HESI Maternity Exam Questions and Answers

HESI Maternity Exam Questions and Answers Which piece of equipment does the nurse use to assess the fetal heartbeat? - ANSWER- Electronic Doppler A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: - ANSWER- The mother may need to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months A nurse assists a pregnant client who is in the second trimester into lithotomy position on the examining table in the obstetrician's office. The client suddenly becomes dizzy, lightheaded, nauseated, and pale. The nurse immediately: - ANSWER- Positions the client on her side A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first: - ANSWER- Instructs the client to take several deep breaths A nurse is performing an assessment of a pregnant woman to determine whether labor has begun. For which sign of true labor does the nurse assess the client? - ANSWER- Contractions that begin in the lower abdomen and back and radiate over the entire abdomen Placental abruption is suspected in a client who is experiencing vaginal bleeding. On assessment, which of the following findings would the nurse expect to note? - ANSWER- Uterine tender to palpation A clinic nurse is performing an assessment of an HIV-positive pregnant woman during the 32nd week of gestation. Which finding requires further follow-up? - ANSWER- Increased shortness of breath and bilateral crackles in the lungs A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes that the labia are edematous and darker than the surrounding skin and that a white mucous vaginal discharge is present. On the basis of these findings, the nurse determines that the appropriate action is: - ANSWER- Documenting the findings (normal findings) A nurse assessing a pregnant woman in labor notes the presence of early decelerations on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of this observation? - ANSWER- Pressure on the fetal head during a contraction A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: - ANSWER- A rubella vaccine must be administered after childbirth A nurse is told that a newborn with myelomeningocele will be admitted to the newborn nursery. In which position does the nurse plan to place the infant? - ANSWER- Prone (to prevent pressure on the sac until surgical repair can be performed) Normal respiratory rate for a newborn infant - ANSWER- 30 to 60 breaths/min A nurse is caring for a client experiencing a partial placental abruption. The client is uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse analyzes the client's behavior as most likely the result of: - ANSWER- Anxiety and the need for support A client in the third trimester of pregnancy is complaining of urinary frequency, and the nurse instructs the client in measures to alleviate the discomfort. Which statement by the client indicates an understanding of these self-care measures? - ANSWER- "I need to drink at least 2000 mL of fluid a day." A pregnant woman at 38 weeks' gestation arrives at the emergency department, reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the nurse determines that the client may be experiencing: - ANSWER- Placenta previa A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to: - ANSWER- Encourage the intake of oral fluids A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots from the uterus. To prevent uterine inversion during this procedure, the nurse: - ANSWER- Simultaneously provides pressure over the lower uterine segment A nurse assists the primary healthcare provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy? - ANSWER- 1. Determining the fetal heart rate 2. Noting the quantity, color, and odor of the amniotic fluid 3. Taking the client's temperature, pulse, and blood pressure 4. Replacing soiled underpads from beneath the client's buttocks 5. Planning evaluation of the client for signs and symptoms of infection A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia (CDH). Which assessment finding would the nurse specifically expect to note in the newborn? - ANSWER- Bowel sounds heard over the chest A nurse is assessing a woman in labor and notes the presence of accelerations on the fetal monitor tracing. Which of the following actions should the nurse perform in response to this observation? - ANSWER- Documenting the finding A nurse teaching a pregnant client about the expectations and complications of pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions: - ANSWER- Are a common occurrence of pregnancy Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history. Which of the following findings is a contraindication to administration of the medication? - ANSWER- A previous hypersensitivity reaction to immune globulin -Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal blood cells in any way A pregnant woman reports that she has just finished taking the prescribed antibiotics to treat her urinary tract infection but expresses concern that her baby will be born with an infection. Which response should the nurse make to help ease these fears? - ANSWER- "Now that you have taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine culture before you leave today." A delivery room nurse performing an initial assessment on a newborn notes that the ears are low set. In light of this finding, which nursing action is appropriate initially? - ANSWER- Notifying the physician A nurse is monitoring a pregnant client with placental abruption. Which pattern on the fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? - ANSWER- Normal FHR A nurse is performing an assessment of a female client with suspected mittelschmerz. Which question does the nurse ask the client to elicit data specific to this disorder? - ANSWER- "Do you have sharp pain on the right or left side of your pelvis?" -Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain, which