HESI Maternity OB Exam Versions 1, 2 & 3 2026/2027 –
Elsevier Evolve – Comprehensive Obstetric & Newborn Care
Competency Assessment Bundle — 290 Questions
Section 1: Antepartum Care and Complications (Questions 1-30)
1 A pregnant client at 28 weeks gestation with a history of systemic lupus erythematosus presents with
hypertension, proteinuria (3+ on dipstick), and elevated liver enzymes. Which pathophysiology is most
consistent with this presentation?
A) Exacerbation of lupus nephritis due to increased glomerular filtration rate
B) HELLP syndrome secondary to microangiopathic hemolysis
C) Superimposed preeclampsia with features of thrombotic microangiopathy
D) Acute fatty liver of pregnancy with hepatic encephalopathy
Answer: C
Rationale: Superimposed preeclampsia is common in women with lupus and presents with hypertension,
proteinuria, and elevated liver enzymes. HELLP syndrome (option B) typically includes hemolysis and low
platelets, not stated here. Lupus nephritis (option A) may cause proteinuria but not hypertension in this context.
Acute fatty liver (option D) presents with hypoglycemia and coagulopathy, not primarily hypertension.
2 A client at 34 weeks gestation with type 1 diabetes mellitus has a glycosylated hemoglobin (HbA1c) of 8.2%.
Which fetal complication is most likely to be detected on a detailed ultrasound?
A) Sacral agenesis
B) Diaphragmatic hernia
C) Transposition of the great arteries
D) Duodenal atresia
Answer: A
Rationale: Poor glycemic control in early pregnancy (elevated HbA1c) is associated with caudal regression
syndrome, including sacral agenesis. Diaphragmatic hernia (B) and transposition of the great arteries (C) are not
specifically linked to maternal diabetes. Duodenal atresia (D) is associated with polyhydramnios but not
specifically with HbA1c levels.
3 A client at 32 weeks gestation with a body mass index of 38 kg/m² is diagnosed with mild preeclampsia. Which
pharmacologic intervention is most appropriate to prevent disease progression?
A) Labetalol 200 mg orally twice daily
B) Methyldopa 500 mg orally twice daily
C) Nifedipine 30 mg extended-release orally daily
D) Low-dose aspirin 81 mg orally daily
Answer: D
Rationale: Low-dose aspirin (81 mg daily) is recommended for preeclampsia prevention in high-risk women
(obesity, prior preeclampsia). Labetalol (A) and nifedipine (C) are used for treatment of hypertension, not
prevention. Methyldopa (B) is a second-line antihypertensive in pregnancy but not for prevention of progression.
4 A client at 26 weeks gestation with no prior history of diabetes undergoes a 1-hour 50-gram glucose challenge
test; the plasma glucose level is 155 mg/dL. Which follow-up is most appropriate?
A) Initiate insulin therapy and refer to endocrinology
,B) Perform a 3-hour 100-gram oral glucose tolerance test
C) Repeat the 1-hour glucose challenge test in 2 weeks
D) Diagnose gestational diabetes mellitus and start metformin
Answer: B
Rationale: A 1-hour glucose challenge test result "e140 mg/dL (some thresholds 130-140) warrants a diagnostic
3-hour OGTT. Insulin (A) or metformin (D) should not be initiated without a diagnosis. Repeating the test (C) is
less efficient than proceeding to the definitive diagnostic test.
5 A client at 30 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a placenta previa
extending 2 cm over the internal cervical os. Which finding would most likely indicate the need for immediate
cesarean delivery?
A) Fetal heart rate baseline of 140 bpm with moderate variability
B) Maternal blood pressure of 100/60 mm Hg and pulse 90 bpm
C) Three episodes of bright red bleeding within 1 hour
D) Cervical length of 3.5 cm on transvaginal ultrasound
Answer: C
Rationale: In placenta previa, active hemorrhage (e.g., recurrent bright red bleeding) indicates the need for emergent
cesarean delivery to prevent maternal-fetal compromise. A stable fetal heart rate (A) and cervical length >3 cm (D)
are reassuring. Mild maternal tachycardia (B) may be compensated, but recurrent bleeding is more urgent.
