MATERNITY HESI TEST BANK 2026
REVIEW PACK COMPLETE
QUESTIONS SOLUTIONS GRADED A+
◉ A client who delivered by cesarean section 24 hours ago is using a
PCA pump for pain control. Her oral intake has been ice chips only
since surgery. She is now complaining of nausea and bloating, and states
that because she had nothing to eat, she is too weak to breastfeed her
infant. Which nursing diagnosis has the highest priority?
Answer: Impaired bowel motility related to pain medication and
immobility.Impaired bowel motility caused by surgical anesthesia, pain
medication, and immobility is the priority nursing diagnosis and
addresses the potential problem of a paralytic ileus.
◉ A new mother asks the nurse, "How do I know that my daughter is
getting enough breast milk?" Which explanation is appropriate?
Answer: "Your milk is sufficient if the baby is voiding pale straw-
colored urine 6 to 10 times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10
times/day) , if the infant is adequately hydrated. Although a weight gain
of 30 grams/day is indicative of adequate nutrition, most home scales do
not measure this accurately and this suggestion is likely to make the
mother very anxious.
◉ The nurse is counseling a couple who has sought information about
conceiving. The couple asks the nurse to explain when ovulation usually
occurs. Which statement by the nurse is correct?
,Answer: Two weeks before menstruation.
Ovulation occurs 14 days before the first day of the menstrual period .
While ovulation can occur in the middle of the cycle, or 2 weeks after
menstruation, this is only true for a woman who has a perfect 28-day
cycle. For many women, the length of their menstrual cycle varies.
◉ The nurse is evaluating a full-term multigravida who was induced 3
hours ago. The nurse determines the client is dilated 7 cm, is 100%
effaced at 0 station, with intact membranes. The monitor indicates the
fetal heart rate (FHR) decelerates at the onset of several contractions and
returns to baseline before each contraction ends. What action should the
nurse take?
Answer: Continue to monitor labor progress.
The fetal heart rate indicates early decelerations, which are not an
ominous sign, so the nurse should continue to monitor the labor progress
and document the findings in the client's record.
◉ The nurse instructs a laboring client to use accelerated-blow
breathing. The client begins to complain of tingling fingers and
dizziness. What action should the nurse take?
Answer: Have the client breathe into her cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing
off too much carbon dioxide). Hyperventilation is treated by retaining
,carbon dioxide. This can be facilitated by breathing into a paper bag or
cupped hands .
◉ Twenty-four hours after admission to the newborn nursery, a full-term
male infant develops localized swelling on the right side of his head.
What is the most likely cause of this accumulation of blood between the
periosteum and skull that does not cross the suture line in a newborn?
Answer: A cephalhematoma, which is caused by forceps trauma.
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 the skull.
◉ One hour following a normal vaginal delivery, a newborn infant boy's
axillary temperature is 96° F, his lower lip is shaking, and when the
nurse assesses for a Moro reflex, his hands shake. What intervention
should the nurse implement first?
Answer: Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary
to a low body temperature. The nurse should first determine the serum
glucose level .
◉ A client in active labor is becoming increasingly fearful because her
contractions are occurring more often than she expected. Her partner is
also becoming anxious. The nurse's response should focus on which
content?
, Answer: Asking the client and her partner if they would like the nurse
stay in the room.
Offering to remain with the client and her partner (C) offers support
without providing false reassurance. The length of labor is not always
predictable, but (A and B) do not offer the client the support that is
needed at this time. (D) may be reassuring regarding the fetal heart rate,
but it does not provide the client the emotional support she needs at this
time during the labor process.
◉ A breastfeeding postpartum client is diagnosed with mastitis and
antibiotic therapy is prescribed. What instruction should the nurse
provide to this client?
Answer: Breastfeed the infant, ensuring that both breasts are completely
emptied.
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.
◉ Twenty minutes after a continuous epidural anesthetic is
administered, a laboring client's blood pressure drops from 120/80 to
90/60. What action should the nurse take immediately?
