2019 Maternity HESI
1. The nurse is planning discharge teaching for a client who
had an evacu- ation of gestational trophoblastic disease (GTD)
two days ago. Which infor- mation is most important for the
nurse to include in this client's teaching plan?: Oral
contraceptive use for at least one year.
2. 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?: Be- tamethasone (Celestone)
12 mg deep IM.
3. The nurse places one hand above the symphysis while
massaging the fundus of a multiparous client whose uterine
tone is boggy 15 minutes after delivering a 7 pound 10 ounce
infant. Which information should the nurse provide the client
about this fiding?: Both the lower uterine segment and the
fundus must be massaged
4. Which instruction should the nurse include in the discharge
teaching plan of a 7-year-old girl with a history of frequent
urinary tract infections?: Monitor for changes in urinary odor.
5. A pregnant woman in the first trimester of pregnancy has a
hemoglobin of
8.6 mg/dl and a hematocrit of 25.1%. What foot should the
nurse encourage this client to include in her diet?: Chicken.
,6. The newborn nursery admission protocol includes a
prescption for phy- tonadione (Vitamin K1, AquaMEPHYTON)
0.5 mg IM to newborns upon ad- mission. The ampoule
provides 2 mg/ml. How many ml should the nurse
administer?: 0.3
7. The nurse is preparing to administer methylergonovine
maleate (Methergine) to a postpartum client. Based on
what assessment finding should the nurse withhold the
drug?: Blood pressure 149/90.
8. The nurse is preparing a 10-year-old with a lacerated
forehead for suturing. Both parents and a 12-year-old sibling
are the child bedside. Which instruc- tion best supports this
family?: While waiting for the healthcare provider, only one visitor
may stay with the child"
9. The nurse is planning care for a 16-year-old, who has
juvenile rheumatoid arthritis (JRA). The nurse includes
activities to strengthen and mobilize the joints and
surrounding muscle. Which physical therapy regimen should
the nurse encourage the adolescent to implement?:
Exercise in a swimming pool.
10. A primigravida arrives at the observation unit of the
maternity unit be- cause she believes she is in labor. The
nurse applies the external fetal
,heart monitor and determines that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly
every 10 to 15 minutes. What assessment finding confirms to
the nurse that the client is in not labor at this time?:
Contractions decrease with walking.
11.Which toy is most appropriate for a 10-year-old child with
acute rheumatic fever who is on strict bedrest?: Checkers
12.The nurse has completed a teaching plan for the mother of
a child who is taking digitalis and a diuretic for treatment of
the heart failure. Choosing which lunch would indicate that the
mother understands the best diet for her child?: Peanut
butter and banana sandwich with orange juice.
13.A breastfeeding infant, screened for congenital
hypothyroidism, is found to have low levels of thyroxine (T4)
and high levels of thyroid stimulating hormone (TSH). What is
the best explanation for this finding?: The TSH is high
because of the low production of T4 by the thyroid.
14.A full-term, 24-hour-old infant in the nursery regurgitates
and suddenly turns cyanotic. What should the nurse do first?:
Stimulate the infant to cry.
15.At 6-weeks gestation, the rubella titer of a client indicates
she is non-im- mune. When is the best time to administer a
rubella vaccine to this client?: - Early postpartum, within 72
hours of delivery.
, 16.A client delivers a viable infant, but begins to have
excessive uncontrolled vaginal bleeding after the IV Pitocin is
infused. When notifying the healthcare provider of the client's
condition, what information is most important for the nurse to
provide?: Maternal blood pressure.
17.While obtaining the vital signs of a 10-year-old who had a
tonsillectomy this morning, the nurse observes the child
swallowing every 2 to 3 min- utes. Which assessment should
the nurse implement?: Inspect the posterior oropharynx.
18.During a routine clinic visit, the nurse determines that a 5-
year-old boy's blood pressure is 112/70. When calculating the
child's blood pressure per- centile, the nurse adjusts the
calculation for age and height. What actions should the nurse
implement next?: Compare the child's blood pressure with
readings from previous visits.
19.A neonate who has congenital adrenal hyperplasia (CAH)
presents with ambiguous genitalia. What is the primary
nursing consideration when sup- porting the parents of a child
with this anomaly?: Offer information about ultrasonography
and genotyping to determine sex assignment.