6 A client at 35 weeks gestation with a history of cervical insufficiency presents with a cervical length of 1.5 cm
and funneling. Which intervention is most appropriate at this gestational age?
A) Placement of a McDonald cerclage
B) Administration of betamethasone 12 mg intramuscularly
C) Initiation of indomethacin 50 mg orally every 6 hours
D) Bed rest with pelvic rest and fetal monitoring
Answer: B
Rationale: At 35 weeks, cerclage is typically not placed due to risk of infection and preterm labor. Betamethasone is
given to enhance fetal lung maturity. Indomethacin (C) is used for tocolysis but not primary management. Bed rest
(D) is supportive but not the most appropriate intervention for lung maturity.
7 A client at 20 weeks gestation is found to have a positive triple screen for trisomy 21 (1:45 risk). Which
diagnostic test should be offered to confirm the diagnosis?
A) Chorionic villus sampling
B) Amniocentesis with karyotype analysis
C) Cell-free fetal DNA testing
D) Nuchal translucency measurement
Answer: B
Rationale: Amniocentesis at 15-20 weeks is the gold standard for diagnostic confirmation of trisomy 21. CVS (A) is
done earlier (10-13 weeks) and carries higher risk. Cell-free fetal DNA (C) is a screening test, not diagnostic.
Nuchal translucency (D) is also a screening tool.
8 A client at 28 weeks gestation with a history of preterm birth at 32 weeks presents with regular contractions and
cervical dilation of 2 cm. Fetal fibronectin test is positive. Which pharmacologic agent is contraindicated for
tocolysis in this scenario?
A) Terbutaline 0.25 mg subcutaneously
B) Magnesium sulfate 4 g IV bolus
,C) Nifedipine 20 mg orally every 6 hours
D) Indomethacin 100 mg rectally
Answer: D
Rationale: Indomethacin is contraindicated after 32 weeks gestation due to risk of premature closure of the ductus
arteriosus and oligohydramnios. Terbutaline (A), magnesium sulfate (B), and nifedipine (C) are acceptable
tocolytics at this gestation, though terbutaline is less favored due to maternal side effects.
9 A client at 36 weeks gestation with a diagnosis of intrahepatic cholestasis of pregnancy has a fasting bile acid
level of 50 µmol/L. Which fetal surveillance is most critical?
A) Daily nonstress tests
B) Biweekly biophysical profiles
C) Doppler velocimetry of umbilical artery
D) Early delivery at 36 weeks
Answer: A
Rationale: Bile acid levels "e40 µmol/L are associated with increased risk of stillbirth, necessitating intensive fetal
surveillance such as daily NSTs. Biophysical profiles (B) and Doppler (C) are less sensitive for acute fetal
compromise in cholestasis. Early delivery (D) is considered at 36-37 weeks, but surveillance is still critical before
delivery.
10 A client at 24 weeks gestation with a history of two prior unexplained stillbirths presents for prenatal care.
Which screening protocol is most appropriate for this pregnancy?
A) Serial ultrasounds for fetal growth and anatomy every 4 weeks
B) Antiphospholipid antibody panel and lupus anticoagulant testing
C) First-trimester combined screening for aneuploidy
D) Glucose tolerance test at 24-28 weeks
Answer: B
Rationale: Unexplained stillbirths raise suspicion for antiphospholipid syndrome (APS), which requires testing for
antiphospholipid antibodies. Serial growth scans (A) are important but not the initial screening. Aneuploidy
screening (C) and GDM testing (D) are standard but not specific to recurrent stillbirth.
11 A pregnant individual at 28 weeks gestation presents with a blood pressure of 158/102 mmHg and 3+
proteinuria on a random urine sample. The patient denies headache, visual changes, or epigastric pain.
Laboratory results show platelet count 120,000/¼L, AST 45 U/L, ALT 50 U/L, and serum creatinine 0.9 mg/dL.
Which of the following is the most appropriate next step in management?
