2020 HESI OB/MATERNITY V 2
1. The nurse is caring for a client who had an emergency cesarean 4. A client is receiving an epidural infusion of a narcotic for pain relief
section, with her husband in attendance the day before. The baby’s after a cesarean section. The nurse would report to the
Apgar was 9/9. The woman and her partner had attended childbirth anesthesiologist if which of the following were assessed?
education classes and had anticipated having a water birth with family
present. Which of the following comments by the nurse is a) Respiratory rate 8 rpm.
appropriate? b) Complaint of thirst.
a) “Sometimes babies just don’t deliver the way we expect c) Urinary output of 250 cc/hr.
d) Numbness of feet and ankles.
them to.”
b) “With all of your preparations, it must have been
disappointing for you to have had a cesarean.” 5. A client, 2 days postoperative from a cesarean section, complains to
c) “I know you had to have surgery, but you are very lucky the nurse that she has yet to have a bowel movement since the surgery.
that your baby was born healthy.” Which of the following responses by the nurse would be appropriate at
d) “At least your husband was able to be with you when the baby this time?
was born.” a) “That is very concerning. I will request that your physician
2. A nurse has brought a 2-hour-old baby to a mother from the order an enema for you.”
nursery. The nurse is going to assist the mother with the first b) “Two days is not that bad. Some patients go four days or
breastfeeding experience. Which of the following actions should the longer without a movement.”
nurse perform first? c) “You have been taking antibiotics through your
a) Compare mother’s and baby’s identification bracelets. intravenous. That is probably why you are constipated.”
b) Help the mother into a comfortable position. d) “Fluids and exercise often help to combat constipation. Take
c) Teach the mother about a proper breast latch. a stroll around the unit and drink lots of fluid.”
d) Tickle the baby’s lips with the mother’s nipple.
6. A post–cesarean section, breastfeeding client, whose subjective pain
3. The obstetrician has ordered that a post-op cesarean section level is 2/5, requests her as needed (prn) narcotic analgesics every 3
client’s patient-controlled analgesia (PCA) be discontinued. Which of hours. She states, “I have decided to make sure that I feel as little pain
the following actions by the nurse is appropriate? from this experience as possible.” Which of the following should the
nurse conclude in relation to this woman’s behavior?
a) Discard the remaining medication in the presence of another
nurse. a) The woman needs a stronger narcotic order.
b) Recommend waiting until her pain level is zero to discontinue b) The woman is high risk for severe constipation.
the medicine. c) The woman’s breast milk volume may drop while taking
c) Discontinue the medication only after the analgesia is the medicine.
completely absorbed. d) The woman’s newborn may become addicted to
d) Return the unused portion of medication to the narcotics the medication.
cabinet.
,7. A nurse is assessing a 1-day postpartum woman who had her baby d) Irrigate incision twice daily with antibiotic solution.
by cesarean section. Which of the following should the nurse report
to the surgeon? 11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal
delivery with local anesthesia, states that she needs to urinate. Which
a) Fundus at the umbilicus. of the following actions by the nurse is appropriate at this time?
b) Nodular breasts.
c) Pulse rate 60 bpm. a) Provide the woman with a bedpan.
d) Pad saturation every 30 minutes. b) Advise the woman that the feeling is likely related to the
trauma of delivery.
8. The nurse is assessing the midline episiotomy on a postpartum c) Remind the woman that she still has a catheter in place from
client. Which of the following findings should the nurse expect to the delivery.
see? d) Assist the woman to the bathroom.
a) Moderate serosanguinous drainage.
b) Well-approximated edges. 12. A nurse is assessing the fundus of a client during the immediate
c) Ecchymotic area distal to the episiotomy. postpartum period. Which of the following actions indicates that
d) An area of redness adjacent to the incision. the nurse is performing the skill correctly?
9. A client, G1P1, who had an epidural, has just delivered a daughter, a) The nurse measures the fundal height using a paper centimeter
Apgar 9/9, over a mediolateral episiotomy. The physician used low tape.
forceps. While recovering, the client states, “I’m a failure. I couldn’t b) The nurse stabilizes the base of the uterus with his or her
stand the pain and couldn’t even push my baby out by myself!” dependent hand.
Which of the following is the best response for the nurse to make? c) The nurse palpates the fundus with the tips of his or her
fingers.
a) “You’ll feel better later after you have had a chance to rest d) The nurse precedes the assessment with a sterile vaginal exam.
and to eat.”
b) “Don’t say that. There are many women who would be
ecstatic to have that baby.” 13. A 1-day postpartum woman states, “I think I have a urinary tract
c) “I am sure that you will have another baby. I bet that it will infection. I have to go to the bathroom all the time.” Which of the
be a natural delivery.” following actions should the nurse take?
d) “To have things work out differently than you had planned
is disappointing.” a) Assure the woman that frequent urination is normal after
delivery.
10. The nurse is developing a standard care plan for postpartum clients b) Obtain an order for a urine culture.
who have had midline episiotomies. Which of the following c) Assess the urine for cloudiness.
interventions should be included in the plan? d) Ask the woman if she is prone to urinary tract infections.
a) Assist with stitch removal on third postpartum day.
b) Administer analgesics every four hours per doctor orders.
c) Teach client to contract her buttocks before sitting.
