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)
During stage two of labor, what assessments must the labor nurse perform? (Select
all that apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - ANSWER: A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions
to determine the fetal response to the contractions. Frequency may slow during the
second stage. Duration will help facilitate decent of the presenting part. The uterine
tone between contractions should be soft to facilitate placental filling after the
contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm
and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate
increases with each contraction and returns to baseline after the contraction. What
is the next nursing action?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin infusion. - ANSWER: D. Increase the rate of the
oxytocin infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2 to
3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.
FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin)
infusion should be increased per protocol to stimulate the frequency and intensity of
contractions. Options A and C are indicated for fetal stress. A sterile vaginal
examination places the client at risk for infection and should be performed when the
client exhibits signs of progressing labor, which is not indicated at this time.
The nurse is teaching a prenatal class about the structure of the pelvis and is using a
model of a pelvis in the presentation. Which statements will the nurse include in the
teaching plan? (Select all that apply.)
A. "The baby has to pass through the true pelvis."
,B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - ANSWER: A, B, C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining statements
are true.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours
each day. She 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?
A.Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing. - ANSWER: C. Move about every hour.
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. Option A would increase venous return from
varicose veins in the lower extremities but would be of little help with swelling.
Option B might be helpful with generalized edema but is not specific for edematous
lower extremities. Option D does not address venous return, and there is no
indication in the question that constrictive clothing is a problem.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close.
Which statement is accurate regarding the timing of closure of an infant's fontanels
that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the
end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the
end of the second week.
C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the
end of the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the
end of the second month. - ANSWER: D. The anterior fontanel closes at 12 to 18
months and the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and
development milestones are frequently included in questions on the licensure
examination. Options A, B, and C are incorrect.
,The laboring client at term states to the nurse, "I think my water just broke." The
nurse observes a shiny, gelatinous, rope-like structure protruding from the client's
vaginal area. What is the next nursing action?
A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - ANSWER: B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical cord.
Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest
position reduces the weight of the presenting part off of the cord. The nurse will
need to complete the remaining options, but oxygenation of the fetus takes priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-
term infant who has developed localized swelling on the right side of the 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?
A. Cephalohematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage - ANSWER: A.
Cephalohematoma, which is caused by forceps trauma
Cephalohematoma, 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. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common
variation of the newborn. Options B and D both involve intracranial bleeding and
could not be detected by physical assessment alone.
The postpartum client is preparing for discharge. She states to the nurse, "I have not
had a bowel movement yet." What are the nurse's recommendations for this client?
(Select all that apply.)
A. "Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per
day."
B. "Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and
pears."
C. "Increase the frequency of breast-feeding to no less than every two hours."
D. "Since it is nice outside, take a 15-minute walk two to three times a day."
E. "Take your narcotic pain medications as prescribed, every 3 to 4 hours." -
ANSWER: A, B, D
For post-partum constipation, drink at least 2000 mL of water every day. Eating
foods high in fiber will help with constipation. Ambulation also helps with
, constipation. Increasing the frequency of breastfeeding helps with uterine
involution, but not with constipation. Frequent use of narcotic pain medication can
be constipating.
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes
the student understands the teaching when which statements are made? (Select all
that apply.)
A. The umbilical cord contains two veins and one artery.
B. Umbilical arterial blood has the highest oxygenation.
C. Fetal oxygenation occurs through the placenta.
D. The foramen ovale is open in the fetal state.
E. Blood flows from the placenta to the fetal heart. - ANSWER: C, D, E
The umbilical cord contains one vein and 2 arteries. Umbilical venous blood has the
highest level of oxygenation. The remaining statements are true.
The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted
client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and
start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3
to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units.
What supplies will the nurse need to gather to start the infusion? (Select all that
apply.)
A. 1000 mL bag of normal saline
B. Three vials of oxytocin
C. 22 gauge IV catheter
D. Alcohol wipe
E. IV start kit
F. One or three mL syringe - ANSWER: B, D, E, F
Normal saline is for the oxytocin infusion and the order reads 500 mL not 1000 mL.
The main line IV fluid will be a fluid such as D5LR, or LR, for hydration. Three vials of
oxytocin equals 30 units, the alcohol wipe will be to open the glass vial to avoid a cut
by the glass vial. A 22 gauge IV catheter is too small for an induction. Pregnant
women have a nearly 50% increase in their blood volume. In a healthy pregnant
woman there is generally no problem inserting an 18 gauge IV catheter. The 1 or 3
mL syringe is used to draw up the oxytocin for the infusion.
Six hours after an oxytocin induction was begun and 2 hours after spontaneous
rupture of the membranes, the nurse notes several sudden decreases in the fetal
heart rate with quick return to baseline, with and without contractions. Based on
this fetal heart rate pattern, which intervention is best for the nurse to implement?
