RN HESI Maternity exam q&a
A primigravida at 40 weeks gestation is contraction q2 minutes her cervix is 9cm dilated and
100% effaced. The fetus heart rate is 120 beats per minute. The client is screaming and her
husband is alarmed. What intervention should the nurse do?A. Notify rapid response
B. Have delivery table set up
C. Ask husband to step out
D. Administer a PRN narcotic - ANSWER-B. Have delivery table set up
The nurse is assessing a client at 29 weeks gestation. Which assessment measure would provide
the most accurate determination of fetal position?
A. Ultrasound
B. Vaginal examination
C. Leopolds maneuver
D. Doppler - ANSWER-A. Ultrasound
A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a
motor vehicle collision. While stabilizing the patient , the nurse obtains fetal monitor reading.
Which action should the nurse take if the fetus is tachycardic is on the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - ANSWER-D. Contact
the healthcare provider after initiating oxygen per face mask
On the first postpartum day, the nurse examines the breasts of the new mother. Which
condition is the nurse most likely to.
A. Slightly firm with immediate let down response
B. Filing and secreting colostrum
C. Soft, with no change from before delivery
D. Firm, larger very tender to touch - ANSWER-B. Filling and secreting colostrum
The nurse who is working at a prenatal clinic notes a woman that is at 18 weeks of gestation has
two elevated maternal alpha feto-protein (MSAFP) values. What action should the nurse
implement?
A. Instruct the client to increase intake of folic acid supplements
B. Request a consultation with genetic counselor
C. Schedule a sonogram in the radiology department
,D. Send the client to the laboratory for repeat MSAFP - ANSWER-C. schedule a sonogram in the
radiology department
A primigravida arrives at the observation unit of the maternity unit because thinks 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 not labor at this time? - ANSWER-
Contractions decrease with walking.
A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the
grieving process which intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in privacy
C. Encourage the parents to seek counseling within the next few weeks
D. Assist the couple to request autopsy - ANSWER-B. provide a time for the parents to hold their
infant in privacy
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to
prevent urinary retention. The home health nurse notes that the child has developed episodes
of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important
for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change - ANSWER-C. Change to latex-free
gloves when handling infant
The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2
proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a
severe frontal headache. Which medication should the nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate - ANSWER-D. Magnesium sulfate
A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment,
the nurse notes the client's temperature to be 101.2F, with severe abdominal or uterine
tenderness on palpation. The nurse knows that these findings are indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
, D. Viral infection. - ANSWER-B. Chorioamnionitis
A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who
tells the nurse that the child refuses to drink anything. The nurse determines that the child has a
weak cry with no tears. Which prescription is most important to implement?
A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket - ANSWER-B. Infuse normal saline intravenously
A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing
intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises - ANSWER-D. remove restraints
one at a time to provide ROM exercises
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child
something besides breast milk, but is concerned that the infant is too young to start eating solid
foods. How should the nurse respond?
A. encourage the mother to schedule a developmental assessment of the infant
B. advise the mother to wait at least another month before starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
D. reassure the mother that the infant is old enough to eat iron-fortified cereal - ANSWER-D.
reassure the mother that the infant is old enough to eat iron-fortified cereal
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart
rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the
nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position - ANSWER-D. Change the maternal position
A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam)
after delivery of an infant who is Rh-positive. Which information should the nure provide this
client?
A primigravida at 40 weeks gestation is contraction q2 minutes her cervix is 9cm dilated and
100% effaced. The fetus heart rate is 120 beats per minute. The client is screaming and her
husband is alarmed. What intervention should the nurse do?A. Notify rapid response
B. Have delivery table set up
C. Ask husband to step out
D. Administer a PRN narcotic - ANSWER-B. Have delivery table set up
The nurse is assessing a client at 29 weeks gestation. Which assessment measure would provide
the most accurate determination of fetal position?
A. Ultrasound
B. Vaginal examination
C. Leopolds maneuver
D. Doppler - ANSWER-A. Ultrasound
A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a
motor vehicle collision. While stabilizing the patient , the nurse obtains fetal monitor reading.
Which action should the nurse take if the fetus is tachycardic is on the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - ANSWER-D. Contact
the healthcare provider after initiating oxygen per face mask
On the first postpartum day, the nurse examines the breasts of the new mother. Which
condition is the nurse most likely to.
A. Slightly firm with immediate let down response
B. Filing and secreting colostrum
C. Soft, with no change from before delivery
D. Firm, larger very tender to touch - ANSWER-B. Filling and secreting colostrum
The nurse who is working at a prenatal clinic notes a woman that is at 18 weeks of gestation has
two elevated maternal alpha feto-protein (MSAFP) values. What action should the nurse
implement?
A. Instruct the client to increase intake of folic acid supplements
B. Request a consultation with genetic counselor
C. Schedule a sonogram in the radiology department
,D. Send the client to the laboratory for repeat MSAFP - ANSWER-C. schedule a sonogram in the
radiology department
A primigravida arrives at the observation unit of the maternity unit because thinks 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 not labor at this time? - ANSWER-
Contractions decrease with walking.
A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the
grieving process which intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in privacy
C. Encourage the parents to seek counseling within the next few weeks
D. Assist the couple to request autopsy - ANSWER-B. provide a time for the parents to hold their
infant in privacy
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to
prevent urinary retention. The home health nurse notes that the child has developed episodes
of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important
for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change - ANSWER-C. Change to latex-free
gloves when handling infant
The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2
proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a
severe frontal headache. Which medication should the nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate - ANSWER-D. Magnesium sulfate
A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment,
the nurse notes the client's temperature to be 101.2F, with severe abdominal or uterine
tenderness on palpation. The nurse knows that these findings are indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
, D. Viral infection. - ANSWER-B. Chorioamnionitis
A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who
tells the nurse that the child refuses to drink anything. The nurse determines that the child has a
weak cry with no tears. Which prescription is most important to implement?
A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket - ANSWER-B. Infuse normal saline intravenously
A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing
intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises - ANSWER-D. remove restraints
one at a time to provide ROM exercises
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child
something besides breast milk, but is concerned that the infant is too young to start eating solid
foods. How should the nurse respond?
A. encourage the mother to schedule a developmental assessment of the infant
B. advise the mother to wait at least another month before starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
D. reassure the mother that the infant is old enough to eat iron-fortified cereal - ANSWER-D.
reassure the mother that the infant is old enough to eat iron-fortified cereal
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart
rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the
nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position - ANSWER-D. Change the maternal position
A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam)
after delivery of an infant who is Rh-positive. Which information should the nure provide this
client?
