HESI MATERNITY EXAM 2024 ACTUAL EXAM COMPLETE 100 QUESTIONS WITH
DETAILED VERIFIED ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED
A+
Which piece of equipment does the nurse use to assess the fetal heartbeat? Electronic Doppler
answersA pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and
fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis.
The nurse, providing instructions to the mother regarding therapeutic management of the disease,
tells the mother that: The mother may need to take isoniazid (INH), pyrazinamide, and rifampin
(Rifadin) for a total of 9 months
answersA nurse assists a pregnant client who is in the second trimester into lithotomy position
on the examining table in the obstetrician's office. The client suddenly becomes dizzy,
lightheaded, nauseated, and pale. The nurse immediately: Positions the client on her side
answersA nurse is monitoring a client who was given an epidural opioid for a cesarean birth.
The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first:
Instructs the client to take several deep breaths
answersA nurse is performing an assessment of a pregnant woman to determine whether labor
has begun. For which sign of true labor does the nurse assess the client? Contractions that
begin in the lower abdomen and back and radiate over the entire abdomen
answersPlacental abruption is suspected in a client who is experiencing vaginal bleeding. On
assessment, which of the following findings would the nurse expect to note? Uterine tender
to palpation
answersA clinic nurse is performing an assessment of an HIV-positive pregnant woman during
the 32nd week of gestation. Which finding requires further follow-up? Increased shortness of
breath and bilateral crackles in the lungs
answersA nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes
that the labia are edematous and darker than the surrounding skin and that a white mucous
vaginal discharge is present. On the basis of these findings, the nurse determines that the
appropriate action is: Documenting the findings (normal findings)
answersA nurse assessing a pregnant woman in labor notes the presence of early decelerations
on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of
this observation? Pressure on the fetal head during a contraction
, answersA rubella antibody screen is performed in a pregnant client, and the results indicate that
the client is not immune to rubella. The nurse tells the client that: A rubella vaccine must be
administered after childbirth
answersA nurse is told that a newborn with myelomeningocele will be admitted to the newborn
nursery. In which position does the nurse plan to place the infant? Prone (to prevent pressure on
the sac until surgical repair can be performed)
answersNormal respiratory rate for a newborn infant 30 to 60 breaths/min
answersA nurse is caring for a client experiencing a partial placental abruption. The client is
uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse
analyzes the client's behavior as most likely the result of: Anxiety and the need for support
answersA client in the third trimester of pregnancy is complaining of urinary frequency, and the
nurse instructs the client in measures to alleviate the discomfort. Which statement by the client
indicates an understanding of these self-care measures? "I need to drink at least 2000 mL of
fluid a day."
answersA pregnant woman at 38 weeks' gestation arrives at the emergency department,
reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the
nurse determines that the client may be experiencing: Placenta previa
answersA nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse
takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing
action would be to: Encourage the intake of oral fluids
answersA nurse is assessing the uterine fundus of a client who has just delivered a baby and
notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots
from the uterus. To prevent uterine inversion during this procedure, the nurse:
Simultaneously provides pressure over the lower uterine segment
answersA nurse assists the primary healthcare provider in performing an amniotomy on a client
in labor. In which order should the nurse perform the following actions after the amniotomy?
1. Determining the fetal heart rate
2. Noting the quantity, color, and odor of the amniotic fluid
3. Taking the client's temperature, pulse, and blood pressure
4. Replacing soiled underpads from beneath the client's buttocks
5. Planning evaluation of the client for signs and symptoms of infection
, answersA nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia
(CDH). Which assessment finding would the nurse specifically expect to note in the newborn?
Bowel sounds heard over the chest
answersA nurse is assessing a woman in labor and notes the presence of accelerations on the
fetal monitor tracing. Which of the following actions should the nurse perform in response to this
observation? Documenting the finding
answersA nurse teaching a pregnant client about the expectations and complications of
pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions:
Are a common occurrence of pregnancy
answersRho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before
administering the medication, the nurse reviews the client's history. Which of the following
findings is a contraindication to administration of the medication? A previous hypersensitivity
reaction to immune globulin
-Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal
blood cells in any way
answersA pregnant woman reports that she has just finished taking the prescribed antibiotics to
treat her urinary tract infection but expresses concern that her baby will be born with an
infection. Which response should the nurse make to help ease these fears? "Now that you have
taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine
culture before you leave today."
answersA delivery room nurse performing an initial assessment on a newborn notes that the ears
are low set. In light of this finding, which nursing action is appropriate initially? Notifying the
physician
answersA nurse is monitoring a pregnant client with placental abruption. Which pattern on the
fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? Normal FHR
answersA nurse is performing an assessment of a female client with suspected mittelschmerz.
