MATERNITY HESI TEST II CONCEPT REVIEW
GUIDE 2026 NEWBORN ASSESSMENT AND
FAMILY CENTERED CARE
◉ 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).
Answer: C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect
changes that may indicate the presence of cord compression or
prolapse. An amniotomy (artificial rupture of membranes [AROM])
is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and
,consistency. Option A should be assessed every 15 to 20 minutes
during labor but is not specific for AROM. Option B is monitored
hourly after the membranes are ruptured to detect the development
of amnionitis. Option D should be determined for all clients in labor.
◉ 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.
Answer: 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..
Answer: 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..
Answer: 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.
GUIDE 2026 NEWBORN ASSESSMENT AND
FAMILY CENTERED CARE
◉ 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).
Answer: C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect
changes that may indicate the presence of cord compression or
prolapse. An amniotomy (artificial rupture of membranes [AROM])
is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and
,consistency. Option A should be assessed every 15 to 20 minutes
during labor but is not specific for AROM. Option B is monitored
hourly after the membranes are ruptured to detect the development
of amnionitis. Option D should be determined for all clients in labor.
◉ 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.
Answer: 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..
Answer: 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..
Answer: 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.
