NURS 220 HESI
Maternity Practice
Questions
1. 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
2. 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
3. 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
4. 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*
5. 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
6. 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.
7. 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
8. 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 *
9. A 25-year-old client who had a severe postpartum hemorrhage
following the vaginal birth of twins is transferred to the postpartum
Maternity Practice
Questions
1. 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
2. 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
3. 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
4. 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*
5. 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
6. 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.
7. 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
8. 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 *
9. A 25-year-old client who had a severe postpartum hemorrhage
following the vaginal birth of twins is transferred to the postpartum