Which question does the nurse ask the client to elicit data specific to this disorder? "Do
you have sharp pain on the right or left side of your pelvis?"
-Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual
periods or at the time of ovulation. The pain, which is fairly sharp, is felt on the right or left side
of the pelvis.
answersA nurse is reviewing the criteria for early discharge of a newborn infant. Which of the
following, if noted in the infant, would indicate that the criteria for early discharge have been
met? The infant has urinated.
The infant has passed 1 stool.
, Vital signs are documented as normal.
The infant has completed one successful feeding.
answersA nurse is monitoring a pregnant client with sepsis for signs of disseminated
intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to
suspect DIC? Increased fibrin degradation products
-DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread
bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets
are decreased because they are consumed by the process; coagulation studies show no clot
formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature
diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and
activated partial thromboplastin times are prolonged, and fibrin degradation products are
increased.
answersA nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to
stimulate labor. Which of the following findings would prompt the nurse to stop the infusion?
Nonreassuring fetal heart rate pattern
answersA nurse is conducting a home visit with a mother and her 1-week-old infant, who is at
risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the
nurse look for while assessing the infant? A copper-colored rash
answersA client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the
administration of: Calcium gluconate
answersA nurse provides instructions to a breastfeeding mother who is experiencing breast
engorgement about measures for treating the problem. The nurse tells the mother to: Gently
massage the breasts during breastfeeding to help empty the breasts
answersA woman being seen in the prenatal clinic and complains of morning sickness that
continues throughout the day. What does the nurse tell the client to do to overcome this
discomfort? Eat dry crackers every 2 hours to prevent an empty stomach
answersA nurse performing an assessment of a pregnant client is preparing to take the client's
blood pressure. The nurse positions the client: In a sitting position with the arm in a
horizontal position at heart level
answersA nurse is monitoring a client in labor for signs of intrauterine infection. Which sign,
indicative of infection, would prompt the nurse to contact the healthcare provider? Strong-
smelling amniotic fluid
DETAILED VERIFIED ANSWERS (100% CORRECT ANSWERS) /ALREADY GRADED
A+
Which piece of equipment does the nurse use to assess the fetal heartbeat? Electronic Doppler
answersA pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and
fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis.
The nurse, providing instructions to the mother regarding therapeutic management of the disease,
tells the mother that: The mother may need to take isoniazid (INH), pyrazinamide, and rifampin
(Rifadin) for a total of 9 months
answersA nurse assists a pregnant client who is in the second trimester into lithotomy position
on the examining table in the obstetrician's office. The client suddenly becomes dizzy,
lightheaded, nauseated, and pale. The nurse immediately: Positions the client on her side
answersA nurse is monitoring a client who was given an epidural opioid for a cesarean birth.
The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse first:
Instructs the client to take several deep breaths
answersA nurse is performing an assessment of a pregnant woman to determine whether labor
has begun. For which sign of true labor does the nurse assess the client? Contractions that
begin in the lower abdomen and back and radiate over the entire abdomen
answersPlacental abruption is suspected in a client who is experiencing vaginal bleeding. On
assessment, which of the following findings would the nurse expect to note? Uterine tender
to palpation
answersA clinic nurse is performing an assessment of an HIV-positive pregnant woman during
the 32nd week of gestation. Which finding requires further follow-up? Increased shortness of
breath and bilateral crackles in the lungs
answersA nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes
that the labia are edematous and darker than the surrounding skin and that a white mucous
vaginal discharge is present. On the basis of these findings, the nurse determines that the
appropriate action is: Documenting the findings (normal findings)
answersA nurse assessing a pregnant woman in labor notes the presence of early decelerations
on the fetal monitor tracing. Which of the following situations would the nurse suspect in light of
this observation? Pressure on the fetal head during a contraction
, answersA rubella antibody screen is performed in a pregnant client, and the results indicate that
the client is not immune to rubella. The nurse tells the client that: A rubella vaccine must be
administered after childbirth
answersA nurse is told that a newborn with myelomeningocele will be admitted to the newborn
nursery. In which position does the nurse plan to place the infant? Prone (to prevent pressure on
the sac until surgical repair can be performed)
answersNormal respiratory rate for a newborn infant 30 to 60 breaths/min
answersA nurse is caring for a client experiencing a partial placental abruption. The client is
uncooperative, refusing any interventions until her husband arrives at the hospital. The nurse
analyzes the client's behavior as most likely the result of: Anxiety and the need for support
answersA client in the third trimester of pregnancy is complaining of urinary frequency, and the
nurse instructs the client in measures to alleviate the discomfort. Which statement by the client
indicates an understanding of these self-care measures? "I need to drink at least 2000 mL of
fluid a day."
