MATERNITY HESI EXIT 2023 VERSION D/HESI EXIT
MATERNITY HESI EXIT LATEST EXAM QUESTIONS AND
DETAILED ANSWERS WITH RATIONALES|AGRADE
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: -
ANSWER: Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What
warrants further evaluation? - ANSWER: Too much weight gain, gestational weight
gain should only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is
"vigorous"? - ANSWER: Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should
say... - ANSWER: If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with
moderate - ANSWER: Inspect perineal and rectal area.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery.
Nursing Dx? - ANSWER: Fluid volume excess.
RATIONALE: 3rd spacing.
Cesarean - hemorrhage risk assessment? - ANSWER: Check for fundal firmness Q15
min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after
delivery. Q15 min checks stimulate fundus to contract and prevents bleeding.
Water broke, umbilical cord is on perineum, what does nurse do? - ANSWER: Place
pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and
holding up the presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s? - ANSWER: To
evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority?
- ANSWER: Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled
anesthesia. What would be a therapeutic response to the injection? - ANSWER:
Increased HR and decrease in oral secretions.
Newborn assessment that indicates a cardiac problem? - ANSWER: RR 78/min.
,RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give?
- ANSWER: Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding. - ANSWER: Assess infants position while
feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery. - ANSWER: Rhogam prevents maternal
antibody formation for future Rh positive babies.
24 hours after birth, cephalohematoma, what intervention? - ANSWER: Examine
jaundice Q8 hours.
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
. Patient had twins born to multigravida, 12 hours ago. Nursing Dx? - ANSWER:
Assess fundal tone and lochia flow.
. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station,
vertex presentation, greenish colored amniotic fluid, contractions Q3-5 min with
deceased in FHR after the last 4 contraction peaks. What to do FIRST? - ANSWER: 02
via facemask.
Terbutaline (Brethine) injections for preterm labor. When do you hold and call the
MD? - ANSWER: Bilateral crackles in lungs on auscultation (critical complication).
RATIONALE: Could indicate pulmonary edema.
APGAR 3. Intervention? - ANSWER: Continue resuscitation efforts.
In PACU, the most important assessment for first 8 hours after cesarean: - ANSWER:
Uterine atony.
RATIONALE: Uterine atony can lead to hemorrhage.
Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse
response? - ANSWER: Increased risk for spontaneous miscarriage.
RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in
miscarriage.
Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station. -
ANSWER: Apply counter pressure to sacral area.
RATIONALE: Caused by malposition of the fetus.
Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine
be given? - ANSWER: Give early postpartum within 72 hours.
HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing
congenital heart disease, congenital cataracts, or both. All women should have their
,titers checked during pregnancy. If a woman's titers are low, she should receive the
vaccine after delivery and be instructed not to get pregnant within 3 months. Breast-
feeding mothers may take the vaccine" (p. 288).
Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and
nausea. Nurse Dx? - ANSWER: Pain r/t transitional phase of labor.
Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse
do? - ANSWER: Tell mother it is normal.
RATIONALE: Newborns can lose 10% of their wt and regain it later.
Receiving report on laboring pt from ER. Water broke and didn't know it. First thing
the nurse does? - ANSWER: Take temperature.
RATIONALE: Length of time membranes ruptured is important to monitor for
infection.
Postpartum temporary bed-rest should be placed if? - ANSWER: Positive Homan's
sign.
. Fundus hand placement: 1 massages the fundus the other is for... - ANSWER: The
other hand anchors the lower uterine section.
DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do? - ANSWER:
Contact MD for BPP (BioPhysical Profile).
Symptoms of hemorrhage/bleeding out: - ANSWER: LR 200 mL/hr using 18 gauge
needle.
Most accurate way to determine fetal position at 29 weeks gestation. - ANSWER:
Ultrasound.
RATIONALE: Provides direct view of the fetus.
To measure contractions... - ANSWER: From beginning of a contraction, to the
beginning of the next contractions.
. Newborn assessment for respiratory distress. - ANSWER: Flaring of the nares.
RATIONALE: Forced inspiration, grunting, tachy (respirations >60), cyanosis, and
retractions over chest wall).
40 weeks pregnant, laboring, patient states supine is position of comfort, the nurse
should? - ANSWER: Place pillow wedge under right hip.
RATIONALE: Hypotension from pressure on vena cava is risk, the wedge relieves the
pressure on the vena cava.
MVA, 36 weeks, BP 80/50, HR 130, what does the nurse do? - ANSWER: Tilt the
backboard to displace uterus.
, . Patient concerned about yellow nipple discharge. - ANSWER: Tell the patient it is
normal.
Nutrition teaching for pregnant teens. - ANSWER: Iron-deficient anemia.