A) Administer betamethasone and plan for delivery within 48 hours
B) Start oral labetalol and schedule outpatient blood pressure monitoring twice weekly
C) Admit for intravenous magnesium sulfate and antihypertensive therapy with planned delivery after 34 weeks
D) Prescribe methyldopa and recommend bed rest at home with daily fetal movement counts
Answer: C
Rationale: This presentation meets criteria for severe preeclampsia (BP "e160/110, proteinuria, thrombocytopenia).
Admission for magnesium sulfate seizure prophylaxis and antihypertensive therapy is indicated, with delivery
planning after 34 weeks or earlier if maternal/fetal status deteriorates. Option A is premature without immediate
delivery indication; option B is insufficient for severe disease; option D with methyldopa is not first-line for severe
hypertension.
, 12 A primigravid individual at 32 weeks gestation is diagnosed with gestational diabetes mellitus (GDM) via a
2-hour 75g OGTT. Fasting glucose is 95 mg/dL, 1-hour 180 mg/dL, and 2-hour 155 mg/dL. The patient has a
BMI of 32 kg/m² and no prior history of GDM. Which of the following management strategies is most strongly
associated with improved perinatal outcomes in this scenario?
A) Initiate insulin glargine at bedtime and rapid-acting insulin before meals targeting fasting glucose <95 mg/dL
and 1-hour postprandial <140 mg/dL
B) Start metformin 500 mg twice daily and monitor fasting and postprandial glucose weekly
C) Prescribe a low-glycemic index diet and recommend self-monitoring of blood glucose four times daily, with
pharmacotherapy if targets are not met within two weeks
D) Refer for immediate induction of labor at 37 weeks due to the risk of macrosomia
Answer: C
Rationale: Initial management of GDM involves medical nutrition therapy and glucose monitoring, with
pharmacotherapy (insulin or metformin) added if targets are not achieved. Option A skips dietary intervention;
option B uses metformin as first-line, which is not standard; option D is premature without evidence of poor
control or complications.
13 A patient at 24 weeks gestation with a history of two prior unexplained second-trimester losses presents for
cervical length screening. Transvaginal ultrasound reveals a cervical length of 22 mm. Which of the following
interventions has been shown to reduce the risk of preterm birth in this specific population?
A) Daily oral progesterone supplementation starting at 16 weeks
B) Cervical cerclage placement at the time of diagnosis
C) Intramuscular 17-alpha-hydroxyprogesterone caproate weekly from 16 to 36 weeks
D) Vaginal progesterone 200 mg daily until 36 weeks
Answer: D
Rationale: For a patient with prior spontaneous preterm birth and a short cervix (<25 mm) in the current pregnancy,
vaginal progesterone reduces preterm birth risk. Option A (oral progesterone) is not recommended; option B
(cerclage) is indicated for prior second-trimester loss or cervical insufficiency, but not solely for short cervix
without prior painless dilation; option C (17-OHPC) is for prior preterm birth without short cervix, but recent trials
show limited efficacy.
14 A pregnant individual at 30 weeks gestation with a history of systemic lupus erythematosus (SLE) presents
with a blood pressure of 145/90 mmHg and new-onset proteinuria (urine protein-to-creatinine ratio 0.5).
Laboratory evaluation reveals low C3 and C4 complement levels, positive anti-dsDNA antibodies, and a
normal platelet count. Which of the following is the most likely diagnosis?
A) Preeclampsia with severe features
B) Lupus nephritis flare
C) Chronic hypertension with superimposed preeclampsia
D) Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome
Answer: B
Rationale: The combination of active lupus serologies (low complement, positive anti-dsDNA) with hypertension
and proteinuria favors lupus nephritis over preeclampsia. Preeclampsia typically does not cause low complement or
anti-dsDNA. HELLP syndrome involves hemolysis and thrombocytopenia, which are absent here. Superimposed
preeclampsia is less likely given the serologic findings.
15 A patient at 35 weeks gestation with a diagnosis of placenta previa (complete, anterior) experiences a small
episode of painless vaginal bleeding that resolves spontaneously. Fetal heart rate tracing is category I. Which of
the following management plans is most appropriate?
