HESI MATERNITY ALL PRACTICE QUESTIONS
1. A client at 40-weeks’ gestation presents to the obstetrical floor and indicates that
the amniotic membranes ruptured spontaneously at home. She is in active labor
and feels the need to bear down and push. What information is most important
for the nurse to obtain first?
a. the estimated amount of fluid
b. time the membranes ruptured
c. color and consistency of the fluid
d. any odor noted when membranes ruptured.
2. A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action
should the nurse take first?
a. assess the urine for proteinuria
b. record the finding on a flowsheet
c. obtain blood pressure reading
d. notify the healthcare provider
3. The nurse is preparing to draw blood from a newborn to obtain hemoglobin and
hematocrit levels. What is the best method to obtain this blood sample?
a. use a butterfly, small gauge needle to do a venous puncture on the hand
b. draw blood from the infant's antecubital vein using a small gauge needle
c. use a small gauge needle to puncture the vastus lateralis
d. use a lancet to puncture the outer lateral aspect of the heel *
4. A 25-year-old client who had a severe postpartum hemorrhage following the
vaginal birth of twins is transferred to the postpartum unit. The nurse knows that
assessment for what complication has the highest priority for this client?
a. postpartum psychosis
b. hard, painful uterine afterpains
c. placenta accreta
d. disseminated intravascular coagulation*
5. A primigravida client receives a prescription for an infusion of oxytocin (Pitocin)
at 12 milliunits/minute. The available solution is ringers lactated 1,000 ml with
Piton 10 units. The nurse should program the infusion pump to deliver how many
ml/hour?
6. A client is admitted to the postpartum unit and tells the nurse she had rheumatic
fever as a child, which resulted in some “heart damage.” The nurse knows that
this client is at particular risk for developing heart failure during the immediate
, postpartum period. Based on this client’s history, which nursing diagnosis has
the highest priority?
a. sleep deprivation
b. risk for infection
c. fluid volume excess *
d. nausea and vomiting
7. The nurse is planning care for a client at 30 weeks gestation who is experiencing
preterm labor. What maternal prescription is most important in preventing this
fetus from developing respiratory distress syndrome?
a. terbutaline (Brethine) 0.25 mg SubQ Q15 mins x 3
b. Betamethasone (Celestone) 12 mg deep IM
c. Butorphanol 1 mg IV push q2h PRN pain
d. Ampicillin 1-gram IV push q8h
8. A primigravida client confides in the nurse that her sister told her that she should
eliminate all salt once she is at 26 weeks’ gestation because it will eliminate fluid
retention and swelling. How should the nurse respond?
a. Salt foods lightly during cooking but add no additional salt at the table.
b. eliminate all added salt from the diet to improve kidney function during pregnancy
c. limit grain, meat and milk products which are significant sources of sodium
d. use canned food products to obtain salt because it is easier to monitor salt intake
9. A one-day-old neonate develops a cephalohematoma. The nurse should closely
assess this neonate for which common complication?
a. jaundice*
b. brain damage
c. poor appetite
d. hypoglycemia
10. The mother of a breastfeeding 24 hr old infant is very concerned about the
techniques involved in breastfeeding. She calls the nurse with each feeding to
seek reassurance that she is “doing it right.” She tells the nurse, “I just know my
daughter is not getting enough to eat.” What response would be best for the
nurse to make?
a. feed your baby hourly until you feel confident that your child is receiving enough milk
b. don’t worry, soon your milk will come in, and you will feel how full your breasts are
c. since you are so concerned, you should probably supplement breastfeeding with
formula
d. if your baby’s urine is straw-colored, she is getting enough milk*
, 11. A client at 30 weeks gestation reports that she has not felt the baby move in the
last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she
is immediately sent to the hospital. Which assessment finding warrants
immediate intervention by the nurse?
a. the onset of uterine contractions
b. leaking amniotic fluid
c. fetal heart rate 60 beats/min*
d. ruptured amniotic membrane
12. A client at 40-weeks’ gestation presents to the obstetrical floor and indicates that
the amniotic membranes ruptured spontaneously at home. She is in active labor
and feels the need to bear down and push. What information is most important
for the nurse to obtain first?
e. the estimated amount of fluid
f. time the membranes ruptured
g. color and consistency of the fluid
h. any odor noted when membranes ruptured.
13. A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action
should the nurse take first?
e. assess the urine for proteinuria
f. record the finding on a flowsheet
g. obtain blood pressure reading
h. notify the healthcare provider
14. The nurse is preparing to draw blood from a newborn to obtain hemoglobin and
hematocrit levels. What is the best method to obtain this blood sample?
e. use a butterfly, small gauge needle to do a venous puncture on the hand
f. draw blood from the infant's antecubital vein using a small gauge needle
g. use a small gauge needle to puncture the vastus lateralis
h. use a lancet to puncture the outer lateral aspect of the heel *
15. A 25-year-old client who had a severe postpartum hemorrhage following the
vaginal birth of twins is transferred to the postpartum unit. The nurse knows that
assessment for what complication has the highest priority for this client?
e. postpartum psychosis
f. hard, painful uterine afterpains
g. placenta accreta
h. disseminated intravascular coagulation*
16. A primigravida client receives a prescription for an infusion of oxytocin (Pitocin)
at 12 milliunits/minute. The available solution is ringers lactated 1,000 ml with
1. A client at 40-weeks’ gestation presents to the obstetrical floor and indicates that
the amniotic membranes ruptured spontaneously at home. She is in active labor
and feels the need to bear down and push. What information is most important
for the nurse to obtain first?
a. the estimated amount of fluid
b. time the membranes ruptured
c. color and consistency of the fluid
d. any odor noted when membranes ruptured.
