Maternity HESI Test Bank e e e e
EXAMeQUESTIONSeANDeANSWERSe100%eCORRECTeLATESTee
ee
1. Ae38-
weekeprimigravidaewhoeworkseaseaesecretaryeandesitseateaecomputerefore8ehourseeached
ayetellsetheenurseethateherefeetehaveebegunetoeswell.eWhicheinstructione wouldebeemostee
ffectiveeinepreventingepoolingeofebloodeinetheelowereextremities?
Moveeabouteeveryehour
Poolingeofebloodeinetheelowereextremitieseresultsefrometheeenlargedeuteruseexertingep
ressuree one thee pelvice veins.e Movinge aboute everye houre wille straightene oute theepe
lviceveinseandeincreaseevenousereturn.
2. Ae26-year-old,egravidae2,eparae1eclienteiseadmittedetoetheehospitaleate28-
weeksegestationeinepretermelabor.eSheeisegivene3edoseseofeterbutalineesulfatee(Brethine)e0
.25emgesubcutaneouslyetoestopeherelaborecontractions.eTheenurseeplansetoemonitoreforew
hicheprimaryesideeeffecteofeterbutalineesulfate?
Tachycardiaeandeaefeelingeofenervousness
Terbutalineesulfatee(Brethine),eaebeta-sympathomimeticedrug,estimulatesebeta-
adrenergicereceptorseinetheeuterineemuscleetoestopecontractions.eTheebeta-
adrenergiceagonistepropertieseofetheedrugemayecauseetachycardia,eincreasedecardiaceoutp
ut,erestlessness,eheadache,eandeaefeelingeofe"nervousness".
,3. Whate doese ae diaphragmatice herniae lookelike
?eScaphoideabdomeneandeanorexia
4. Aenewemothereiseafraidetoetoucheherebaby'seheadeforefeareofehurtingethee"largeesoftespot."e
Whicheexplanationeshouldetheenurseegiveetoethiseanxiouseclient?
There'se ae strong,e toughe membranee theree toe protecte thee babye soe youe neede note beeafra
idetoewasheorecombehis/herehair.
5. Aeclientewhoeiseattendingeantepartumeclasseseasksetheenurseewhyeherehealthcareep
roviderehaseprescribedeironetablets.eTheenurse'seresponseeisebasedeonewhateknow
ledge?
Iteisedifficultetoeconsumee18emgeofeadditionaleironebyedietealone.
Consumingeenougheiron-
containingefoodsetoefacilitateeadequateefetalestorageeofeironeandetoemeetetheedemandseof
pregnancyeisedifficultesoeironesupplementseareeoftenerecommended.
e
6. Whate ise megaloblastice anemiae causedeby
?efoliceacidedeficiency
7. Aewomanewhoethinksesheecouldebeepregnantecallsehereneighbor,eaenurse,etoeaskewhenes
heecouldeuseeaehomeepregnancyetestetoediagnoseepregnancy.eWhicheresponseeisebest?
Aehomeepregnancyetestecanebeeusederighteaftereyourefirstemissedeperiod.
Homeeurineetestseareebasedeonetheechemicaledetectioneofehumanechorionicegonado
trophin,e whiche beginse toe increasee 6e toe 8e dayse aftere conceptione ande isebestedete
ctedeate2eweeks’gestationeoreimmediatelyeafteretheefirstemissedeperiod.
8. Ae28-year-
oldeclienteineactiveelaborecomplainseofecrampseinehereleg.eWhateinterventioneshouldethee
nurseeimplement?
, Extendetheelegeandedorsiflexetheefoot
Dorsiflexingetheefootebyepushingetheesoleeofetheefooteforwardeorebyestandinge(ifetheeclienteise
capable)eandeputtingetheeheeleofetheefooteonetheeflooreisetheebestemeanseoferelievingelegecr
amps.
9. Aeclienteate30-
weeks’gestation,ecomplainingeofepressureeoveretheepubicearea,eiseadmittedeforeobservatio
n.eSheeisecontractingeirregularlyeandedemonstrateseunderlyingeuterineeirritability.eVaginalee
xaminationerevealsethateherecervixeiseclosed,ethick,eandehigh.eBasedeonetheseedata,ewhichei
nterventioneshouldetheenurseeimplementefirst?
Obtainingeaeurineeanalysiseshouldebeedoneefirstebecauseepretermeclientse witheuterinee
irritabilityeandecontractionseareeoftenesufferingefromeaeurinaryetracteinfection,eandethise
shouldebeeruledeoutefirst.
10. Aeclienteineactiveelaboreiseadmittedewithepreeclampsia.eWhicheassessmentefindingeisemostes
ignificanteineplanningethiseclient'secare?
Ae4+ereflexeineaeclientewithepregnancy-
inducedehypertensione indicatesehyperreflexia,ewhicheiseaneindicationeofeaneimpendin
geseizure.
11. WhateiseEpogenefor?
Changeseaneapicalehearterateefromethee180setoethee140s.