Elsevier Evolve – Comprehensive Obstetric & Newborn Care
Competency Assessment Bundle — 290 Questions
Section 1: Antepartum Care and Complications (Questions 1-30)
1 A pregnant client at 28 weeks gestation with a history of systemic lupus erythematosus presents with
hypertension, proteinuria (3+ on dipstick), and elevated liver enzymes. Which pathophysiology is most
consistent with this presentation?
A) Exacerbation of lupus nephritis due to increased glomerular filtration rate
B) HELLP syndrome secondary to microangiopathic hemolysis
C) Superimposed preeclampsia with features of thrombotic microangiopathy
D) Acute fatty liver of pregnancy with hepatic encephalopathy
Answer: C
Rationale: Superimposed preeclampsia is common in women with lupus and presents with hypertension,
proteinuria, and elevated liver enzymes. HELLP syndrome (option B) typically includes hemolysis and low
platelets, not stated here. Lupus nephritis (option A) may cause proteinuria but not hypertension in this context.
Acute fatty liver (option D) presents with hypoglycemia and coagulopathy, not primarily hypertension.
2 A client at 34 weeks gestation with type 1 diabetes mellitus has a glycosylated hemoglobin (HbA1c) of 8.2%.
Which fetal complication is most likely to be detected on a detailed ultrasound?
A) Sacral agenesis
B) Diaphragmatic hernia
C) Transposition of the great arteries
D) Duodenal atresia
Answer: A
Rationale: Poor glycemic control in early pregnancy (elevated HbA1c) is associated with caudal regression
syndrome, including sacral agenesis. Diaphragmatic hernia (B) and transposition of the great arteries (C) are not
specifically linked to maternal diabetes. Duodenal atresia (D) is associated with polyhydramnios but not
specifically with HbA1c levels.
3 A client at 32 weeks gestation with a body mass index of 38 kg/m² is diagnosed with mild preeclampsia. Which
pharmacologic intervention is most appropriate to prevent disease progression?
A) Labetalol 200 mg orally twice daily
B) Methyldopa 500 mg orally twice daily
C) Nifedipine 30 mg extended-release orally daily
D) Low-dose aspirin 81 mg orally daily
Answer: D
Rationale: Low-dose aspirin (81 mg daily) is recommended for preeclampsia prevention in high-risk women
(obesity, prior preeclampsia). Labetalol (A) and nifedipine (C) are used for treatment of hypertension, not
prevention. Methyldopa (B) is a second-line antihypertensive in pregnancy but not for prevention of progression.
4 A client at 26 weeks gestation with no prior history of diabetes undergoes a 1-hour 50-gram glucose challenge
test; the plasma glucose level is 155 mg/dL. Which follow-up is most appropriate?
A) Initiate insulin therapy and refer to endocrinology
,B) Perform a 3-hour 100-gram oral glucose tolerance test
C) Repeat the 1-hour glucose challenge test in 2 weeks
D) Diagnose gestational diabetes mellitus and start metformin
Answer: B
Rationale: A 1-hour glucose challenge test result "e140 mg/dL (some thresholds 130-140) warrants a diagnostic
3-hour OGTT. Insulin (A) or metformin (D) should not be initiated without a diagnosis. Repeating the test (C) is
less efficient than proceeding to the definitive diagnostic test.
5 A client at 30 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a placenta previa
extending 2 cm over the internal cervical os. Which finding would most likely indicate the need for immediate
cesarean delivery?
A) Fetal heart rate baseline of 140 bpm with moderate variability
B) Maternal blood pressure of 100/60 mm Hg and pulse 90 bpm
C) Three episodes of bright red bleeding within 1 hour
D) Cervical length of 3.5 cm on transvaginal ultrasound
Answer: C
Rationale: In placenta previa, active hemorrhage (e.g., recurrent bright red bleeding) indicates the need for emergent
cesarean delivery to prevent maternal-fetal compromise. A stable fetal heart rate (A) and cervical length >3 cm (D)
are reassuring. Mild maternal tachycardia (B) may be compensated, but recurrent bleeding is more urgent.