1. The nurse is planning discharge teaching for a client who
had an evacu- ation of gestational trophoblastic disease (GTD)
two days ago. Which infor- mation is most important for the
nurse to include in this client's teaching plan?: Oral
contraceptive use for at least one year.
2. 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?: Be- tamethasone (Celestone)
12 mg deep IM.
3. The nurse places one hand above the symphysis while
massaging the fundus of a multiparous client whose uterine
tone is boggy 15 minutes after delivering a 7 pound 10 ounce
infant. Which information should the nurse provide the client
about this fiding?: Both the lower uterine segment and the
fundus must be massaged
4. Which instruction should the nurse include in the discharge
teaching plan of a 7-year-old girl with a history of frequent
urinary tract infections?: Monitor for changes in urinary odor.
5. A pregnant woman in the first trimester of pregnancy has a
hemoglobin of
8.6 mg/dl and a hematocrit of 25.1%. What foot should the
nurse encourage this client to include in her diet?: Chicken.
,6. The newborn nursery admission protocol includes a
prescption for phy- tonadione (Vitamin K1, AquaMEPHYTON)
0.5 mg IM to newborns upon ad- mission. The ampoule
provides 2 mg/ml. How many ml should the nurse
administer?: 0.3
7. The nurse is preparing to administer methylergonovine
maleate (Methergine) to a postpartum client. Based on
what assessment finding should the nurse withhold the
drug?: Blood pressure 149/90.
8. The nurse is preparing a 10-year-old with a lacerated
forehead for suturing. Both parents and a 12-year-old sibling
are the child bedside. Which instruc- tion best supports this
family?: While waiting for the healthcare provider, only one visitor
may stay with the child"
9. The nurse is planning care for a 16-year-old, who has
juvenile rheumatoid arthritis (JRA). The nurse includes
activities to strengthen and mobilize the joints and
surrounding muscle. Which physical therapy regimen should
the nurse encourage the adolescent to implement?:
Exercise in a swimming pool.
10. A primigravida arrives at the observation unit of the
maternity unit be- cause she believes she is in labor. The
nurse applies the external fetal
,heart monitor and determines that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly
every 10 to 15 minutes. What assessment finding confirms to
the nurse that the client is in not labor at this time?:
Contractions decrease with walking.
11.Which toy is most appropriate for a 10-year-old child with
acute rheumatic fever who is on strict bedrest?: Checkers
12.The nurse has completed a teaching plan for the mother of
a child who is taking digitalis and a diuretic for treatment of
the heart failure. Choosing which lunch would indicate that the
mother understands the best diet for her child?: Peanut
butter and banana sandwich with orange juice.
13.A breastfeeding infant, screened for congenital
hypothyroidism, is found to have low levels of thyroxine (T4)
and high levels of thyroid stimulating hormone (TSH). What is
the best explanation for this finding?: The TSH is high
because of the low production of T4 by the thyroid.
14.A full-term, 24-hour-old infant in the nursery regurgitates
and suddenly turns cyanotic. What should the nurse do first?:
Stimulate the infant to cry.
15.At 6-weeks gestation, the rubella titer of a client indicates
she is non-im- mune. When is the best time to administer a
rubella vaccine to this client?: - Early postpartum, within 72
hours of delivery.
, 16.A client delivers a viable infant, but begins to have
excessive uncontrolled vaginal bleeding after the IV Pitocin is
infused. When notifying the healthcare provider of the client's
condition, what information is most important for the nurse to
provide?: Maternal blood pressure.
17.While obtaining the vital signs of a 10-year-old who had a
tonsillectomy this morning, the nurse observes the child
swallowing every 2 to 3 min- utes. Which assessment should
the nurse implement?: Inspect the posterior oropharynx.
18.During a routine clinic visit, the nurse determines that a 5-
year-old boy's blood pressure is 112/70. When calculating the
child's blood pressure per- centile, the nurse adjusts the
calculation for age and height. What actions should the nurse
implement next?: Compare the child's blood pressure with
readings from previous visits.
19.A neonate who has congenital adrenal hyperplasia (CAH)
presents with ambiguous genitalia. What is the primary
nursing consideration when sup- porting the parents of a child
with this anomaly?: Offer information about ultrasonography
and genotyping to determine sex assignment.
