Maternity HESI Test bank (combined red hesi and other
sources) with well revised exams and answers verified by
professors with 200 + quiz and answers
Which recommendation should the nurse make to an expectant father who reports that
his wife frequently talks to the fetus, rubs her abdomen, and gently “reprimands” fetal
movement?
A. Suggest immediate psychiatric evaluation for possible delusional thinking
B. Explain that these behaviors suggest maternal ambivalence about the pregnancy
C. Instruct him to document and report these behaviors as abnormal at the next visit
D. Reassure him that these behaviors are consistent with normal maternal–fetal bonding
Correct Answer: D
Extensive Expert Rationale:
Maternal-fetal bonding is a well-established psychological and emotional process that
typically begins in the second trimester, especially after quickening (perception of fetal
movement around 17–20 weeks). During this period, many pregnant individuals begin
interacting with the fetus through touch, speech, and emotional engagement.
Talking to the fetus, rubbing the abdomen, and even “scolding” fetal movement are not
indicators of pathology; rather, they reflect increasing emotional attachment and the
cognitive recognition of the fetus as a separate, developing individual. This is considered a
healthy adaptation that supports postpartum bonding and caregiving behaviors.
Ambivalence about pregnancy would more likely present as emotional withdrawal,
inconsistent prenatal care, or expressed uncertainty about continuing the pregnancy—not
affectionate interaction. There is no evidence in the scenario of psychosis, delusional
thinking, or impairment of reality testing, so psychiatric referral is not indicated.
Option C would inappropriately pathologize normal behavior and may increase anxiety or
stigma. Nursing guidance should instead normalize the behavior and support the family’s
understanding of pregnancy-related psychological changes.
After an amniotomy (artificial rupture of membranes), what is the nurse’s highest priority
assessment?
A. Maternal blood pressure
B. Maternal temperature
,C. Fetal heart rate (FHR)
D. Maternal white blood cell count
Correct Answer: C
Extensive Expert Rationale:
Amniotomy involves intentional rupture of the amniotic sac to augment or induce labor.
Once membranes are ruptured, the fetus is at increased risk for complications such as
umbilical cord prolapse or cord compression due to sudden loss of cushioning fluid.
The most immediate and life-threatening complication is fetal hypoxia caused by cord
compression or prolapse. Therefore, the first and most critical assessment is the fetal
heart rate (FHR), which provides real-time information about fetal oxygenation and
perfusion.
A nonreassuring FHR pattern after rupture may be the earliest indicator of cord
compromise, requiring urgent intervention. Maternal vital signs, including temperature,
are important but reflect later complications such as infection (chorioamnionitis), which
develop over time rather than immediately.
WBC count is not a priority in the acute post-procedure period, as it is not useful for
immediate fetal assessment.
Which newborn finding at 12 hours of life requires the highest priority nursing attention?
A. Acrocyanosis of hands and feet
B. Mild jaundice of the skin
C. Milia on the nose and chin
D. Erythema toxicum rash
Correct Answer: B
Extensive Expert Rationale:
Neonatal jaundice occurring within the first 24 hours of life is considered pathologic until
proven otherwise. Early jaundice may indicate hemolytic disease, infection, or metabolic
disorders and requires prompt evaluation of bilirubin levels.
Physiologic jaundice typically appears after 24 hours of life due to normal breakdown of
fetal hemoglobin and immature hepatic conjugation pathways. However, jaundice at 12
hours is abnormal and may signal excessive red blood cell destruction or impaired bilirubin
clearance.
Acrocyanosis is a normal finding in newborns due to immature peripheral circulation. Milia
are benign keratin-filled cysts that resolve spontaneously. Erythema toxicum neonatorum
is a common, harmless rash in healthy newborns.
,Because early jaundice can progress to kernicterus (bilirubin-induced neurologic damage),
it takes priority over benign skin findings.
What is the appropriate nursing instruction for a breastfeeding client diagnosed with
mastitis?
A. Continue breastfeeding and ensure complete emptying of both breasts
B. Stop breastfeeding and switch to formula feeding until resolved
C. Breastfeed only on the unaffected breast
D. Pump and discard all breast milk until antibiotics are completed
Correct Answer: A
Extensive Expert Rationale:
Mastitis is an inflammatory infection of breast tissue, most commonly caused by milk
stasis and bacterial entry through nipple fissures. Despite being painful, continued milk
removal is essential for recovery.
