expectant father?
A. Suggest that his wife seek professional counseling to deal with her
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 maternal-fetal bonding is occurring.
D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy.
Immediately after the procedure is completed, it is most important for
the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC)
C. Fetal heart rate (FHR)
Rationale:
pg. 4