A. Increase the IV fluids.
B. Begin oxygen by nasal cannula at 2 L/min.
C. Place the client in a slight Trendelenburg position.
EXAM REAL QUESTIONS AND CORRECT DETAILED ANSWERS
(100% CORRECT VERIFIED ANSWERS) A NEW UPDATED
VERSION |GUARANTEED PASS. (FULL REVISED EXAM)
During stage two of labor, what assessments must the labor nurse perform? (Select
all that apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - ANSWER: A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions
to determine the fetal response to the contractions. Frequency may slow during the
second stage. Duration will help facilitate decent of the presenting part. The uterine
tone between contractions should be soft to facilitate placental filling after the
contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm
and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate
increases with each contraction and returns to baseline after the contraction. What
is the next nursing action?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin infusion. - ANSWER: D. Increase the rate of the
oxytocin infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2 to
3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.
FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin)
infusion should be increased per protocol to stimulate the frequency and intensity of
contractions. Options A and C are indicated for fetal stress. A sterile vaginal
examination places the client at risk for infection and should be performed when the
client exhibits signs of progressing labor, which is not indicated at this time.
The nurse is teaching a prenatal class about the structure of the pelvis and is using a
model of a pelvis in the presentation. Which statements will the nurse include in the
teaching plan? (Select all that apply.)
A. "The baby has to pass through the true pelvis."
,B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - ANSWER: A, B, C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining statements
are true.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours
each day. She 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?
A.Wear support stockings.
B. Reduce salt in the diet.
C. Move about every hour.
D. Avoid constrictive clothing. - ANSWER: C. Move about every hour.
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. Option A would increase venous return from
varicose veins in the lower extremities but would be of little help with swelling.
Option B might be helpful with generalized edema but is not specific for edematous
lower extremities. Option D does not address venous return, and there is no
indication in the question that constrictive clothing is a problem.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close.
Which statement is accurate regarding the timing of closure of an infant's fontanels
that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the
end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the
end of the second week.
C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the
end of the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the
end of the second month. - ANSWER: D. The anterior fontanel closes at 12 to 18
months and the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and
development milestones are frequently included in questions on the licensure
examination. Options A, B, and C are incorrect.
,The laboring client at term states to the nurse, "I think my water just broke." The
nurse observes a shiny, gelatinous, rope-like structure protruding from the client's
vaginal area. What is the next nursing action?
A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - ANSWER: B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical cord.
Compression of the cord can lead to fetal anoxia. Placing the client in knee-chest
position reduces the weight of the presenting part off of the cord. The nurse will
need to complete the remaining options, but oxygenation of the fetus takes priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-
term infant who has developed localized swelling on the right side of the 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?
A. Cephalohematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage - ANSWER: A.
Cephalohematoma, which is caused by forceps trauma
Cephalohematoma, 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. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common
variation of the newborn. Options B and D both involve intracranial bleeding and
could not be detected by physical assessment alone.
The postpartum client is preparing for discharge. She states to the nurse, "I have not
had a bowel movement yet." What are the nurse's recommendations for this client?
(Select all that apply.)
A. "Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per
day."
B. "Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and
pears."
C. "Increase the frequency of breast-feeding to no less than every two hours."
D. "Since it is nice outside, take a 15-minute walk two to three times a day."
E. "Take your narcotic pain medications as prescribed, every 3 to 4 hours." -
ANSWER: A, B, D
For post-partum constipation, drink at least 2000 mL of water every day. Eating
foods high in fiber will help with constipation. Ambulation also helps with
, constipation. Increasing the frequency of breastfeeding helps with uterine
involution, but not with constipation. Frequent use of narcotic pain medication can
be constipating.
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes
the student understands the teaching when which statements are made? (Select all
that apply.)
A. The umbilical cord contains two veins and one artery.
B. Umbilical arterial blood has the highest oxygenation.
C. Fetal oxygenation occurs through the placenta.
D. The foramen ovale is open in the fetal state.
E. Blood flows from the placenta to the fetal heart. - ANSWER: C, D, E
The umbilical cord contains one vein and 2 arteries. Umbilical venous blood has the
highest level of oxygenation. The remaining statements are true.
The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted
client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and
start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3
to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units.
What supplies will the nurse need to gather to start the infusion? (Select all that
apply.)
A. 1000 mL bag of normal saline
B. Three vials of oxytocin
C. 22 gauge IV catheter
D. Alcohol wipe
E. IV start kit
F. One or three mL syringe - ANSWER: B, D, E, F
Normal saline is for the oxytocin infusion and the order reads 500 mL not 1000 mL.
The main line IV fluid will be a fluid such as D5LR, or LR, for hydration. Three vials of
oxytocin equals 30 units, the alcohol wipe will be to open the glass vial to avoid a cut
by the glass vial. A 22 gauge IV catheter is too small for an induction. Pregnant
women have a nearly 50% increase in their blood volume. In a healthy pregnant
woman there is generally no problem inserting an 18 gauge IV catheter. The 1 or 3
mL syringe is used to draw up the oxytocin for the infusion.
Six hours after an oxytocin induction was begun and 2 hours after spontaneous
rupture of the membranes, the nurse notes several sudden decreases in the fetal
heart rate with quick return to baseline, with and without contractions. Based on
this fetal heart rate pattern, which intervention is best for the nurse to implement?
A. Increase the IV fluids.
B. Begin oxygen by nasal cannula at 2 L/min.
C. Place the client in a slight Trendelenburg position.