Breastfeeding or pumping helps drain obstructed ducts, reduce bacterial load, and relieve
pressure that contributes to inflammation. Abrupt cessation of breastfeeding can worsen
engorgement and delay recovery.
Antibiotics used to treat mastitis are generally compatible with breastfeeding and do not
require cessation of feeding. The infant benefits from continued feeding, and milk
expression prevents abscess formation.
Feeding only from the unaffected breast or discarding milk unnecessarily increases risk of
worsening infection and undermines treatment goals.
A 38-week pregnant client who sits at a desk for long hours reports lower extremity
swelling. What instruction best promotes venous return?
A. Wear compression stockings continuously
B. Reduce dietary sodium intake
C. Ambulate or change position every hour
D. Avoid tight clothing around the abdomen
Correct Answer: C
Extensive Expert Rationale:
Pregnancy-related peripheral edema is commonly caused by uterine compression of the
inferior vena cava and pelvic veins, which impairs venous return from the lower
extremities.
, Prolonged sitting exacerbates venous stasis, increasing hydrostatic pressure and fluid
accumulation in dependent tissues. The most effective intervention is frequent movement,
which activates the skeletal muscle pump and enhances venous return to the heart.
Ambulating or changing position every hour directly counteracts venous pooling and
improves circulation.
Compression stockings may help in chronic venous insufficiency but do not address
positional venous obstruction as effectively as movement in pregnancy-related edema.
Sodium restriction is more relevant in systemic fluid overload states. Avoiding tight
clothing is general advice but does not significantly improve venous return in this scenario.
Which of the following hormones decreases just before labor?
a. oxytocin
b. prostaglandins
c. progesterone
d. estrogen
C
Which of the following hormones increases before labor? Select all that apply.
a. oxytocin
b. prostaglandins
c. progesterone
d. estrogen
A, B
5 P's of Labor
Powers, passenger, passageway, psychology, position
Though there are 5 P's of labor, which ones are we focusing more on? Select all that apply.
a. Psychology
b. powers
c. position
d. passageway
e. passenger
B, D, E
What is considered to be the passenger in labor?
sources) with well revised exams and answers verified by
professors with 200 + quiz and answers
Which recommendation should the nurse make to an expectant father who reports that
his wife frequently talks to the fetus, rubs her abdomen, and gently “reprimands” fetal
movement?
A. Suggest immediate psychiatric evaluation for possible delusional thinking
B. Explain that these behaviors suggest maternal ambivalence about the pregnancy
C. Instruct him to document and report these behaviors as abnormal at the next visit
D. Reassure him that these behaviors are consistent with normal maternal–fetal bonding
Correct Answer: D
Extensive Expert Rationale:
Maternal-fetal bonding is a well-established psychological and emotional process that
typically begins in the second trimester, especially after quickening (perception of fetal
movement around 17–20 weeks). During this period, many pregnant individuals begin
interacting with the fetus through touch, speech, and emotional engagement.
Talking to the fetus, rubbing the abdomen, and even “scolding” fetal movement are not
indicators of pathology; rather, they reflect increasing emotional attachment and the
cognitive recognition of the fetus as a separate, developing individual. This is considered a
healthy adaptation that supports postpartum bonding and caregiving behaviors.
Ambivalence about pregnancy would more likely present as emotional withdrawal,
inconsistent prenatal care, or expressed uncertainty about continuing the pregnancy—not
affectionate interaction. There is no evidence in the scenario of psychosis, delusional
thinking, or impairment of reality testing, so psychiatric referral is not indicated.
Option C would inappropriately pathologize normal behavior and may increase anxiety or
stigma. Nursing guidance should instead normalize the behavior and support the family’s
understanding of pregnancy-related psychological changes.
After an amniotomy (artificial rupture of membranes), what is the nurse’s highest priority
assessment?
A. Maternal blood pressure
B. Maternal temperature
,C. Fetal heart rate (FHR)
D. Maternal white blood cell count
Correct Answer: C
Extensive Expert Rationale:
Amniotomy involves intentional rupture of the amniotic sac to augment or induce labor.
Once membranes are ruptured, the fetus is at increased risk for complications such as
umbilical cord prolapse or cord compression due to sudden loss of cushioning fluid.
