MATERNITY HESI TEST II EXAM PREPARATION
PACK 2026 KEY CONCEPTS AND REVISION
NOTES
◉ The healthcare provider prescribes terbutaline (Brethine) for a
client in preterm labor. Before initiating this prescription, it is most
important for the nurse to assess the client for which condition?
Answer: Gestational diabetes.
The nurse should evaluate the client for gestational diabetes
because terbutaline (Brethine) increases blood glucose levels.
◉ A client with NO prenatal care arrives at the labor unit screaming,
"The baby is coming!" The nurse performs a vaginal examination
that reveals the cervix is 3 centimeters dilated and 75% effaced.
What additional information is most important for the nurse to
obtain?
Answer: Date of last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus
is preterm and the fetal heart pattern is reassuring, the healthcare
,provider may attempt to prolong the pregnancy and administer
corticosteroids to mature the lungs of the fetus.
◉ The nurse assesses a client admitted to the labor and delivery unit
and obtains the following data: dark red vaginal bleeding, uterus
slightly tense between contractions, BP 110/68, FHR 110
beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse
implement?
Answer: Monitoring bleeding from IV sites
Monitoring bleeding from peripheral sites is the priority
intervention. This client is presenting with signs of placental
abruption. Disseminated intravascular coagulation (DIC) is a
complication of placental abruptio, characterized by abnormal
bleeding.
◉ Immediately after birth a newborn infant is suctioned, dried, and
placed under a radiant warmer. The infant has spontaneous
respirations and the nurse assesses an apical heart rate of 80
beats/minute and respirations of 20 breaths/minute. What action
should the nurse perform next?
Answer: Initiate positive pressure ventilation
,The nurse should immediately begin positive pressure ventilation
because this infant's vital signs are not within the normal range, and
oxygen deprivation leads to cardiac depression in infants. (The
normal newborn pulse is 100 to 160 beats/minute and respirations
are 40 to 60 breaths/minute.)
◉ The nurse is preparing to give an enema to a laboring client.
Which client requires the most caution when carrying out this
procedure?
Answer: A 40-week primigravida who is at 6 cm cervical dilatation
and the presenting part is not engaged.
When the presenting part is ballotable, it is floating out of the pelvis.
In such a situation, the cord can descend before the fetus causing a
prolapsed cord, which is an emergency situation.
◉ The nurse is providing discharge teaching for a client who is 24
hours postpartum. The nurse explains to the client that her vaginal
discharge will change from red to pink and then to white. The client
asks, "What if I start having red bleeding AFTER it changes?" What
should the nurse instruct the client to do?
Answer: Reduce activity level and notify the healthcare provider.
, Lochia should progress in stages from rubra (red) to serosa
(pinkish) to alba (whitish), and not return to red. The return to
rubra usually indicates subinvolution or infection. If such a sign
occurs, the mother should notify the clinic/healthcare provider and
reduce her activity to conserve energy
◉ One hour after giving birth to an 8-pound infant, a client's lochia
rubra has increased from small to large and her fundus is boggy
despite massage. The client's pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes Methergine
0.2 mg IM × 1. What action should the nurse take immediately?
Answer: Contact the healthcare provider and question the
prescription
Methergine is contraindicated for clients with elevated blood
pressure, so the nurse should contact the healthcare provider and
question the prescription
◉ A client at 32-weeks' gestation is diagnosed with preeclampsia.
Which assessment finding is most indicative of an impending
convulsion?
Answer: 3+ deep tendon reflexes and hyper clonus
PACK 2026 KEY CONCEPTS AND REVISION
NOTES
◉ The healthcare provider prescribes terbutaline (Brethine) for a
client in preterm labor. Before initiating this prescription, it is most
important for the nurse to assess the client for which condition?
Answer: Gestational diabetes.
The nurse should evaluate the client for gestational diabetes
because terbutaline (Brethine) increases blood glucose levels.
◉ A client with NO prenatal care arrives at the labor unit screaming,
"The baby is coming!" The nurse performs a vaginal examination
that reveals the cervix is 3 centimeters dilated and 75% effaced.
What additional information is most important for the nurse to
obtain?
Answer: Date of last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus
is preterm and the fetal heart pattern is reassuring, the healthcare
,provider may attempt to prolong the pregnancy and administer
corticosteroids to mature the lungs of the fetus.
◉ The nurse assesses a client admitted to the labor and delivery unit
and obtains the following data: dark red vaginal bleeding, uterus
slightly tense between contractions, BP 110/68, FHR 110
beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse
implement?
Answer: Monitoring bleeding from IV sites
Monitoring bleeding from peripheral sites is the priority
intervention. This client is presenting with signs of placental
abruption. Disseminated intravascular coagulation (DIC) is a
complication of placental abruptio, characterized by abnormal
bleeding.
◉ Immediately after birth a newborn infant is suctioned, dried, and
placed under a radiant warmer. The infant has spontaneous
respirations and the nurse assesses an apical heart rate of 80
beats/minute and respirations of 20 breaths/minute. What action
should the nurse perform next?
Answer: Initiate positive pressure ventilation
,The nurse should immediately begin positive pressure ventilation
because this infant's vital signs are not within the normal range, and
oxygen deprivation leads to cardiac depression in infants. (The
normal newborn pulse is 100 to 160 beats/minute and respirations
are 40 to 60 breaths/minute.)
◉ The nurse is preparing to give an enema to a laboring client.
Which client requires the most caution when carrying out this
procedure?
Answer: A 40-week primigravida who is at 6 cm cervical dilatation
and the presenting part is not engaged.
When the presenting part is ballotable, it is floating out of the pelvis.
In such a situation, the cord can descend before the fetus causing a
prolapsed cord, which is an emergency situation.
◉ The nurse is providing discharge teaching for a client who is 24
hours postpartum. The nurse explains to the client that her vaginal
discharge will change from red to pink and then to white. The client
asks, "What if I start having red bleeding AFTER it changes?" What
should the nurse instruct the client to do?
Answer: Reduce activity level and notify the healthcare provider.
, Lochia should progress in stages from rubra (red) to serosa
(pinkish) to alba (whitish), and not return to red. The return to
rubra usually indicates subinvolution or infection. If such a sign
occurs, the mother should notify the clinic/healthcare provider and
reduce her activity to conserve energy
◉ One hour after giving birth to an 8-pound infant, a client's lochia
rubra has increased from small to large and her fundus is boggy
despite massage. The client's pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes Methergine
0.2 mg IM × 1. What action should the nurse take immediately?
Answer: Contact the healthcare provider and question the
prescription
Methergine is contraindicated for clients with elevated blood
pressure, so the nurse should contact the healthcare provider and
question the prescription
◉ A client at 32-weeks' gestation is diagnosed with preeclampsia.
Which assessment finding is most indicative of an impending
convulsion?
Answer: 3+ deep tendon reflexes and hyper clonus