Epogen,egivenetoepreventeoretreateanemia,estimulateseerythropoietineproduction,eresulting
ineaneincreaseeineRBCs.eSinceetheebodyehasenotehadetoecompensateeforeanemiaewitheanei
e
ncreasedehearterate,echangeseinehearterateefromehighetoenormaleiseoneeindicatorethateEpog
eneiseeffective
3
, 12. Theehealthcareeprovidereprescribeseterbutalinee(Brethine)eforeaeclienteinepretermelabor.eB
eforee initiatinge thise prescription,e ite ise moste importante fore thee nursee toe assesse theecli
enteforewhichecondition?
Gestationalediabetes.
Thee nursee shoulde evaluatee thee cliente fore gestationale diabetese becauseeterbutalinee
(Brethine)eincreasesebloodeglucoseelevels.
13. AeclientewitheNOeprenatalecareearriveseatetheelaboreunitescreaming,e"Theebabyeisecoming!"eT
heenurseeperformseaevaginaleexaminationethaterevealsetheecervixeise3ecentimetersedilatede
ande75%eeffaced.eWhateadditionaleinformationeisemosteimportanteforetheenurseetoeobtain?
Dateeofelastenormalemenstrualeperiod.
Evaluatingetheegestationeofetheepregnancyetakesepriority.eIfetheefetuseisepretermeandethe
fetaleheartepatterneisereassuring,etheehealthcareeprovideremayeattemptetoeprolongethe
pregnancyeandeadministerecorticosteroidsetoematureetheelungseofetheefetus.
e
14. Theenurseeassesseseaeclienteadmittedetoetheelaboreandedeliveryeuniteandeobtainsetheefollo
wingedata:edarkeredevaginalebleeding,euteruseslightlyetenseebetweenecontractions,eBPe11
0/68,eFHRe110ebeats/minute,ecervixe1ecmedilatedeandeuneffaced.eBasedeonetheseeassess
mentefindings,ewhateinterventioneshouldetheenurseeimplement?
MonitoringebleedingefromeIVesites
Monitoringebleedingefromeperipheralesiteseisetheepriorityeintervention.eThiseclienteisepres
entingewithesignseofeplacentaleabruption.eDisseminatedeintravascularecoagulatione(DIC)ei
seaecomplicationeofeplacentaleabruptio,echaracterizedebyeabnormalebleeding.
15. Immediatelyeafterebirtheaenewborneinfanteisesuctioned,edried,eandeplacedeundereaeradiante
4
EXAMeQUESTIONSeANDeANSWERSe100%eCORRECTeLATESTee
ee
1. Ae38-
weekeprimigravidaewhoeworkseaseaesecretaryeandesitseateaecomputerefore8ehourseeached
ayetellsetheenurseethateherefeetehaveebegunetoeswell.eWhicheinstructione wouldebeemostee
ffectiveeinepreventingepoolingeofebloodeinetheelowereextremities?
Moveeabouteeveryehour
Poolingeofebloodeinetheelowereextremitieseresultsefrometheeenlargedeuteruseexertingep
ressuree one thee pelvice veins.e Movinge aboute everye houre wille straightene oute theepe
lviceveinseandeincreaseevenousereturn.
2. Ae26-year-old,egravidae2,eparae1eclienteiseadmittedetoetheehospitaleate28-
weeksegestationeinepretermelabor.eSheeisegivene3edoseseofeterbutalineesulfatee(Brethine)e0
.25emgesubcutaneouslyetoestopeherelaborecontractions.eTheenurseeplansetoemonitoreforew
hicheprimaryesideeeffecteofeterbutalineesulfate?
Tachycardiaeandeaefeelingeofenervousness
Terbutalineesulfatee(Brethine),eaebeta-sympathomimeticedrug,estimulatesebeta-
adrenergicereceptorseinetheeuterineemuscleetoestopecontractions.eTheebeta-
adrenergiceagonistepropertieseofetheedrugemayecauseetachycardia,eincreasedecardiaceoutp
ut,erestlessness,eheadache,eandeaefeelingeofe"nervousness".
,3. Whate doese ae diaphragmatice herniae lookelike
?eScaphoideabdomeneandeanorexia
4. Aenewemothereiseafraidetoetoucheherebaby'seheadeforefeareofehurtingethee"largeesoftespot."e
Whicheexplanationeshouldetheenurseegiveetoethiseanxiouseclient?
There'se ae strong,e toughe membranee theree toe protecte thee babye soe youe neede note beeafra
idetoewasheorecombehis/herehair.
5. Aeclientewhoeiseattendingeantepartumeclasseseasksetheenurseewhyeherehealthcareep
roviderehaseprescribedeironetablets.eTheenurse'seresponseeisebasedeonewhateknow
ledge?
Iteisedifficultetoeconsumee18emgeofeadditionaleironebyedietealone.