38 weeks, laboring, which finding (condition) warrants a cesarean? - ANSWER: Active
herpes lesions on perineum.
. Second stage of labor, what does nurse do first? - ANSWER: Let pt know that birth is
imminent.
RATIONALE: Second stage pt is fully dilated and fetus is crowning.
Baby born breech, in the NICU they assess? - ANSWER: Ortolani's test.
RATIONALE: (from Saunders, couldn't find it in HESI). It is a test of hip laxity, used to
diagnose hip dysplasia.
IV LR 1000 mL with oxytocin (Pitocin) 40 units to deliver 15mL/hr. How many milli-
units/minute is the client receiving? - ANSWER: 10 mu/min.
38 week (IDM) infant of diabetic mother admitted to NICU @ 8.2 lbs. What is the
priority Nursing Dx? - ANSWER: Hypoglycemia.
FHR decreases after each contraction. What should the nurse do? - ANSWER: Give 10
lpm 02 via mask.
. Post partum teaching to prevent pregnancy. - ANSWER: Use condom and
spermicidal gel.
1st trimester, Hgb 8.6, Hct 25.1, what food should the nurse encourage? - ANSWER:
Chicken.
Oxytocin (Pitocin) 20 units in 1000 LR after delivery is for? - ANSWER: To stimulate
uterine contractions to prevent hemorrhage.
RATIONALE: Admin after placenta delivery. Prior to placental delivery would cause
uterus to contract and retain placenta.
. Full term infant, vaginal birth, placed in radiant warmer, is apneic. What to do
FIRST? - ANSWER: Flick soles of feet.
RATIONALE: Infant needs additional stimulation to initiate breathing.
One hand above pubic symphysis while massaging fundus of a patient who has a
boggy uterine tone 15 min after delivery (7 lb baby). What does the nurse tell the
patient? - ANSWER: Tell the patient that clots can form in a boggy uterus.
Patient with preeclampsia is receiving IV Mag 6 grams administered over 20 min. The
nurse attaches a volume control device between the infusion pump and the bag of
MATERNITY HESI EXIT LATEST EXAM QUESTIONS AND
DETAILED ANSWERS WITH RATIONALES|AGRADE
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: -
ANSWER: Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What
warrants further evaluation? - ANSWER: Too much weight gain, gestational weight
gain should only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is
"vigorous"? - ANSWER: Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should
say... - ANSWER: If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with
moderate - ANSWER: Inspect perineal and rectal area.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery.
Nursing Dx? - ANSWER: Fluid volume excess.
RATIONALE: 3rd spacing.
Cesarean - hemorrhage risk assessment? - ANSWER: Check for fundal firmness Q15
min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after
delivery. Q15 min checks stimulate fundus to contract and prevents bleeding.
Water broke, umbilical cord is on perineum, what does nurse do? - ANSWER: Place
pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and
holding up the presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s? - ANSWER: To
evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority?
- ANSWER: Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled
anesthesia. What would be a therapeutic response to the injection? - ANSWER:
Increased HR and decrease in oral secretions.
Newborn assessment that indicates a cardiac problem? - ANSWER: RR 78/min.
,RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give?
- ANSWER: Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding. - ANSWER: Assess infants position while
feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery. - ANSWER: Rhogam prevents maternal
antibody formation for future Rh positive babies.
24 hours after birth, cephalohematoma, what intervention? - ANSWER: Examine
jaundice Q8 hours.
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
. Patient had twins born to multigravida, 12 hours ago. Nursing Dx? - ANSWER:
Assess fundal tone and lochia flow.
. Primigravida, 36 week, admitted, water broke, 2cm dilated, 50% effaced, -2 station,
vertex presentation, greenish colored amniotic fluid, contractions Q3-5 min with
deceased in FHR after the last 4 contraction peaks. What to do FIRST? - ANSWER: 02
via facemask.
Terbutaline (Brethine) injections for preterm labor. When do you hold and call the
MD? - ANSWER: Bilateral crackles in lungs on auscultation (critical complication).
RATIONALE: Could indicate pulmonary edema.
APGAR 3. Intervention? - ANSWER: Continue resuscitation efforts.
In PACU, the most important assessment for first 8 hours after cesarean: - ANSWER:
Uterine atony.
RATIONALE: Uterine atony can lead to hemorrhage.
Cytotec (Misoprostol) for peptic ulcer (Synthetic Prostaglandin E Drug). Nurse
response? - ANSWER: Increased risk for spontaneous miscarriage.
RATIONALE: Cytotec (Misoprostol) can induce uterine contractions resulting in
miscarriage.
Multigravida at term with back labor, cervix is 3 cm dilated, 50% effaced, -1 station. -
ANSWER: Apply counter pressure to sacral area.