answersA pregnant woman at 38 weeks' gestation arrives at the emergency department,
reporting bright-red vaginal bleeding but denying pain. On the basis of this information, the
nurse determines that the client may be experiencing: Placenta previa
answersA nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse
takes the client's temperature and notes that it is 38° C (100.4° F). The most appropriate nursing
action would be to: Encourage the intake of oral fluids
answersA nurse is assessing the uterine fundus of a client who has just delivered a baby and
notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel clots
from the uterus. To prevent uterine inversion during this procedure, the nurse:
Simultaneously provides pressure over the lower uterine segment
answersA nurse assists the primary healthcare provider in performing an amniotomy on a client
in labor. In which order should the nurse perform the following actions after the amniotomy?
1. Determining the fetal heart rate
2. Noting the quantity, color, and odor of the amniotic fluid
3. Taking the client's temperature, pulse, and blood pressure
4. Replacing soiled underpads from beneath the client's buttocks
5. Planning evaluation of the client for signs and symptoms of infection
, answersA nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia
(CDH). Which assessment finding would the nurse specifically expect to note in the newborn?
Bowel sounds heard over the chest
answersA nurse is assessing a woman in labor and notes the presence of accelerations on the
fetal monitor tracing. Which of the following actions should the nurse perform in response to this
observation? Documenting the finding
answersA nurse teaching a pregnant client about the expectations and complications of
pregnancy is describing Braxton Hicks contractions. The nurse tells the client these contractions:
Are a common occurrence of pregnancy
answersRho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before
administering the medication, the nurse reviews the client's history. Which of the following
findings is a contraindication to administration of the medication? A previous hypersensitivity
reaction to immune globulin
-Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-positive fetal
blood cells in any way
answersA pregnant woman reports that she has just finished taking the prescribed antibiotics to
treat her urinary tract infection but expresses concern that her baby will be born with an
infection. Which response should the nurse make to help ease these fears? "Now that you have
taken the medication as prescribed, we'll keep monitoring you closely and repeat the urine
culture before you leave today."
answersA delivery room nurse performing an initial assessment on a newborn notes that the ears
are low set. In light of this finding, which nursing action is appropriate initially? Notifying the
physician
answersA nurse is monitoring a pregnant client with placental abruption. Which pattern on the
fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? Normal FHR
answersA nurse is performing an assessment of a female client with suspected mittelschmerz.
Which question does the nurse ask the client to elicit data specific to this disorder? "Do
you have sharp pain on the right or left side of your pelvis?"
-Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between menstrual
periods or at the time of ovulation. The pain, which is fairly sharp, is felt on the right or left side
of the pelvis.
answersA nurse is reviewing the criteria for early discharge of a newborn infant. Which of the
following, if noted in the infant, would indicate that the criteria for early discharge have been
met? The infant has urinated.
The infant has passed 1 stool.
, Vital signs are documented as normal.
The infant has completed one successful feeding.
answersA nurse is monitoring a pregnant client with sepsis for signs of disseminated
intravascular coagulopathy (DIC). Which of the following laboratory findings causes the nurse to
suspect DIC? Increased fibrin degradation products
-DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread
bleeding. Petechiae, oozing from injection sites, and hematuria are indicative of DIC. Platelets
are decreased because they are consumed by the process; coagulation studies show no clot
formation (and therefore prolonged times); and fibrin plugs may clog the microvasculature
diffusely rather than in an isolated area. Fibrinogen and platelets are decreased, prothrombin and
activated partial thromboplastin times are prolonged, and fibrin degradation products are
increased.
answersA nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to
stimulate labor. Which of the following findings would prompt the nurse to stop the infusion?
Nonreassuring fetal heart rate pattern
answersA nurse is conducting a home visit with a mother and her 1-week-old infant, who is at
risk for acquired neonatal congenital syphilis. Which finding specific to this disease does the
nurse look for while assessing the infant? A copper-colored rash
answersA client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the
administration of: Calcium gluconate
answersA nurse provides instructions to a breastfeeding mother who is experiencing breast
engorgement about measures for treating the problem. The nurse tells the mother to: Gently
massage the breasts during breastfeeding to help empty the breasts
answersA woman being seen in the prenatal clinic and complains of morning sickness that
continues throughout the day. What does the nurse tell the client to do to overcome this
discomfort? Eat dry crackers every 2 hours to prevent an empty stomach
answersA nurse performing an assessment of a pregnant client is preparing to take the client's
blood pressure. The nurse positions the client: In a sitting position with the arm in a
horizontal position at heart level
answersA nurse is monitoring a client in labor for signs of intrauterine infection. Which sign,
indicative of infection, would prompt the nurse to contact the healthcare provider? Strong-
smelling amniotic fluid