is fairly sharp, is felt on the right or left side of the pelvis. A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the following, if noted in the infant, would indicate that the criteria for early discharge have been met? - ANSWER- The infant has urinated. The infant has passed 1 stool. Vital signs are documented as normal. The infant has completed one successful feeding. A nurse is monitoring a pregnant client with sepsis for signs of disseminated intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to suspect DIC? - ANSWER- Increased fibrin degradation products -DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and activated partial thromboplastin times are prolonged, and fibrin degradation products are increased. A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to stimulate labor. Which of the following findings would prompt the nurse to stop the infusion? - ANSWER- Nonreassuring fetal heart rate pattern A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the nurse look for while assessing the infant? - ANSWER- A copper-colored rash A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: - ANSWER- Calcium gluconate A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: - ANSWER- Gently massage the breasts during breastfeeding to help empty the breasts A woman being seen in the prenatal clinic and complains of morning sickness that continues throughout the day. What does the nurse tell the client to do to overcome this discomfort? - ANSWER- Eat dry crackers every 2 hours to prevent an empty stomach A nurse performing an assessment of a pregnant client is preparing to take the client's blood pressure. The nurse positions the client: - ANSWER- In a sitting position with the arm in a horizontal position at heart level A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the healthcare provider? - ANSWER- Strong-smelling amniotic fluid A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? - ANSWER- 20 cm A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result of 155 mg/dL. The nurse tells the client that: - ANSWER- A 3-hour glucose tolerance test will likely be performed to confirm gestational diabetes A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client: - ANSWER- Supine with a wedge under the right hip A nurse provides information about the treatment for hypoglycemia to a client with gestational diabetes who will be taking insulin. The nurse tells the client that if signs and symptoms of hypoglycemia occur, she must immediately: - ANSWER- Check her blood glucose level A woman with severe preeclampsia delivers a healthy newborn infant and continues to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client begins passing more than 100 mL of urine every hour. The nurse recognizes this volume of urine output as an indication of: - ANSWER- Diminished edema and vasoconstriction in the brain and kidneys -In this client, diuresis is a positive sign, indicating that edema and vasoconstriction in the brain and kidneys have decreased. Diuresis also reflects increased tissue perfusion in the kidneys. A multigravida asks a nurse when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted as early as: - ANSWER- 14 to 16 weeks of gestation A postpartum nurse instructs a new mother in how to bathe her newborn. Which statement by the mother indicates a need for FURTHER instruction? - ANSWER- "I should bathe him after a feeding." (may cause regurgitation) A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the maternal blood. The nurse tells the client that: - ANSWER- The infant should receive both the vaccine and hepatitis immune globulin soon after birth A woman in labor suddenly experiences chest pain and dyspnea, and the nurse suspects the presence of amniotic fluid embolism (AFE). The nurse immediately: - ANSWER- Administers oxygen to the woman Immediately after delivery, the uterine fundus should be: - ANSWER- At the level of the umbilicus A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid - ANSWER- Lima beans A nurse teaches a new mother how to perform umbilical cord care and how to recognize the signs of a cord infection. Which of the following findings does the nurse tell the mother is an indicator of infection? - ANSWER- Edema at the base of the cord After an unplanned cesarean section, the nurse finds the client in emotional distress, tearfully expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. Which of the following conclusions should the nurse make? - ANSWER- The client is experiencing low self-esteem. A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: - ANSWER- Apply oil to the affected area on the infant's scalp A nurse is caring for a client experiencing hypotonic labor contractions. The client is discouraged by the lack of progress with labor but refuses an amniotomy or oxytocin (Pitocin) stimulation. The nurse determines that the client's behavior may be a result of: - ANSWER- Concern about her own and the baby's well-being A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective? - ANSWER- The client experiences diuresis within 24 to 48 hours. A nurse is caring for a postpartum client who had a low-lying placenta. The nurse assesses the client most closely for: - ANSWER- Hemorrhage A nurse is assisting a midwife who is assessing a client for ballottement. Which action does the nurse anticipate that the midwife will employ to test for ballottement? - ANSWER- Performing a sudden tap on the cervix -Near midpregnancy, a sudden tap on the cervix during a vaginal exam may cause the fetus to rise in the amniotic fluid and then rebound to its original position, a phenomenon known as ballottement. A nurse teaching a pregnant client about measures to strengthen the pelvic floor instructs the client to: - ANSWER- Perform Kegel exercises in 10 repetitions, three times per day