, 14. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this
morning. Which of the following results should the nurse report to the primary health care provider?
a. White blood cells—12,500 cells/mm3.
b. Red blood cells—4,500,000 cells/mm3.
c. Hematocrit—26%.
d. Hemoglobin—11 g/dL
15. A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal
17. The nurse is examining a 2-day postpartum client whose fundus is
delivery, calls the obstetric office to state that she has saturated 2
2 cm below the umbilicus and whose bright red lochia saturates about
pads in the past 1 hour. Which of the following responses by the
4 inches of a pad in 1 hour. What should the nurse document in the
nurse is appropriate?
nursing record?
a) “You must be doing too much. Lie down for a few hours
a) Abnormal involution, lochia rubra heavy.
and call back if the bleeding has not subsided.”
b) Abnormal involution, lochia serosa scant.
b) “You are probably getting your period back. You will bleed
c) Normal involution, lochia rubra moderate.
like that for a day or two and then it will lighten up.”
d) Normal involution, lochia serosa heavy.
c) “It is not unusual to bleed heavily every once in a while, after a
baby is born. It should subside shortly.” 18. The nurse palpates a distended bladder on a woman who delivered
d) “It is important for you to be examined by the doctor today. vaginally 2 hours earlier. The woman refuses to go to the bathroom,
Let me check to see when you can come in.” “I really don’t need to go.” Which of the following responses by the
nurse is appropriate?
16. A client, 2 days postpartum from a spontaneous vaginal delivery,
asks the nurse about postpartum exercises. Which of the following a) “Okay. I must be palpating your uterus.”
responses by the nurse is appropriate? b) “I understand but I still would like you to try to urinate.”
c) “You still must be numb from the local anesthesia.”
a) “You must wait to begin to perform exercises until after
d) “That is a problem. I will have to catheterize you.”
your six-week postpartum checkup.”
b) “You may begin Kegel exercises today, but do not do any 19. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes
other exercises until the doctor tells you that it is safe.” that the client’s lochia rubra is moderate and her fundus is boggy 2
c) “By next week you will be able to return to the exercise cm above the umbilicus and deviated to the right. Which of the
schedule you had during your prepregnancy.” following actions should the nurse take first?
d) “You can do some Kegel exercises today and then
slowly increase your toning exercises over the next few a) Notify the woman’s primary health care provider.
weeks.” b) Massage the woman’s fundus.
c) Escort the woman to the bathroom to urinate.
d) Check the quantity of lochia on the peripad.
1. The nurse is caring for a client who had an emergency cesarean 4. A client is receiving an epidural infusion of a narcotic for pain relief
section, with her husband in attendance the day before. The baby’s after a cesarean section. The nurse would report to the
Apgar was 9/9. The woman and her partner had attended childbirth anesthesiologist if which of the following were assessed?
education classes and had anticipated having a water birth with family
present. Which of the following comments by the nurse is a) Respiratory rate 8 rpm.
appropriate? b) Complaint of thirst.
a) “Sometimes babies just don’t deliver the way we expect c) Urinary output of 250 cc/hr.
d) Numbness of feet and ankles.
them to.”
b) “With all of your preparations, it must have been
disappointing for you to have had a cesarean.” 5. A client, 2 days postoperative from a cesarean section, complains to
c) “I know you had to have surgery, but you are very lucky the nurse that she has yet to have a bowel movement since the surgery.
that your baby was born healthy.” Which of the following responses by the nurse would be appropriate at
d) “At least your husband was able to be with you when the baby this time?
was born.” a) “That is very concerning. I will request that your physician
2. A nurse has brought a 2-hour-old baby to a mother from the order an enema for you.”
nursery. The nurse is going to assist the mother with the first b) “Two days is not that bad. Some patients go four days or
breastfeeding experience. Which of the following actions should the longer without a movement.”
nurse perform first? c) “You have been taking antibiotics through your
a) Compare mother’s and baby’s identification bracelets. intravenous. That is probably why you are constipated.”
b) Help the mother into a comfortable position. d) “Fluids and exercise often help to combat constipation. Take
c) Teach the mother about a proper breast latch. a stroll around the unit and drink lots of fluid.”
d) Tickle the baby’s lips with the mother’s nipple.
6. A post–cesarean section, breastfeeding client, whose subjective pain
3. The obstetrician has ordered that a post-op cesarean section level is 2/5, requests her as needed (prn) narcotic analgesics every 3
client’s patient-controlled analgesia (PCA) be discontinued. Which of hours. She states, “I have decided to make sure that I feel as little pain
the following actions by the nurse is appropriate? from this experience as possible.” Which of the following should the
nurse conclude in relation to this woman’s behavior?
a) Discard the remaining medication in the presence of another
nurse. a) The woman needs a stronger narcotic order.
b) Recommend waiting until her pain level is zero to discontinue b) The woman is high risk for severe constipation.
the medicine. c) The woman’s breast milk volume may drop while taking
c) Discontinue the medication only after the analgesia is the medicine.
completely absorbed. d) The woman’s newborn may become addicted to
d) Return the unused portion of medication to the narcotics the medication.
cabinet.
