HESI PN MATERNITY EXIT EXAM 2023/ PN MATERNITY HESI EXIT ACTUAL EXAM
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES |ALREADY
GRADED A+
1. During labor, the fetal heart rate slowly decelerates at the beginning of the
contraction and returns to baseline at the end of the contraction. What action
should the nurse take?
a. Turn the mother to her left side.
b. Administer oxygen to the mother via face mask.
c. Notify the health care provider regarding the findings.
d. Continue to monitor the progress of the client's labor.
: D) Continue to monitor the progress of the client's labor.
Rationale:
Early decelerations during labor are frequently caused by head compression within
the uterus, and no nursing intervention is required except to monitor the mother's
progress during labor.
2. Which maternal behavior is the practical nurse (PN) most likely to see when
a new mother receives her infant for the first time?
a. She eagerly undresses the infant and examines the infant completely.
b. She receives the infant and touches the infant's face with her fingertips.
c. She reaches and cuddles the infant to her own body.
d. She reaches but hesitates for the nurse's encouragement.
: B) She receives the infant and touches the infant's face with her fingertips.
Rationale:
Attachment/bonding theory indicates that most mothers will touch the infant's face
during the first visit with the newborn.
3. A new father asks the practical nurse (PN) why ointment is instilled into
the eyes of his newborn infant. Which infection should the PN identify when
describing the purpose of this treatment?
,a. Herpes
b. Staphylococcus
c. Gonorrhea
d. Syphilis
: C) Gonorrhea
Rationale:
Erythromycin ointment is instilled into the lower conjunctiva of each eye within
2 hours after birth to prevent ophthalmia neonatorum, an infection caused by
gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia.
4. The nurse is taking the temperature of a client who is 6 hours postpartum.
The nurse notes that the client's temperature is 38° C (100.4° F). Which inter-
vention should the nurse implement?
a. Encourage fluids to increase hydration.
b. Recheck the temperature in 15 minutes.
c. Place an ice pack on the client's forehead.
d. Obtain a prescription for acetaminophen.
: A) Encourage fluids to increase hydration.
Rationale:
It is normal for the postpartum client to have a temperature up to 38° C (100.4° F)
because of dehydration caused by labor. The most appropriate intervention is to
encourage fluids to rehydrate the patient.
*Above 38° C (100.4° F) is critical
5. A newborn infant is breathing satisfactorily but appears dusky. What action
should the practical nurse (PN) take first?
a. Notify the pediatrician immediately.
,b. Suction the infant's nares and then the oral cavity.
c. Check the infant's oxygen saturation rate.
d. Position the infant on the right side.
: C) Check the infant's oxygen saturation rate.
Rationale:
The PN should first obtain measurable objective data; an oxygen saturation rate pro-
vides such information. The pediatrician should be notified if the oxygen saturation
rate is below 90%.
6. The practical nurse (PN) caring for a laboring client encourages her to void
at least every 2 hours and records each time the client empties her bladder.
What is the rationale for implementing this nursing intervention?
a. Emptying the bladder during delivery is difficult because of the position of
the presenting fetal part
b. An overdistended bladder could be traumatized during labor and could
prolong the progress of labor.
c. Urine specimens for glucose and protein must be obtained at certain
intervals throughout labor.
d. Frequent voiding minimizes the need for catheterization, which increases
the chance of bladder infection.
: B) An overdistended bladder could be traumatized during labor and could prolong
the progress of labor.
Rationale:
A full bladder can impair the efficiency of the uterine contractions and impede
descent of the fetus during labor. Also, because of the close proximity of the bladder
to the uterus, the bladder can be traumatized by the descent of the fetus.
, 7. During a prenatal visit, the practical nurse (PN) discusses with a client
the effects that smoking has on the fetus. The nurse realizes the teaching is
effective if the client identifies which possible effect on the fetus?
a. Lower Apgar score recorded at delivery.
b. Lower initial weight documented at birth.
c. Higher oxygen used to stimulate breathing.
d. Higher prevalence of congenital anomalies.
: B) Lower initial weight documented at birth.
Rationale:
Smoking is associated with low-birth-weight infants.
8. Following a vaginal delivery, a postpartum client complains of severe
cramping after breastfeeding her newborn. Which explanation describes the
most likely reason for the client's pain?
a. A retained placenta
b. Problems with the process of involution
c. The release of oxytocin hormone
d. A possible ileus
: C) The release of oxytocin hormone
Rationale:
During breastfeeding, oxytocin is released and will cause uterine contractions and
cramping.
9. A female who thinks she could be pregnant calls her neighbor, a practical
nurse (PN), to ask when she should use a home pregnancy test to diagnose
pregnancy. Which response is best?
QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES |ALREADY
GRADED A+
1. During labor, the fetal heart rate slowly decelerates at the beginning of the
contraction and returns to baseline at the end of the contraction. What action
should the nurse take?
a. Turn the mother to her left side.
b. Administer oxygen to the mother via face mask.
c. Notify the health care provider regarding the findings.
d. Continue to monitor the progress of the client's labor.
: D) Continue to monitor the progress of the client's labor.
Rationale:
Early decelerations during labor are frequently caused by head compression within
the uterus, and no nursing intervention is required except to monitor the mother's
progress during labor.
2. Which maternal behavior is the practical nurse (PN) most likely to see when
a new mother receives her infant for the first time?
a. She eagerly undresses the infant and examines the infant completely.
b. She receives the infant and touches the infant's face with her fingertips.
c. She reaches and cuddles the infant to her own body.
d. She reaches but hesitates for the nurse's encouragement.
: B) She receives the infant and touches the infant's face with her fingertips.
Rationale:
Attachment/bonding theory indicates that most mothers will touch the infant's face
during the first visit with the newborn.
3. A new father asks the practical nurse (PN) why ointment is instilled into
the eyes of his newborn infant. Which infection should the PN identify when
describing the purpose of this treatment?
,a. Herpes
b. Staphylococcus
c. Gonorrhea
d. Syphilis
: C) Gonorrhea
Rationale:
Erythromycin ointment is instilled into the lower conjunctiva of each eye within
2 hours after birth to prevent ophthalmia neonatorum, an infection caused by
gonorrhea, and inclusion conjunctivitis, an infection caused by Chlamydia.
4. The nurse is taking the temperature of a client who is 6 hours postpartum.
The nurse notes that the client's temperature is 38° C (100.4° F). Which inter-
vention should the nurse implement?
a. Encourage fluids to increase hydration.
b. Recheck the temperature in 15 minutes.
c. Place an ice pack on the client's forehead.
d. Obtain a prescription for acetaminophen.
: A) Encourage fluids to increase hydration.
Rationale:
It is normal for the postpartum client to have a temperature up to 38° C (100.4° F)
because of dehydration caused by labor. The most appropriate intervention is to
encourage fluids to rehydrate the patient.
*Above 38° C (100.4° F) is critical
5. A newborn infant is breathing satisfactorily but appears dusky. What action
should the practical nurse (PN) take first?
a. Notify the pediatrician immediately.
,b. Suction the infant's nares and then the oral cavity.
c. Check the infant's oxygen saturation rate.
d. Position the infant on the right side.
: C) Check the infant's oxygen saturation rate.
Rationale:
The PN should first obtain measurable objective data; an oxygen saturation rate pro-
vides such information. The pediatrician should be notified if the oxygen saturation
rate is below 90%.
6. The practical nurse (PN) caring for a laboring client encourages her to void
at least every 2 hours and records each time the client empties her bladder.
What is the rationale for implementing this nursing intervention?
a. Emptying the bladder during delivery is difficult because of the position of
the presenting fetal part
b. An overdistended bladder could be traumatized during labor and could
prolong the progress of labor.
c. Urine specimens for glucose and protein must be obtained at certain
intervals throughout labor.
d. Frequent voiding minimizes the need for catheterization, which increases
the chance of bladder infection.
: B) An overdistended bladder could be traumatized during labor and could prolong
the progress of labor.
Rationale:
A full bladder can impair the efficiency of the uterine contractions and impede
descent of the fetus during labor. Also, because of the close proximity of the bladder
to the uterus, the bladder can be traumatized by the descent of the fetus.
, 7. During a prenatal visit, the practical nurse (PN) discusses with a client
the effects that smoking has on the fetus. The nurse realizes the teaching is
effective if the client identifies which possible effect on the fetus?
a. Lower Apgar score recorded at delivery.
b. Lower initial weight documented at birth.
c. Higher oxygen used to stimulate breathing.
d. Higher prevalence of congenital anomalies.
: B) Lower initial weight documented at birth.
Rationale:
Smoking is associated with low-birth-weight infants.
8. Following a vaginal delivery, a postpartum client complains of severe
cramping after breastfeeding her newborn. Which explanation describes the
most likely reason for the client's pain?
a. A retained placenta
b. Problems with the process of involution
c. The release of oxytocin hormone
d. A possible ileus
: C) The release of oxytocin hormone
Rationale:
During breastfeeding, oxytocin is released and will cause uterine contractions and
cramping.
9. A female who thinks she could be pregnant calls her neighbor, a practical
nurse (PN), to ask when she should use a home pregnancy test to diagnose
pregnancy. Which response is best?