Answer: Place the client in a lateral position. The nurse should
immediately turn the client to a lateral position or place a pillow or
wedge under one hip to deflect the uterus. Other immediate interventions
include increasing the rate of the main line IV infusion and
REVIEW PACK COMPLETE
QUESTIONS SOLUTIONS GRADED A+
◉ A client who delivered by cesarean section 24 hours ago is using a
PCA pump for pain control. Her oral intake has been ice chips only
since surgery. She is now complaining of nausea and bloating, and states
that because she had nothing to eat, she is too weak to breastfeed her
infant. Which nursing diagnosis has the highest priority?
Answer: Impaired bowel motility related to pain medication and
immobility.Impaired bowel motility caused by surgical anesthesia, pain
medication, and immobility is the priority nursing diagnosis and
addresses the potential problem of a paralytic ileus.
◉ A new mother asks the nurse, "How do I know that my daughter is
getting enough breast milk?" Which explanation is appropriate?
Answer: "Your milk is sufficient if the baby is voiding pale straw-
colored urine 6 to 10 times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10
times/day) , if the infant is adequately hydrated. Although a weight gain
of 30 grams/day is indicative of adequate nutrition, most home scales do
not measure this accurately and this suggestion is likely to make the
mother very anxious.
◉ The nurse is counseling a couple who has sought information about
conceiving. The couple asks the nurse to explain when ovulation usually
occurs. Which statement by the nurse is correct?
,Answer: Two weeks before menstruation.
Ovulation occurs 14 days before the first day of the menstrual period .
While ovulation can occur in the middle of the cycle, or 2 weeks after
menstruation, this is only true for a woman who has a perfect 28-day
cycle. For many women, the length of their menstrual cycle varies.
◉ The nurse is evaluating a full-term multigravida who was induced 3
hours ago. The nurse determines the client is dilated 7 cm, is 100%
effaced at 0 station, with intact membranes. The monitor indicates the
fetal heart rate (FHR) decelerates at the onset of several contractions and
returns to baseline before each contraction ends. What action should the
nurse take?
Answer: Continue to monitor labor progress.
The fetal heart rate indicates early decelerations, which are not an
ominous sign, so the nurse should continue to monitor the labor progress
and document the findings in the client's record.
◉ The nurse instructs a laboring client to use accelerated-blow
breathing. The client begins to complain of tingling fingers and
dizziness. What action should the nurse take?
Answer: Have the client breathe into her cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing
off too much carbon dioxide). Hyperventilation is treated by retaining
,carbon dioxide. This can be facilitated by breathing into a paper bag or
cupped hands .
◉ Twenty-four hours after admission to the newborn nursery, a full-term
male infant develops localized swelling on the right side of his head.
What is the most likely cause of this accumulation of blood between the
periosteum and skull that does not cross the suture line in a newborn?
Answer: A cephalhematoma, which is caused by forceps trauma.
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 the skull.
◉ One hour following a normal vaginal delivery, a newborn infant boy's
axillary temperature is 96° F, his lower lip is shaking, and when the
nurse assesses for a Moro reflex, his hands shake. What intervention
should the nurse implement first?
Answer: Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary
to a low body temperature. The nurse should first determine the serum
glucose level .
◉ A client in active labor is becoming increasingly fearful because her
contractions are occurring more often than she expected. Her partner is
also becoming anxious. The nurse's response should focus on which
content?
, Answer: Asking the client and her partner if they would like the nurse
stay in the room.
Offering to remain with the client and her partner (C) offers support
without providing false reassurance. The length of labor is not always
predictable, but (A and B) do not offer the client the support that is
needed at this time. (D) may be reassuring regarding the fetal heart rate,
but it does not provide the client the emotional support she needs at this
time during the labor process.
◉ A breastfeeding postpartum client is diagnosed with mastitis and
antibiotic therapy is prescribed. What instruction should the nurse
provide to this client?
Answer: Breastfeed the infant, ensuring that both breasts are completely
emptied.
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.
◉ Twenty minutes after a continuous epidural anesthetic is
administered, a laboring client's blood pressure drops from 120/80 to
90/60. What action should the nurse take immediately?
Answer: Place the client in a lateral position. The nurse should
immediately turn the client to a lateral position or place a pillow or
wedge under one hip to deflect the uterus. Other immediate interventions
include increasing the rate of the main line IV infusion and