RATIONALE: Caused by malposition of the fetus.
Not Rubella immune (negative titer) and 6 weeks pregnant. When should the vaccine
be given? - ANSWER: Give early postpartum within 72 hours.
HESI HINT: "Rubella is teratogenic to the fetus during the first trimester, causing
congenital heart disease, congenital cataracts, or both. All women should have their
,titers checked during pregnancy. If a woman's titers are low, she should receive the
vaccine after delivery and be instructed not to get pregnant within 3 months. Breast-
feeding mothers may take the vaccine" (p. 288).
Gravida 1, para 0, cervix dilated 8 cm, contractions Q2 min, bloody show, and
nausea. Nurse Dx? - ANSWER: Pain r/t transitional phase of labor.
Baby weighs 7.5 lbs today, tomorrow 7 lbs (5 lb weight loss). What does the nurse
do? - ANSWER: Tell mother it is normal.
RATIONALE: Newborns can lose 10% of their wt and regain it later.
Receiving report on laboring pt from ER. Water broke and didn't know it. First thing
the nurse does? - ANSWER: Take temperature.
RATIONALE: Length of time membranes ruptured is important to monitor for
infection.
Postpartum temporary bed-rest should be placed if? - ANSWER: Positive Homan's
sign.
. Fundus hand placement: 1 massages the fundus the other is for... - ANSWER: The
other hand anchors the lower uterine section.
DM I, HbgA1c level 7.8 at 10 weeks pregnant. What should the nurse do? - ANSWER:
Contact MD for BPP (BioPhysical Profile).
Symptoms of hemorrhage/bleeding out: - ANSWER: LR 200 mL/hr using 18 gauge
needle.
Most accurate way to determine fetal position at 29 weeks gestation. - ANSWER:
Ultrasound.
RATIONALE: Provides direct view of the fetus.
To measure contractions... - ANSWER: From beginning of a contraction, to the
beginning of the next contractions.
. Newborn assessment for respiratory distress. - ANSWER: Flaring of the nares.
RATIONALE: Forced inspiration, grunting, tachy (respirations >60), cyanosis, and
retractions over chest wall).
40 weeks pregnant, laboring, patient states supine is position of comfort, the nurse
should? - ANSWER: Place pillow wedge under right hip.
RATIONALE: Hypotension from pressure on vena cava is risk, the wedge relieves the
pressure on the vena cava.
MVA, 36 weeks, BP 80/50, HR 130, what does the nurse do? - ANSWER: Tilt the
backboard to displace uterus.
, . Patient concerned about yellow nipple discharge. - ANSWER: Tell the patient it is
normal.
Nutrition teaching for pregnant teens. - ANSWER: Iron-deficient anemia.
38 weeks, laboring, which finding (condition) warrants a cesarean? - ANSWER: Active
herpes lesions on perineum.
. Second stage of labor, what does nurse do first? - ANSWER: Let pt know that birth is
imminent.
RATIONALE: Second stage pt is fully dilated and fetus is crowning.
Baby born breech, in the NICU they assess? - ANSWER: Ortolani's test.
RATIONALE: (from Saunders, couldn't find it in HESI). It is a test of hip laxity, used to
diagnose hip dysplasia.
IV LR 1000 mL with oxytocin (Pitocin) 40 units to deliver 15mL/hr. How many milli-
units/minute is the client receiving? - ANSWER: 10 mu/min.
38 week (IDM) infant of diabetic mother admitted to NICU @ 8.2 lbs. What is the
priority Nursing Dx? - ANSWER: Hypoglycemia.
FHR decreases after each contraction. What should the nurse do? - ANSWER: Give 10
lpm 02 via mask.
. Post partum teaching to prevent pregnancy. - ANSWER: Use condom and
spermicidal gel.
1st trimester, Hgb 8.6, Hct 25.1, what food should the nurse encourage? - ANSWER:
Chicken.
Oxytocin (Pitocin) 20 units in 1000 LR after delivery is for? - ANSWER: To stimulate
uterine contractions to prevent hemorrhage.
RATIONALE: Admin after placenta delivery. Prior to placental delivery would cause
uterus to contract and retain placenta.
. Full term infant, vaginal birth, placed in radiant warmer, is apneic. What to do
FIRST? - ANSWER: Flick soles of feet.
RATIONALE: Infant needs additional stimulation to initiate breathing.
One hand above pubic symphysis while massaging fundus of a patient who has a
boggy uterine tone 15 min after delivery (7 lb baby). What does the nurse tell the
patient? - ANSWER: Tell the patient that clots can form in a boggy uterus.
Patient with preeclampsia is receiving IV Mag 6 grams administered over 20 min. The
nurse attaches a volume control device between the infusion pump and the bag of