6 A client at 35 weeks gestation with a history of cervical insufficiency presents with a cervical length of 1.5 cm
and funneling. Which intervention is most appropriate at this gestational age?
A) Placement of a McDonald cerclage
B) Administration of betamethasone 12 mg intramuscularly
C) Initiation of indomethacin 50 mg orally every 6 hours
D) Bed rest with pelvic rest and fetal monitoring
Answer: B
Rationale: At 35 weeks, cerclage is typically not placed due to risk of infection and preterm labor. Betamethasone is
given to enhance fetal lung maturity. Indomethacin (C) is used for tocolysis but not primary management. Bed rest
(D) is supportive but not the most appropriate intervention for lung maturity.
7 A client at 20 weeks gestation is found to have a positive triple screen for trisomy 21 (1:45 risk). Which
diagnostic test should be offered to confirm the diagnosis?
A) Chorionic villus sampling
B) Amniocentesis with karyotype analysis
C) Cell-free fetal DNA testing
D) Nuchal translucency measurement
Answer: B
Rationale: Amniocentesis at 15-20 weeks is the gold standard for diagnostic confirmation of trisomy 21. CVS (A) is
done earlier (10-13 weeks) and carries higher risk. Cell-free fetal DNA (C) is a screening test, not diagnostic.
Nuchal translucency (D) is also a screening tool.
8 A client at 28 weeks gestation with a history of preterm birth at 32 weeks presents with regular contractions and
cervical dilation of 2 cm. Fetal fibronectin test is positive. Which pharmacologic agent is contraindicated for
tocolysis in this scenario?
A) Terbutaline 0.25 mg subcutaneously
B) Magnesium sulfate 4 g IV bolus
,C) Nifedipine 20 mg orally every 6 hours
D) Indomethacin 100 mg rectally
Answer: D
Rationale: Indomethacin is contraindicated after 32 weeks gestation due to risk of premature closure of the ductus
arteriosus and oligohydramnios. Terbutaline (A), magnesium sulfate (B), and nifedipine (C) are acceptable
tocolytics at this gestation, though terbutaline is less favored due to maternal side effects.
9 A client at 36 weeks gestation with a diagnosis of intrahepatic cholestasis of pregnancy has a fasting bile acid
level of 50 µmol/L. Which fetal surveillance is most critical?
A) Daily nonstress tests
B) Biweekly biophysical profiles
C) Doppler velocimetry of umbilical artery
D) Early delivery at 36 weeks
Answer: A
Rationale: Bile acid levels "e40 µmol/L are associated with increased risk of stillbirth, necessitating intensive fetal
surveillance such as daily NSTs. Biophysical profiles (B) and Doppler (C) are less sensitive for acute fetal
compromise in cholestasis. Early delivery (D) is considered at 36-37 weeks, but surveillance is still critical before
delivery.
10 A client at 24 weeks gestation with a history of two prior unexplained stillbirths presents for prenatal care.
Which screening protocol is most appropriate for this pregnancy?
A) Serial ultrasounds for fetal growth and anatomy every 4 weeks
B) Antiphospholipid antibody panel and lupus anticoagulant testing
C) First-trimester combined screening for aneuploidy
D) Glucose tolerance test at 24-28 weeks
Answer: B
Rationale: Unexplained stillbirths raise suspicion for antiphospholipid syndrome (APS), which requires testing for
antiphospholipid antibodies. Serial growth scans (A) are important but not the initial screening. Aneuploidy
screening (C) and GDM testing (D) are standard but not specific to recurrent stillbirth.
11 A pregnant individual at 28 weeks gestation presents with a blood pressure of 158/102 mmHg and 3+
proteinuria on a random urine sample. The patient denies headache, visual changes, or epigastric pain.
Laboratory results show platelet count 120,000/¼L, AST 45 U/L, ALT 50 U/L, and serum creatinine 0.9 mg/dL.
Which of the following is the most appropriate next step in management?