,7. A nurse is assessing a 1-day postpartum woman who had her baby d) Irrigate incision twice daily with antibiotic solution.
by cesarean section. Which of the following should the nurse report
to the surgeon? 11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal
delivery with local anesthesia, states that she needs to urinate. Which
a) Fundus at the umbilicus. of the following actions by the nurse is appropriate at this time?
b) Nodular breasts.
c) Pulse rate 60 bpm. a) Provide the woman with a bedpan.
d) Pad saturation every 30 minutes. b) Advise the woman that the feeling is likely related to the
trauma of delivery.
8. The nurse is assessing the midline episiotomy on a postpartum c) Remind the woman that she still has a catheter in place from
client. Which of the following findings should the nurse expect to the delivery.
see? d) Assist the woman to the bathroom.
a) Moderate serosanguinous drainage.
b) Well-approximated edges. 12. A nurse is assessing the fundus of a client during the immediate
c) Ecchymotic area distal to the episiotomy. postpartum period. Which of the following actions indicates that
d) An area of redness adjacent to the incision. the nurse is performing the skill correctly?
9. A client, G1P1, who had an epidural, has just delivered a daughter, a) The nurse measures the fundal height using a paper centimeter
Apgar 9/9, over a mediolateral episiotomy. The physician used low tape.
forceps. While recovering, the client states, “I’m a failure. I couldn’t b) The nurse stabilizes the base of the uterus with his or her
stand the pain and couldn’t even push my baby out by myself!” dependent hand.
Which of the following is the best response for the nurse to make? c) The nurse palpates the fundus with the tips of his or her
fingers.
a) “You’ll feel better later after you have had a chance to rest d) The nurse precedes the assessment with a sterile vaginal exam.
and to eat.”
b) “Don’t say that. There are many women who would be
ecstatic to have that baby.” 13. A 1-day postpartum woman states, “I think I have a urinary tract
c) “I am sure that you will have another baby. I bet that it will infection. I have to go to the bathroom all the time.” Which of the
be a natural delivery.” following actions should the nurse take?
d) “To have things work out differently than you had planned
is disappointing.” a) Assure the woman that frequent urination is normal after
delivery.
10. The nurse is developing a standard care plan for postpartum clients b) Obtain an order for a urine culture.
who have had midline episiotomies. Which of the following c) Assess the urine for cloudiness.
interventions should be included in the plan? d) Ask the woman if she is prone to urinary tract infections.
a) Assist with stitch removal on third postpartum day.
b) Administer analgesics every four hours per doctor orders.
c) Teach client to contract her buttocks before sitting.
, 14. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this
morning. Which of the following results should the nurse report to the primary health care provider?
a. White blood cells—12,500 cells/mm3.
b. Red blood cells—4,500,000 cells/mm3.
c. Hematocrit—26%.
d. Hemoglobin—11 g/dL
15. A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal
17. The nurse is examining a 2-day postpartum client whose fundus is
delivery, calls the obstetric office to state that she has saturated 2
2 cm below the umbilicus and whose bright red lochia saturates about
pads in the past 1 hour. Which of the following responses by the
4 inches of a pad in 1 hour. What should the nurse document in the
nurse is appropriate?
nursing record?
a) “You must be doing too much. Lie down for a few hours
a) Abnormal involution, lochia rubra heavy.
and call back if the bleeding has not subsided.”
b) Abnormal involution, lochia serosa scant.
b) “You are probably getting your period back. You will bleed
c) Normal involution, lochia rubra moderate.
like that for a day or two and then it will lighten up.”
d) Normal involution, lochia serosa heavy.
c) “It is not unusual to bleed heavily every once in a while, after a
baby is born. It should subside shortly.” 18. The nurse palpates a distended bladder on a woman who delivered
d) “It is important for you to be examined by the doctor today. vaginally 2 hours earlier. The woman refuses to go to the bathroom,
Let me check to see when you can come in.” “I really don’t need to go.” Which of the following responses by the
nurse is appropriate?
16. A client, 2 days postpartum from a spontaneous vaginal delivery,
asks the nurse about postpartum exercises. Which of the following a) “Okay. I must be palpating your uterus.”
responses by the nurse is appropriate? b) “I understand but I still would like you to try to urinate.”
c) “You still must be numb from the local anesthesia.”
a) “You must wait to begin to perform exercises until after
d) “That is a problem. I will have to catheterize you.”
your six-week postpartum checkup.”
b) “You may begin Kegel exercises today, but do not do any 19. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes
other exercises until the doctor tells you that it is safe.” that the client’s lochia rubra is moderate and her fundus is boggy 2
c) “By next week you will be able to return to the exercise cm above the umbilicus and deviated to the right. Which of the
schedule you had during your prepregnancy.” following actions should the nurse take first?
d) “You can do some Kegel exercises today and then
slowly increase your toning exercises over the next few a) Notify the woman’s primary health care provider.
weeks.” b) Massage the woman’s fundus.
c) Escort the woman to the bathroom to urinate.
d) Check the quantity of lochia on the peripad.
