HESI Maternity with Questions and Verified
Answers Updated
Question 1
Which action should the nurse implement to prevent conductive heat loss in a
newborn?
Place the infant under a radiant warming system.
Put a blanket on the scale when weighing the infant.
Dry the newborn with a warmed blanket.
Position the crib away from the windows.
Correct Answer
Put a blanket on the scale when weighing the infant.
Question 2
STUDY MODE: Maternity
Question 18 of 125
ID: 4_6
A client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since
surgery. She is now complaining of bloating. Which nursing action takes the highest
priority? (Select all that apply.)
A. Call the health care provider to obtain an order to increase her diet.
B. Administer the ordered magnesium hydroxide.
C. Encourage her to change position every 30 minutes.
D. Turn out the lights and discourage visitors.
E. Encourage her to breast feed every two hours.
Correct Answer
B, C
Impaired bowel motility caused by surgical anesthesia, pain medication, and
immobility is the priority nursing diagnosis and addresses the potential problem of
a paralytic ileus. Options A and B are both caused by impaired bowel motility.
Option D is not as important as impaired motility.
Page 1 of 116
,Question 3
A client in the first stage of active labor is using a shallow pattern of rapid breaths
that is twice the normal adult breathing rate. The client reports feeling light-headed
and dizzy, and she states that her fingers are tingling. Which action should the nurse
implement?
Notify the healthcare provider.
Help her breathe into a paper bag.
Administer oxygen via nasal cannula.
Tell the client to slow her breathing.
Correct Answer
Help her breathe into a paper bag.
Question 4
The nurse is using the Silverman-Anderson index to assess an infant with respiratory
distress and determines that the infant is demonstrating marked nasal flaring, an
audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this
scale, which score should the nurse assign?
A. 3
B. 4
C. 5
D. 8
Correct Answer
C. 5
The Silverman-Anderson index is an assessment scale that scores a newborn's
respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of
the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No
respiratory distress is graded 0, and a total of 10 indicates maximum respiratory
distress. This infant is demonstrating respiratory distress with maximal effort, so a
grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory
grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options
A, B, and D are not accurate.
Page 2 of 116
,Question 5
A multiparous client delivered a 7-pound, 10-ounce infant 5 hours ago. Upon fundal
assessment, the nurse determines the uterus is boggy and is displaced above and to
the right of the umbilicus. Which action should the nurse implement next?
Document the color of the lochia.
Observe maternal vital signs.
Assist the client to the bathroom.
Notify the healthcare provider.
Correct Answer
Assist the client to the bathroom.
Question 6
The nurse observes that an antepartum client who is on bed rest for preterm labor is
eating ice rather than the food on her breakfast tray. The client states that she has a
craving for ice and then feels too full to eat anything else. What is the best nursing
action?
A. Remove all ice from the client's room.
B. Ask the client what foods she might consider eating.
C. Remind the client that what she eats affects her baby.
D. Notify the health care provider.
Correct Answer
D. Notify the health care provider.
The health care provider should be notified when a client practices pica (craving for
and consumption of nonfood substances). The practice of pica may displace more
nutritious foods from the diet, and the client should be evaluated for anemia.
Option A is overreacting and may be perceived as punishment by the client. Option
B allows the dietary department to customize the client's tray but fails to address
physiologic problems associated with not consuming nutritious foods in pregnancy.
Option C is judgmental and blocks further communication.
Page 3 of 116
, Question 7
The nurse calls a client who is 4 days postpartum to follow up about her transition
with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I
love my baby, but I feel so let down. I seem to cry for no reason!" Which adjustment
phase should the nurse determine the client is experiencing?
A. Taking-in phase
B. Postpartum blues
C. Attachment difficulty
D. Letting-go phase
Correct Answer
B. Postpartum blues
During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her
own psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
Question 8
The nurse is teaching a nursing student about the abbreviation GTPAL to note
pregnancy outcomes. The nurse determines the teaching was successful when the
students relates the abbreviation GTPAL to which terms? (Select all that apply.)
A. 𝙶̲ravidity
B. 𝚃̲otal
C. 𝙿̲arity
D. Born 𝙰̲live
E. 𝙻̲iving
Correct Answer
A, E
Gravidity and Living are correct. T - term pregnancies, born after 37 weeks
gestation. P - preterm pregnancies, born between 20 and 37 weeks. A - abortions,
delivery before 20 weeks.
Page 4 of 116
Answers Updated
Question 1
Which action should the nurse implement to prevent conductive heat loss in a
newborn?