2. A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action
should the nurse take first?
a. assess the urine for proteinuria
b. record the finding on a flowsheet
c. obtain blood pressure reading
d. notify the healthcare provider
3. The nurse is preparing to draw blood from a newborn to obtain hemoglobin and
hematocrit levels. What is the best method to obtain this blood sample?
a. use a butterfly, small gauge needle to do a venous puncture on the hand
b. draw blood from the infant's antecubital vein using a small gauge needle
c. use a small gauge needle to puncture the vastus lateralis
d. use a lancet to puncture the outer lateral aspect of the heel *
4. A 25-year-old client who had a severe postpartum hemorrhage following the
vaginal birth of twins is transferred to the postpartum unit. The nurse knows that
assessment for what complication has the highest priority for this client?
a. postpartum psychosis
b. hard, painful uterine afterpains
c. placenta accreta
d. disseminated intravascular coagulation*
5. A primigravida client receives a prescription for an infusion of oxytocin (Pitocin)
at 12 milliunits/minute. The available solution is ringers lactated 1,000 ml with
Piton 10 units. The nurse should program the infusion pump to deliver how many
ml/hour?
6. A client is admitted to the postpartum unit and tells the nurse she had rheumatic
fever as a child, which resulted in some “heart damage.” The nurse knows that
this client is at particular risk for developing heart failure during the immediate
, postpartum period. Based on this client’s history, which nursing diagnosis has
the highest priority?
a. sleep deprivation
b. risk for infection
c. fluid volume excess *
d. nausea and vomiting
7. The nurse is planning care for a client at 30 weeks gestation who is experiencing
preterm labor. What maternal prescription is most important in preventing this
fetus from developing respiratory distress syndrome?
a. terbutaline (Brethine) 0.25 mg SubQ Q15 mins x 3
b. Betamethasone (Celestone) 12 mg deep IM
c. Butorphanol 1 mg IV push q2h PRN pain
d. Ampicillin 1-gram IV push q8h
8. A primigravida client confides in the nurse that her sister told her that she should
eliminate all salt once she is at 26 weeks’ gestation because it will eliminate fluid
retention and swelling. How should the nurse respond?
a. Salt foods lightly during cooking but add no additional salt at the table.
b. eliminate all added salt from the diet to improve kidney function during pregnancy
c. limit grain, meat and milk products which are significant sources of sodium
d. use canned food products to obtain salt because it is easier to monitor salt intake
9. A one-day-old neonate develops a cephalohematoma. The nurse should closely
assess this neonate for which common complication?
a. jaundice*
b. brain damage
c. poor appetite
d. hypoglycemia
10. The mother of a breastfeeding 24 hr old infant is very concerned about the
techniques involved in breastfeeding. She calls the nurse with each feeding to
seek reassurance that she is “doing it right.” She tells the nurse, “I just know my
daughter is not getting enough to eat.” What response would be best for the
nurse to make?
a. feed your baby hourly until you feel confident that your child is receiving enough milk
b. don’t worry, soon your milk will come in, and you will feel how full your breasts are
c. since you are so concerned, you should probably supplement breastfeeding with
formula
d. if your baby’s urine is straw-colored, she is getting enough milk*
, 11. A client at 30 weeks gestation reports that she has not felt the baby move in the
last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she
is immediately sent to the hospital. Which assessment finding warrants
immediate intervention by the nurse?
a. the onset of uterine contractions
b. leaking amniotic fluid
c. fetal heart rate 60 beats/min*
d. ruptured amniotic membrane
12. A client at 40-weeks’ gestation presents to the obstetrical floor and indicates that
the amniotic membranes ruptured spontaneously at home. She is in active labor
and feels the need to bear down and push. What information is most important
for the nurse to obtain first?
e. the estimated amount of fluid
f. time the membranes ruptured
g. color and consistency of the fluid
h. any odor noted when membranes ruptured.
13. A 32-week gestation client has deep tendon reflexes (DTRs) are 4+. What action
should the nurse take first?
e. assess the urine for proteinuria
f. record the finding on a flowsheet
g. obtain blood pressure reading
h. notify the healthcare provider
14. The nurse is preparing to draw blood from a newborn to obtain hemoglobin and
hematocrit levels. What is the best method to obtain this blood sample?
e. use a butterfly, small gauge needle to do a venous puncture on the hand
f. draw blood from the infant's antecubital vein using a small gauge needle
g. use a small gauge needle to puncture the vastus lateralis
h. use a lancet to puncture the outer lateral aspect of the heel *
15. A 25-year-old client who had a severe postpartum hemorrhage following the
vaginal birth of twins is transferred to the postpartum unit. The nurse knows that
assessment for what complication has the highest priority for this client?
e. postpartum psychosis
f. hard, painful uterine afterpains
g. placenta accreta
h. disseminated intravascular coagulation*
16. A primigravida client receives a prescription for an infusion of oxytocin (Pitocin)
at 12 milliunits/minute. The available solution is ringers lactated 1,000 ml with
