LATEST HESI MATERNITY EXAM / HESI MATERNITY ACTUAL
EXAM REAL QUESTIONS AND CORRECT DETAILED ANSWERS
(100% CORRECT VERIFIED ANSWERS) A NEW UPDATED
VERSION |GUARANTEED PASS. (FULL REVISED EXAM)
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being
prepared for discharge. Which nursing intervention should be included in this
infant's discharge teaching plan? - ANSWER: Observe the parents applying a Pavlik
harness.
Rationale: It is important that the hips of infants with hip dysplasia are maintained in
an abducted position, which can be accomplished by using the Pavlik harness ; this
keeps the hips and knees flexed, the hips abducted, and the femoral head in the
acetabulum.
The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling fingers and dizziness. Which action should the nurse
take? - ANSWER: Have the client breathe into her cupped hands.
Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too
much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This
can be facilitated by breathing into a paper bag or cupped hands
A client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since
surgery. She is now complaining of nausea and bloating, and states that because she
had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis
has the highest priority? - ANSWER: Impaired bowel motility related to pain
medication and immobility.
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication,
and immobility is the priority nursing diagnosis and addresses the potential problem
of a paralytic ileus.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. In a newborn, what is the
most likely cause of this accumulation of blood between the periosteum and skull
that does not cross the suture line? - ANSWER: Cephalhematoma, which is caused by
forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually
arises within the first 24 hours after delivery. Trauma from delivery causes capillary
bleeding between the periosteum and skull.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports
that her lochia is getting lighter in color and asks when the flow will stop. How
should the nurse respond? - ANSWER: When the placental site has healed
Rationale: The placental site in the uterus usually heals in 3 to 6 weeks, and the
lochial flow should cease at that time.
, The nurse is using the Silverman-Anderson index to assess an infant with respiratory
distress and determines that the infant is demonstrating marked nasal flaring, an
audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using
this scale, which score should the nurse assign? - ANSWER: 5
Rationale: The Silverman-Anderson index is an assessment scale that scores a
newborn's respiratory status as grade 0, 1, or 2 for each component; it includes
synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt.
No respiratory distress is graded 0 and a total of 10 indicates maximum respiratory
distress. This infant is demonstrating respiratory distress with maximal effort, so a
grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory
grunting, plus grade 1 for just visible retractions, which is a total score of 5
On admission to the prenatal clinic, a client tells the nurse that her last menstrual
period began on February 15 and that previously her periods were regular (28-day
cycle). Her pregnancy test is positive. What is this client's expected date of birth
(EDB)? - ANSWER: November 22
Rationale: Subtract 3 months, add 7 days.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority? - ANSWER: Put baby to breast immediately.
Rationale: The stimulation of breast milk with help clamp down the uterus to
prevent postpartum hemorrhage.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction will aid
in the prevention of pooling of blood in the lower extremities? - ANSWER: Move
about ever hour.
Rationale: Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve pressure
on the pelvic veins and increase venous return.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn? - ANSWER: "Breastfeeding my infant
consistently every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method
A new mother is having trouble breastfeeding her newborn. The child is making
frantic rooting motions and will not grasp the nipple. Which intervention should the
nurse implement? - ANSWER: Encourage the mother to stop feeding for a few
minutes and comfort the infant.
Rationale: The infant is becoming frustrated and so is the mother; both need a time
out. The mother should be encouraged to comfort the infant and to relax herself.
After such a time out, breastfeeding is often more successful.
EXAM REAL QUESTIONS AND CORRECT DETAILED ANSWERS
(100% CORRECT VERIFIED ANSWERS) A NEW UPDATED
VERSION |GUARANTEED PASS. (FULL REVISED EXAM)
A newborn infant, diagnosed with developmental dysplasia of the hip (DDH), is being
prepared for discharge. Which nursing intervention should be included in this
infant's discharge teaching plan? - ANSWER: Observe the parents applying a Pavlik
harness.
Rationale: It is important that the hips of infants with hip dysplasia are maintained in
an abducted position, which can be accomplished by using the Pavlik harness ; this
keeps the hips and knees flexed, the hips abducted, and the femoral head in the
acetabulum.
The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling fingers and dizziness. Which action should the nurse
take? - ANSWER: Have the client breathe into her cupped hands.
Rationale: Tingling fingers and dizziness are signs of hyperventilation (blowing off too
much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This
can be facilitated by breathing into a paper bag or cupped hands
A client who delivered by cesarean section 24 hours ago is using a patient-controlled
analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since
surgery. She is now complaining of nausea and bloating, and states that because she
had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis
has the highest priority? - ANSWER: Impaired bowel motility related to pain
medication and immobility.
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication,
and immobility is the priority nursing diagnosis and addresses the potential problem
of a paralytic ileus.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. In a newborn, what is the
most likely cause of this accumulation of blood between the periosteum and skull
that does not cross the suture line? - ANSWER: Cephalhematoma, which is caused by
forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually
arises within the first 24 hours after delivery. Trauma from delivery causes capillary
bleeding between the periosteum and skull.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports
that her lochia is getting lighter in color and asks when the flow will stop. How
should the nurse respond? - ANSWER: When the placental site has healed
Rationale: The placental site in the uterus usually heals in 3 to 6 weeks, and the
lochial flow should cease at that time.
, The nurse is using the Silverman-Anderson index to assess an infant with respiratory
distress and determines that the infant is demonstrating marked nasal flaring, an
audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using
this scale, which score should the nurse assign? - ANSWER: 5
Rationale: The Silverman-Anderson index is an assessment scale that scores a
newborn's respiratory status as grade 0, 1, or 2 for each component; it includes
synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt.
No respiratory distress is graded 0 and a total of 10 indicates maximum respiratory
distress. This infant is demonstrating respiratory distress with maximal effort, so a
grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory
grunting, plus grade 1 for just visible retractions, which is a total score of 5
On admission to the prenatal clinic, a client tells the nurse that her last menstrual
period began on February 15 and that previously her periods were regular (28-day
cycle). Her pregnancy test is positive. What is this client's expected date of birth
(EDB)? - ANSWER: November 22
Rationale: Subtract 3 months, add 7 days.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority? - ANSWER: Put baby to breast immediately.
Rationale: The stimulation of breast milk with help clamp down the uterus to
prevent postpartum hemorrhage.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction will aid
in the prevention of pooling of blood in the lower extremities? - ANSWER: Move
about ever hour.
Rationale: Pooling of blood in the lower extremities results from the enlarged uterus
exerting pressure on the pelvic veins. Moving about every hour will relieve pressure
on the pelvic veins and increase venous return.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn? - ANSWER: "Breastfeeding my infant
consistently every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method
A new mother is having trouble breastfeeding her newborn. The child is making
frantic rooting motions and will not grasp the nipple. Which intervention should the
nurse implement? - ANSWER: Encourage the mother to stop feeding for a few
minutes and comfort the infant.
Rationale: The infant is becoming frustrated and so is the mother; both need a time
out. The mother should be encouraged to comfort the infant and to relax herself.
After such a time out, breastfeeding is often more successful.