The most immediate and life-threatening complication is fetal hypoxia caused by cord
compression or prolapse. Therefore, the first and most critical assessment is the fetal
heart rate (FHR), which provides real-time information about fetal oxygenation and
perfusion.
A nonreassuring FHR pattern after rupture may be the earliest indicator of cord
compromise, requiring urgent intervention. Maternal vital signs, including temperature,
are important but reflect later complications such as infection (chorioamnionitis), which
develop over time rather than immediately.
WBC count is not a priority in the acute post-procedure period, as it is not useful for
immediate fetal assessment.
Which newborn finding at 12 hours of life requires the highest priority nursing attention?
A. Acrocyanosis of hands and feet
B. Mild jaundice of the skin
C. Milia on the nose and chin
D. Erythema toxicum rash
Correct Answer: B
Extensive Expert Rationale:
Neonatal jaundice occurring within the first 24 hours of life is considered pathologic until
proven otherwise. Early jaundice may indicate hemolytic disease, infection, or metabolic
disorders and requires prompt evaluation of bilirubin levels.
Physiologic jaundice typically appears after 24 hours of life due to normal breakdown of
fetal hemoglobin and immature hepatic conjugation pathways. However, jaundice at 12
hours is abnormal and may signal excessive red blood cell destruction or impaired bilirubin
clearance.
Acrocyanosis is a normal finding in newborns due to immature peripheral circulation. Milia
are benign keratin-filled cysts that resolve spontaneously. Erythema toxicum neonatorum
is a common, harmless rash in healthy newborns.
,Because early jaundice can progress to kernicterus (bilirubin-induced neurologic damage),
it takes priority over benign skin findings.
What is the appropriate nursing instruction for a breastfeeding client diagnosed with
mastitis?
A. Continue breastfeeding and ensure complete emptying of both breasts
B. Stop breastfeeding and switch to formula feeding until resolved
C. Breastfeed only on the unaffected breast
D. Pump and discard all breast milk until antibiotics are completed
Correct Answer: A
Extensive Expert Rationale:
Mastitis is an inflammatory infection of breast tissue, most commonly caused by milk
stasis and bacterial entry through nipple fissures. Despite being painful, continued milk
removal is essential for recovery.
Breastfeeding or pumping helps drain obstructed ducts, reduce bacterial load, and relieve
pressure that contributes to inflammation. Abrupt cessation of breastfeeding can worsen
engorgement and delay recovery.
Antibiotics used to treat mastitis are generally compatible with breastfeeding and do not
require cessation of feeding. The infant benefits from continued feeding, and milk
expression prevents abscess formation.
Feeding only from the unaffected breast or discarding milk unnecessarily increases risk of
worsening infection and undermines treatment goals.
A 38-week pregnant client who sits at a desk for long hours reports lower extremity
swelling. What instruction best promotes venous return?
A. Wear compression stockings continuously
B. Reduce dietary sodium intake
C. Ambulate or change position every hour
D. Avoid tight clothing around the abdomen
Correct Answer: C
Extensive Expert Rationale:
Pregnancy-related peripheral edema is commonly caused by uterine compression of the
inferior vena cava and pelvic veins, which impairs venous return from the lower
extremities.
, Prolonged sitting exacerbates venous stasis, increasing hydrostatic pressure and fluid
accumulation in dependent tissues. The most effective intervention is frequent movement,
which activates the skeletal muscle pump and enhances venous return to the heart.
Ambulating or changing position every hour directly counteracts venous pooling and
improves circulation.
Compression stockings may help in chronic venous insufficiency but do not address
positional venous obstruction as effectively as movement in pregnancy-related edema.
Sodium restriction is more relevant in systemic fluid overload states. Avoiding tight
clothing is general advice but does not significantly improve venous return in this scenario.
Which of the following hormones decreases just before labor?
a. oxytocin
b. prostaglandins
c. progesterone
d. estrogen
C
Which of the following hormones increases before labor? Select all that apply.
a. oxytocin
b. prostaglandins
c. progesterone
d. estrogen
A, B
5 P's of Labor
Powers, passenger, passageway, psychology, position
Though there are 5 P's of labor, which ones are we focusing more on? Select all that apply.
a. Psychology
b. powers
c. position
d. passageway
e. passenger
B, D, E
What is considered to be the passenger in labor?
