Maternity HESI Test bank (combined red
hesi and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby
when it moves too much. Which recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. Ans- D) Reassure him that normal
maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No
intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of
gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are
not necessary because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
,D.White blood cell count (WBC) Ans- C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may indicate the
presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is
used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for
color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not
specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the
development of amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk Ans- B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be
further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a
common finding in newborns; it occurs because the capillary system is immature. Milia are small white
papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a
few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a
common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
,B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. Ans-
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the
inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast
tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse
that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the
lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. Ans- C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous
return. Option A would increase venous return from varicose veins in the lower extremities but would
be of little help with swelling. Option B might be helpful with generalized edema but is not specific for
edematous lower extremities. Option D does not address venous return, and there is no indication in
the question that constrictive clothing is a problem.
, Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized
swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of
blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage Ans- A.Cephalhematoma, which is caused by
forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first
24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and
skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during
vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial
bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical
cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath Ans- C.Allow the cord to air-dry as much as possible.
hesi and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby
when it moves too much. Which recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. Ans- D) Reassure him that normal
maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No
intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks of
gestation and begins a new phase of prenatal bonding during the second trimester. Options A and C are
not necessary because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
,D.White blood cell count (WBC) Ans- C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may indicate the
presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes [AROM]) is
used to stimulate labor when the condition of the cervix is favorable. The fluid should be assessed for
color, odor, and consistency. Option A should be assessed every 15 to 20 minutes during labor but is not
specific for AROM. Option B is monitored hourly after the membranes are ruptured to detect the
development of amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk Ans- B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be
further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a
common finding in newborns; it occurs because the capillary system is immature. Milia are small white
papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a
few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a
common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
,B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. Ans-
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the
inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast
tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse
that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the
lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. Ans- C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous
return. Option A would increase venous return from varicose veins in the lower extremities but would
be of little help with swelling. Option B might be helpful with generalized edema but is not specific for
edematous lower extremities. Option D does not address venous return, and there is no indication in
the question that constrictive clothing is a problem.
, Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized
swelling on the right side of his head. In a newborn, what is the most likely cause of this accumulation of
blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage Ans- A.Cephalhematoma, which is caused by
forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the first
24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and
skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during
vaginal delivery, and is a common variation of the newborn. Options B and D both involve intracranial
bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical
cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath Ans- C.Allow the cord to air-dry as much as possible.
