HESI Maternity Quiz
The mother of a neonate asks the nurse why it is so important to keep the infant warm. What
information should the nurse provide?
A. The kidneys and renal function are not fully developed.
B. Warmth promotes sleep so the infant will grow quickly.
C. A large body surface area favors heat loss to the environment.
D. The thick layer of subcutaneous fat is inadequate for insulation.
- Thermoregulation, heat regulation, is critical to the survival of a neonate because the
newborn's larger surface area (C) per unit of weight predisposes to heat loss. While keeping the
infant warm may help the infant to sleep, it promotes transitional homeostasis, not growth (B).
(A) is unrelated to cold stress of the newborn. (D) does not support the metabolic cascade that
results from neonatal heat loss.
A client at 26-weeks gestation comes to the labor and delivery unit and complains, "Something
is not right." Which finding should the nurse assess further?
A. Estriol is absent from the maternal saliva.
B. Irregular mild uterine contractions occurring daily.
C. Fetal fibronectin is absent in vaginal secretions.
D. The cervix is effacing and dilated to 2 cm.
- Cervical changes (B), such as shortened endocervical length, effacement, and dilation
accompanied by regular contractions indicate labor at any gestation period, so the client should
be monitored for pre-term labor. Estriol is a form of estrogen found in plasma at 9-weeks
gestation, and increased levels of salivary estriol, not (A), have been shown to occur before
preterm birth. The presence of fetal fibronectin in vaginal secretions, not (C), between 24 and
36 weeks of gestation has a 20% to 40% positive predictive value for preterm labor. Irregular
mild contractions (D) that do not cause cervical change indicate Braxton Hicks contractions or
false labor. Category: Maternity
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 complains of feeling light-headed, dizzy, and states
that her fingers are tingling. What action should the nurse implement?
A. Administer oxygen via nasal cannula.
B. Tell the client to slow her breathing.
C. Notify the healthcare provider.
, D. Help her breathe into a paper bag.
- Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness,
tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around
the mouth and nose (B) enables the client to rebreathe carbon dioxide, which reduces
depletion of carbonic acid. and compensates for the respiratory alkalosis. (A) is unnecessary,
and (C and D) are less effective than (B).
When assessing a newborn infant's heart rate, which technique is most important for the nurse
to use?
A. Listen at the apex of the heart.
B. Palpate the umbilical cord.
C. Quiet the infant before counting the heart rate.
D. Count the heart rate for at least one full minute.
- It is most important for the nurse to count the heart rate for at least one full minute (C) so
that irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be
correctly auscultated. The heart rate can be heard clearly over any point of an infant's chest,
not just (B). Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the
most accurate method of obtaining a newborn's heart rate.
A client is receiving an oxytocin infusion for induction of labor. When the client begins active
labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent
return to baseline before each contraction ends. What action should the nurse implement?
A. Discontinue the oxytocin infusion.
B. Insert an internal monitor device.
C. Document the finding in the client record.
D. Change the woman's position.
- Early FHR decelerations are a normal finding during active labor that occurs from fetal head
compression, so the finding should be documented in the client record (D). Although the
client's status should be monitored continuously, this is a reassuring FHR pattern, so (A, B, and
C) are not indicated.
The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The
infant expels a bloody stool. What nursing action should the nurse implement?
A. Obtain a rectal temperature.
B. Institute contact precautions.
The mother of a neonate asks the nurse why it is so important to keep the infant warm. What
information should the nurse provide?
A. The kidneys and renal function are not fully developed.
B. Warmth promotes sleep so the infant will grow quickly.
C. A large body surface area favors heat loss to the environment.
D. The thick layer of subcutaneous fat is inadequate for insulation.
- Thermoregulation, heat regulation, is critical to the survival of a neonate because the
newborn's larger surface area (C) per unit of weight predisposes to heat loss. While keeping the
infant warm may help the infant to sleep, it promotes transitional homeostasis, not growth (B).
(A) is unrelated to cold stress of the newborn. (D) does not support the metabolic cascade that
results from neonatal heat loss.
A client at 26-weeks gestation comes to the labor and delivery unit and complains, "Something
is not right." Which finding should the nurse assess further?
A. Estriol is absent from the maternal saliva.
B. Irregular mild uterine contractions occurring daily.
C. Fetal fibronectin is absent in vaginal secretions.
D. The cervix is effacing and dilated to 2 cm.
- Cervical changes (B), such as shortened endocervical length, effacement, and dilation
accompanied by regular contractions indicate labor at any gestation period, so the client should
be monitored for pre-term labor. Estriol is a form of estrogen found in plasma at 9-weeks
gestation, and increased levels of salivary estriol, not (A), have been shown to occur before
preterm birth. The presence of fetal fibronectin in vaginal secretions, not (C), between 24 and
36 weeks of gestation has a 20% to 40% positive predictive value for preterm labor. Irregular
mild contractions (D) that do not cause cervical change indicate Braxton Hicks contractions or
false labor. Category: Maternity
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 complains of feeling light-headed, dizzy, and states
that her fingers are tingling. What action should the nurse implement?
A. Administer oxygen via nasal cannula.
B. Tell the client to slow her breathing.
C. Notify the healthcare provider.
, D. Help her breathe into a paper bag.
- Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness,
tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around
the mouth and nose (B) enables the client to rebreathe carbon dioxide, which reduces
depletion of carbonic acid. and compensates for the respiratory alkalosis. (A) is unnecessary,
and (C and D) are less effective than (B).
When assessing a newborn infant's heart rate, which technique is most important for the nurse
to use?
A. Listen at the apex of the heart.
B. Palpate the umbilical cord.
C. Quiet the infant before counting the heart rate.
D. Count the heart rate for at least one full minute.
- It is most important for the nurse to count the heart rate for at least one full minute (C) so
that irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be
correctly auscultated. The heart rate can be heard clearly over any point of an infant's chest,
not just (B). Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the
most accurate method of obtaining a newborn's heart rate.
A client is receiving an oxytocin infusion for induction of labor. When the client begins active
labor, the fetal heart rate (FHR) slows at the onset of several contractions with subsequent
return to baseline before each contraction ends. What action should the nurse implement?
A. Discontinue the oxytocin infusion.
B. Insert an internal monitor device.
C. Document the finding in the client record.
D. Change the woman's position.
- Early FHR decelerations are a normal finding during active labor that occurs from fetal head
compression, so the finding should be documented in the client record (D). Although the
client's status should be monitored continuously, this is a reassuring FHR pattern, so (A, B, and
C) are not indicated.
The nurse is preparing to gavage feed a preterm infant who is receiving IV antibiotics. The
infant expels a bloody stool. What nursing action should the nurse implement?
A. Obtain a rectal temperature.
B. Institute contact precautions.