Consumingeenougheiron-
containingefoodsetoefacilitateeadequateefetalestorageeofeironeandetoemeetetheedemandseof
pregnancyeisedifficultesoeironesupplementseareeoftenerecommended.
e
6. Whate ise megaloblastice anemiae causedeby
?efoliceacidedeficiency
7. Aewomanewhoethinksesheecouldebeepregnantecallsehereneighbor,eaenurse,etoeaskewhenes
heecouldeuseeaehomeepregnancyetestetoediagnoseepregnancy.eWhicheresponseeisebest?
Aehomeepregnancyetestecanebeeusederighteaftereyourefirstemissedeperiod.
Homeeurineetestseareebasedeonetheechemicaledetectioneofehumanechorionicegonado
trophin,e whiche beginse toe increasee 6e toe 8e dayse aftere conceptione ande isebestedete
ctedeate2eweeks’gestationeoreimmediatelyeafteretheefirstemissedeperiod.
8. Ae28-year-
oldeclienteineactiveelaborecomplainseofecrampseinehereleg.eWhateinterventioneshouldethee
nurseeimplement?
, Extendetheelegeandedorsiflexetheefoot
Dorsiflexingetheefootebyepushingetheesoleeofetheefooteforwardeorebyestandinge(ifetheeclienteise
capable)eandeputtingetheeheeleofetheefooteonetheeflooreisetheebestemeanseoferelievingelegecr
amps.
9. Aeclienteate30-
weeks’gestation,ecomplainingeofepressureeoveretheepubicearea,eiseadmittedeforeobservatio
n.eSheeisecontractingeirregularlyeandedemonstrateseunderlyingeuterineeirritability.eVaginalee
xaminationerevealsethateherecervixeiseclosed,ethick,eandehigh.eBasedeonetheseedata,ewhichei
nterventioneshouldetheenurseeimplementefirst?
Obtainingeaeurineeanalysiseshouldebeedoneefirstebecauseepretermeclientse witheuterinee
irritabilityeandecontractionseareeoftenesufferingefromeaeurinaryetracteinfection,eandethise
shouldebeeruledeoutefirst.
10. Aeclienteineactiveelaboreiseadmittedewithepreeclampsia.eWhicheassessmentefindingeisemostes
ignificanteineplanningethiseclient'secare?
Ae4+ereflexeineaeclientewithepregnancy-
inducedehypertensione indicatesehyperreflexia,ewhicheiseaneindicationeofeaneimpendin
geseizure.
11. WhateiseEpogenefor?
Changeseaneapicalehearterateefromethee180setoethee140s.
Epogen,egivenetoepreventeoretreateanemia,estimulateseerythropoietineproduction,eresulting
ineaneincreaseeineRBCs.eSinceetheebodyehasenotehadetoecompensateeforeanemiaewitheanei
e
ncreasedehearterate,echangeseinehearterateefromehighetoenormaleiseoneeindicatorethateEpog
eneiseeffective
3
, 12. Theehealthcareeprovidereprescribeseterbutalinee(Brethine)eforeaeclienteinepretermelabor.eB
eforee initiatinge thise prescription,e ite ise moste importante fore thee nursee toe assesse theecli
enteforewhichecondition?
Gestationalediabetes.
Thee nursee shoulde evaluatee thee cliente fore gestationale diabetese becauseeterbutalinee
(Brethine)eincreasesebloodeglucoseelevels.
13. AeclientewitheNOeprenatalecareearriveseatetheelaboreunitescreaming,e"Theebabyeisecoming!"eT
heenurseeperformseaevaginaleexaminationethaterevealsetheecervixeise3ecentimetersedilatede
ande75%eeffaced.eWhateadditionaleinformationeisemosteimportanteforetheenurseetoeobtain?
Dateeofelastenormalemenstrualeperiod.
Evaluatingetheegestationeofetheepregnancyetakesepriority.eIfetheefetuseisepretermeandethe
fetaleheartepatterneisereassuring,etheehealthcareeprovideremayeattemptetoeprolongethe
pregnancyeandeadministerecorticosteroidsetoematureetheelungseofetheefetus.
e
14. Theenurseeassesseseaeclienteadmittedetoetheelaboreandedeliveryeuniteandeobtainsetheefollo
wingedata:edarkeredevaginalebleeding,euteruseslightlyetenseebetweenecontractions,eBPe11
0/68,eFHRe110ebeats/minute,ecervixe1ecmedilatedeandeuneffaced.eBasedeonetheseeassess
mentefindings,ewhateinterventioneshouldetheenurseeimplement?
MonitoringebleedingefromeIVesites
Monitoringebleedingefromeperipheralesiteseisetheepriorityeintervention.eThiseclienteisepres
entingewithesignseofeplacentaleabruption.eDisseminatedeintravascularecoagulatione(DIC)ei
seaecomplicationeofeplacentaleabruptio,echaracterizedebyeabnormalebleeding.
15. Immediatelyeafterebirtheaenewborneinfanteisesuctioned,edried,eandeplacedeundereaeradiante
4