A) Administer betamethasone and plan for delivery within 48 hours
B) Start oral labetalol and schedule outpatient blood pressure monitoring twice weekly
C) Admit for intravenous magnesium sulfate and antihypertensive therapy with planned delivery after 34 weeks
D) Prescribe methyldopa and recommend bed rest at home with daily fetal movement counts
Answer: C
Rationale: This presentation meets criteria for severe preeclampsia (BP "e160/110, proteinuria, thrombocytopenia).
Admission for magnesium sulfate seizure prophylaxis and antihypertensive therapy is indicated, with delivery
planning after 34 weeks or earlier if maternal/fetal status deteriorates. Option A is premature without immediate
delivery indication; option B is insufficient for severe disease; option D with methyldopa is not first-line for severe
hypertension.
, 12 A primigravid individual at 32 weeks gestation is diagnosed with gestational diabetes mellitus (GDM) via a
2-hour 75g OGTT. Fasting glucose is 95 mg/dL, 1-hour 180 mg/dL, and 2-hour 155 mg/dL. The patient has a
BMI of 32 kg/m² and no prior history of GDM. Which of the following management strategies is most strongly
associated with improved perinatal outcomes in this scenario?
A) Initiate insulin glargine at bedtime and rapid-acting insulin before meals targeting fasting glucose <95 mg/dL
and 1-hour postprandial <140 mg/dL
B) Start metformin 500 mg twice daily and monitor fasting and postprandial glucose weekly
C) Prescribe a low-glycemic index diet and recommend self-monitoring of blood glucose four times daily, with
pharmacotherapy if targets are not met within two weeks
D) Refer for immediate induction of labor at 37 weeks due to the risk of macrosomia
Answer: C
Rationale: Initial management of GDM involves medical nutrition therapy and glucose monitoring, with
pharmacotherapy (insulin or metformin) added if targets are not achieved. Option A skips dietary intervention;
option B uses metformin as first-line, which is not standard; option D is premature without evidence of poor
control or complications.
13 A patient at 24 weeks gestation with a history of two prior unexplained second-trimester losses presents for
cervical length screening. Transvaginal ultrasound reveals a cervical length of 22 mm. Which of the following
interventions has been shown to reduce the risk of preterm birth in this specific population?
A) Daily oral progesterone supplementation starting at 16 weeks
B) Cervical cerclage placement at the time of diagnosis
C) Intramuscular 17-alpha-hydroxyprogesterone caproate weekly from 16 to 36 weeks
D) Vaginal progesterone 200 mg daily until 36 weeks
Answer: D
Rationale: For a patient with prior spontaneous preterm birth and a short cervix (<25 mm) in the current pregnancy,
vaginal progesterone reduces preterm birth risk. Option A (oral progesterone) is not recommended; option B
(cerclage) is indicated for prior second-trimester loss or cervical insufficiency, but not solely for short cervix
without prior painless dilation; option C (17-OHPC) is for prior preterm birth without short cervix, but recent trials
show limited efficacy.
14 A pregnant individual at 30 weeks gestation with a history of systemic lupus erythematosus (SLE) presents
with a blood pressure of 145/90 mmHg and new-onset proteinuria (urine protein-to-creatinine ratio 0.5).
Laboratory evaluation reveals low C3 and C4 complement levels, positive anti-dsDNA antibodies, and a
normal platelet count. Which of the following is the most likely diagnosis?
A) Preeclampsia with severe features
B) Lupus nephritis flare
C) Chronic hypertension with superimposed preeclampsia
D) Hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome
Answer: B
Rationale: The combination of active lupus serologies (low complement, positive anti-dsDNA) with hypertension
and proteinuria favors lupus nephritis over preeclampsia. Preeclampsia typically does not cause low complement or
anti-dsDNA. HELLP syndrome involves hemolysis and thrombocytopenia, which are absent here. Superimposed
preeclampsia is less likely given the serologic findings.
15 A patient at 35 weeks gestation with a diagnosis of placenta previa (complete, anterior) experiences a small
episode of painless vaginal bleeding that resolves spontaneously. Fetal heart rate tracing is category I. Which of
the following management plans is most appropriate?
