# 2022 – 2023 HESI OB MATERNITY TEST BANK
QUESTIONS & ANSWERS INCLUDED
---
**01.** A nurse is caring for a client who is 38 weeks pregnant and reports a sudden gush of fluid from
the vagina. The fluid is clear and has no odor. Which action should the nurse take first?
A) Assess the fetal heart rate
B) Perform a Nitrazine test
C) Check cervical dilation
D) Notify the provider immediately
🔍 RATIONALE💡-- A sudden gush of fluid suggests rupture of membranes. The priority is to assess fetal
heart rate to detect any signs of distress or cord prolapse. After that, confirm rupture with Nitrazine or
fern test, then notify the provider.
ANSWER💫✔️-- A) Assess the fetal heart rate
---
**02.** A nurse is assessing a client who is 12 hours postpartum. The fundus is firm, at the umbilicus,
and deviated to the right. What is the priority action?
A) Massage the fundus vigorously
B) Notify the provider
C) Assist the client to void
D) Administer oxytocin
,🔍 RATIONALE💡-- A deviated uterus (usually to the right) indicates a full bladder displacing the uterus.
The nurse should assist the client to void, then reassess fundal position. Massaging a firm fundus is
unnecessary.
ANSWER💫✔️-- C) Assist the client to void
---
**03.** A nurse is providing education to a client at 10 weeks gestation. Which statement indicates
understanding of folic acid supplementation?
A) “Folic acid prevents neural tube defects in my baby.”
B) “I only need folic acid during the third trimester.”
C) “Folic acid will prevent gestational diabetes.”
D) “I should take folic acid every other day.”
🔍 RATIONALE💡-- Folic acid (400-800 mcg daily) before conception and during early pregnancy
significantly reduces the risk of neural tube defects. It is most critical in the first trimester.
ANSWER💫✔️-- A) “Folic acid prevents neural tube defects in my baby.”
---
**04.** A nurse is caring for a client receiving IV magnesium sulfate for severe preeclampsia. Which
finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urinary output 40 mL/hr
C) Respiratory rate 10 breaths/min
D) Blood pressure 140/90 mm Hg
,🔍 RATIONALE💡-- Respiratory rate <12 breaths/min is a sign of magnesium toxicity. Other signs include
absent deep tendon reflexes and decreased urine output (<30 mL/hr). Normal reflexes are 2+; output 40
mL/hr is adequate.
ANSWER💫✔️-- C) Respiratory rate 10 breaths/min
---
**05.** A nurse is assessing a newborn of a mother with gestational diabetes. Which finding is the
newborn at greatest risk for?
A) Hypercalcemia
B) Hypoglycemia
C) Hyperbilirubinemia
D) Hypothermia
🔍 RATIONALE💡-- Infants of diabetic mothers have high insulin levels after birth, leading to
hypoglycemia in the first few hours of life. Blood glucose should be monitored.
ANSWER💫✔️-- B) Hypoglycemia
---
**06.** A nurse is reinforcing teaching about breastfeeding to a new mother. Which instruction is
correct?
A) “Wash your nipples with soap and water before each feeding.”
B) “Feed your baby on a strict 4‑hour schedule.”
C) “Allow the baby to breastfeed until satisfied, including the hindmilk.”
D) “Limit feedings to 5 minutes on each breast to prevent soreness.”
🔍 RATIONALE💡-- Hindmilk (later milk) is higher in fat and calories. Allowing the baby to feed until
satisfied ensures adequate nutrition and helps establish milk supply.
, ANSWER💫✔️-- C) “Allow the baby to breastfeed until satisfied, including the hindmilk.”
---
**07.** A nurse is caring for a client with placenta previa at 34 weeks gestation. Which finding is most
characteristic?
A) Painless, bright red vaginal bleeding
B) Severe abdominal pain with dark bleeding
C) Uterine tenderness and rigidity
D) Fever and foul discharge
🔍 RATIONALE💡-- Placenta previa presents with painless, bright red vaginal bleeding in the second or
third trimester. Abruptio placentae presents with painful, dark bleeding and uterine tenderness.
ANSWER💫✔️-- A) Painless, bright red vaginal bleeding
---
**08.** A nurse is assessing a client who is 24 hours postpartum. The client reports severe perineal pain
and a feeling of pressure. The perineum is swollen and ecchymotic. What complication should the nurse
suspect?
A) Endometritis
B) Hematoma
C) Uterine atony
D) Retained placental fragments
🔍 RATIONALE💡-- Severe pain, pressure, and perineal swelling with ecchymosis suggest a vulvar or
perineal hematoma. This requires surgical evacuation.
