2022 HESI OB/MATERNITY V 1
,1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the
following must the nurse include in her discharge teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. The mother must wear a surgical mask when she cares for the baby.
4. Passive antibodies transported across the placenta will protect the baby.
208 MATERNAL AND NEWBORN SUCCESS
2. A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital.
Which of the following rationales should guide the nurse’s response?
1. The client’s obstetric status is optimal for receiving the vaccine.
2. The client’s immune system is highly responsive during the postpartum period.
3. The client’s baby will be high risk for acquiring rubella if the woman does not
receive the vaccine.
4. The client’s insurance company will pay for the shot if it is given during the immediate
postpartum period.
3. A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the
following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids.
4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with a povidone-iodine solution after toileting.
5. A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch.
When asked when she last fed the baby her reply is, “I fed the baby last evening. I let the nurses feed him in the
nursery last night. I needed to rest.” Which of the following actions should the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman.
6. A breastfeeding woman has been counseled on how to prevent engorgement.
, Which of the following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula.
7. A 2-day-postpartum breastfeeding woman states, “I am sick of being fat. When can I go on a diet?” Which of
the following responses is appropriate?
1. “It is fine for you to start dieting right now as long as you drink plenty of milk.”
2. “Your breast milk will be low in vitamins if you start to diet while breastfeeding.”
3. “You must eat at least 3000 calories per day in order to produce enough milk for your baby.”
4. “Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day.”
8. A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that
the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following
actions should the nurse take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman’s fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman’s primary health care provider.
9. A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the
nurse encourage the client to perform?
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
10. The nurse in the obstetric clinic received a telephone call from a bottlefeeding mother of a 3-day-old. The
client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for
the nurse to advise the client to perform?
1. Intermittently apply ice packs to her axillae and breasts.
2. Apply lanolin to her breasts and nipples every 3 hours.
3. Express milk from the breasts every 3 hours.
4. Ask the primary health care provider to order a milk suppressant.
11. A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant.
Which of the following responses by the nurse is appropriate?
1. Suggest that the woman bottlefeed for a few days.
2. Instruct the patient on how to massage her fundus.
3. Instruct the patient to feed using an alternate position.
,1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the
following must the nurse include in her discharge teaching regarding the vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. The mother must wear a surgical mask when she cares for the baby.
4. Passive antibodies transported across the placenta will protect the baby.
208 MATERNAL AND NEWBORN SUCCESS
2. A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital.
Which of the following rationales should guide the nurse’s response?
1. The client’s obstetric status is optimal for receiving the vaccine.
2. The client’s immune system is highly responsive during the postpartum period.
3. The client’s baby will be high risk for acquiring rubella if the woman does not
receive the vaccine.
4. The client’s insurance company will pay for the shot if it is given during the immediate
postpartum period.
3. A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the
following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids.
4. To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with a povidone-iodine solution after toileting.
5. A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch.
When asked when she last fed the baby her reply is, “I fed the baby last evening. I let the nurses feed him in the
nursery last night. I needed to rest.” Which of the following actions should the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman.
6. A breastfeeding woman has been counseled on how to prevent engorgement.
, Which of the following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula.
7. A 2-day-postpartum breastfeeding woman states, “I am sick of being fat. When can I go on a diet?” Which of
the following responses is appropriate?
1. “It is fine for you to start dieting right now as long as you drink plenty of milk.”
2. “Your breast milk will be low in vitamins if you start to diet while breastfeeding.”
3. “You must eat at least 3000 calories per day in order to produce enough milk for your baby.”
4. “Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day.”
8. A G2P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that
the fundus is firm at the umbilicus, there is heavy lochia, and perineal sutures are intact. Which of the following
actions should the nurse take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman’s fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman’s primary health care provider.
9. A client informs the nurse that she intends to bottlefeed her baby. Which of the following actions should the
nurse encourage the client to perform?
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
10. The nurse in the obstetric clinic received a telephone call from a bottlefeeding mother of a 3-day-old. The
client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for
the nurse to advise the client to perform?
1. Intermittently apply ice packs to her axillae and breasts.
2. Apply lanolin to her breasts and nipples every 3 hours.
3. Express milk from the breasts every 3 hours.
4. Ask the primary health care provider to order a milk suppressant.
11. A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her infant.
Which of the following responses by the nurse is appropriate?
1. Suggest that the woman bottlefeed for a few days.
2. Instruct the patient on how to massage her fundus.
3. Instruct the patient to feed using an alternate position.