Place the infant under a radiant warming system.
Put a blanket on the scale when weighing the infant.
Dry the newborn with a warmed blanket.
Position the crib away from the windows.
Correct Answer
Put a blanket on the scale when weighing the infant.
Question 2
STUDY MODE: Maternity
Question 18 of 125
ID: 4_6
A client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since
surgery. She is now complaining of bloating. Which nursing action takes the highest
priority? (Select all that apply.)
A. Call the health care provider to obtain an order to increase her diet.
B. Administer the ordered magnesium hydroxide.
C. Encourage her to change position every 30 minutes.
D. Turn out the lights and discourage visitors.
E. Encourage her to breast feed every two hours.
Correct Answer
B, C
Impaired bowel motility caused by surgical anesthesia, pain medication, and
immobility is the priority nursing diagnosis and addresses the potential problem of
a paralytic ileus. Options A and B are both caused by impaired bowel motility.
Option D is not as important as impaired motility.
Page 1 of 116
,Question 3
A client in the first stage of active labor is using a shallow pattern of rapid breaths
that is twice the normal adult breathing rate. The client reports feeling light-headed
and dizzy, and she states that her fingers are tingling. Which action should the nurse
implement?
Notify the healthcare provider.
Help her breathe into a paper bag.
Administer oxygen via nasal cannula.
Tell the client to slow her breathing.
Correct Answer
Help her breathe into a paper bag.
Question 4
The nurse is using the Silverman-Anderson index to assess an infant with respiratory
distress and determines that the infant is demonstrating marked nasal flaring, an
audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this
scale, which score should the nurse assign?
A. 3
B. 4
C. 5
D. 8
Correct Answer
C. 5
The Silverman-Anderson index is an assessment scale that scores a newborn's
respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of
the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No
respiratory distress is graded 0, and a total of 10 indicates maximum respiratory
distress. This infant is demonstrating respiratory distress with maximal effort, so a
grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory
grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options
A, B, and D are not accurate.
Page 2 of 116
,Question 5
A multiparous client delivered a 7-pound, 10-ounce infant 5 hours ago. Upon fundal
assessment, the nurse determines the uterus is boggy and is displaced above and to
the right of the umbilicus. Which action should the nurse implement next?
Document the color of the lochia.
Observe maternal vital signs.
Assist the client to the bathroom.
Notify the healthcare provider.
Correct Answer
Assist the client to the bathroom.
Question 6
The nurse observes that an antepartum client who is on bed rest for preterm labor is
eating ice rather than the food on her breakfast tray. The client states that she has a
craving for ice and then feels too full to eat anything else. What is the best nursing
action?
A. Remove all ice from the client's room.
B. Ask the client what foods she might consider eating.
C. Remind the client that what she eats affects her baby.
D. Notify the health care provider.
Correct Answer
D. Notify the health care provider.
The health care provider should be notified when a client practices pica (craving for
and consumption of nonfood substances). The practice of pica may displace more
nutritious foods from the diet, and the client should be evaluated for anemia.
Option A is overreacting and may be perceived as punishment by the client. Option
B allows the dietary department to customize the client's tray but fails to address
physiologic problems associated with not consuming nutritious foods in pregnancy.
Option C is judgmental and blocks further communication.
Page 3 of 116
, Question 7
The nurse calls a client who is 4 days postpartum to follow up about her transition
with her newborn at home. The woman tells the nurse, "I don't know what is wrong. I
love my baby, but I feel so let down. I seem to cry for no reason!" Which adjustment
phase should the nurse determine the client is experiencing?
A. Taking-in phase
B. Postpartum blues
C. Attachment difficulty
D. Letting-go phase
Correct Answer
B. Postpartum blues
During the postpartum period, when serum hormone levels fall, women are
emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her
own psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
Question 8
The nurse is teaching a nursing student about the abbreviation GTPAL to note
pregnancy outcomes. The nurse determines the teaching was successful when the
students relates the abbreviation GTPAL to which terms? (Select all that apply.)
A. 𝙶̲ravidity
B. 𝚃̲otal
C. 𝙿̲arity
D. Born 𝙰̲live
E. 𝙻̲iving
Correct Answer
A, E
Gravidity and Living are correct. T - term pregnancies, born after 37 weeks
gestation. P - preterm pregnancies, born between 20 and 37 weeks. A - abortions,
delivery before 20 weeks.
Page 4 of 116