QUESTIONS & ANSWERS INCLUDED
---
**01.** A nurse is caring for a client who is 38 weeks pregnant and reports a sudden gush of fluid from
the vagina. The fluid is clear and has no odor. Which action should the nurse take first?
A) Assess the fetal heart rate
B) Perform a Nitrazine test
C) Check cervical dilation
D) Notify the provider immediately
🔍 RATIONALE💡-- A sudden gush of fluid suggests rupture of membranes. The priority is to assess fetal
heart rate to detect any signs of distress or cord prolapse. After that, confirm rupture with Nitrazine or
fern test, then notify the provider.
ANSWER💫✔️-- A) Assess the fetal heart rate
---
**02.** A nurse is assessing a client who is 12 hours postpartum. The fundus is firm, at the umbilicus,
and deviated to the right. What is the priority action?
A) Massage the fundus vigorously
B) Notify the provider
C) Assist the client to void
D) Administer oxytocin
,🔍 RATIONALE💡-- A deviated uterus (usually to the right) indicates a full bladder displacing the uterus.
The nurse should assist the client to void, then reassess fundal position. Massaging a firm fundus is
unnecessary.
ANSWER💫✔️-- C) Assist the client to void
---
**03.** A nurse is providing education to a client at 10 weeks gestation. Which statement indicates
understanding of folic acid supplementation?
A) “Folic acid prevents neural tube defects in my baby.”
B) “I only need folic acid during the third trimester.”
C) “Folic acid will prevent gestational diabetes.”
D) “I should take folic acid every other day.”
🔍 RATIONALE💡-- Folic acid (400-800 mcg daily) before conception and during early pregnancy
significantly reduces the risk of neural tube defects. It is most critical in the first trimester.
ANSWER💫✔️-- A) “Folic acid prevents neural tube defects in my baby.”
---
**04.** A nurse is caring for a client receiving IV magnesium sulfate for severe preeclampsia. Which
finding indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Urinary output 40 mL/hr
C) Respiratory rate 10 breaths/min
D) Blood pressure 140/90 mm Hg
,🔍 RATIONALE💡-- Respiratory rate <12 breaths/min is a sign of magnesium toxicity. Other signs include
absent deep tendon reflexes and decreased urine output (<30 mL/hr). Normal reflexes are 2+; output 40
mL/hr is adequate.
ANSWER💫✔️-- C) Respiratory rate 10 breaths/min
---
**05.** A nurse is assessing a newborn of a mother with gestational diabetes. Which finding is the
newborn at greatest risk for?
A) Hypercalcemia
B) Hypoglycemia
C) Hyperbilirubinemia
D) Hypothermia
🔍 RATIONALE💡-- Infants of diabetic mothers have high insulin levels after birth, leading to
hypoglycemia in the first few hours of life. Blood glucose should be monitored.
ANSWER💫✔️-- B) Hypoglycemia
---
**06.** A nurse is reinforcing teaching about breastfeeding to a new mother. Which instruction is
correct?
A) “Wash your nipples with soap and water before each feeding.”
B) “Feed your baby on a strict 4‑hour schedule.”
C) “Allow the baby to breastfeed until satisfied, including the hindmilk.”
D) “Limit feedings to 5 minutes on each breast to prevent soreness.”
🔍 RATIONALE💡-- Hindmilk (later milk) is higher in fat and calories. Allowing the baby to feed until
satisfied ensures adequate nutrition and helps establish milk supply.
, ANSWER💫✔️-- C) “Allow the baby to breastfeed until satisfied, including the hindmilk.”
---
**07.** A nurse is caring for a client with placenta previa at 34 weeks gestation. Which finding is most
characteristic?
A) Painless, bright red vaginal bleeding
B) Severe abdominal pain with dark bleeding
C) Uterine tenderness and rigidity
D) Fever and foul discharge
🔍 RATIONALE💡-- Placenta previa presents with painless, bright red vaginal bleeding in the second or
third trimester. Abruptio placentae presents with painful, dark bleeding and uterine tenderness.
ANSWER💫✔️-- A) Painless, bright red vaginal bleeding
---
**08.** A nurse is assessing a client who is 24 hours postpartum. The client reports severe perineal pain
and a feeling of pressure. The perineum is swollen and ecchymotic. What complication should the nurse
suspect?
A) Endometritis
B) Hematoma
C) Uterine atony
D) Retained placental fragments
🔍 RATIONALE💡-- Severe pain, pressure, and perineal swelling with ecchymosis suggest a vulvar or
perineal hematoma. This requires surgical evacuation.
