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2023 OB Maternity HESI EXIT VERSION 1 TEST BANK
ACTUAL EXAM WITH ALL UPDATED QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) WITH
RATIONALES (ALREADY GRADED A+)
The nurse is preparing to give an enema to a laboring client.
Which client requires the most caution when carrying out this
procedure? - ANSWER-A 40-week primigravida who is at 6 cm
cervical dilatation and the presenting part is not engaged.
When the presenting part is ballotable, it is floating out of the
pelvis. In such a situation, the cord can descend before the
fetus causing a prolapsed cord, which is an emergency
situation.
The nurse is providing discharge teaching for a client who is 24
hours postpartum. The nurse explains to the client that her
vaginal discharge will change from red to pink and then to white.
The client asks, "What if I start having red bleeding AFTER it
changes?" What should the nurse instruct the client to do? -
ANSWER-Reduce activity level and notify the healthcare provider.
Lochia should progress in stages from rubra (red) to serosa
(pinkish) to alba (whitish), and not return to red. The return to
rubra usually indicates subinvolution or infection. If such a
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sign occurs, the mother should notify the clinic/healthcare
provider and reduce her activity to conserve energy
One hour after giving birth to an 8-pound infant, a client's lochia
rubra has increased from small to large and her fundus is boggy
despite massage. The client's pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes
Methergine 0.2 mg IM × 1. What action should the nurse take
immediately? - ANSWER-Contact the healthcare provider and
question the prescription
Methergine is contraindicated for clients with elevated blood
pressure, so the nurse should contact the healthcare
provider and question the prescription
A client at 32-weeks' gestation is diagnosed with preeclampsia.
Which assessment finding is most indicative of an impending
convulsion? - ANSWER-3+ deep tendon reflexes and hyper
clonus
A client at 32-weeks' gestation comes to the prenatal clinic with
complaints of pedal edema, dyspnea, fatigue, and a moist cough.
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Which question is most important for the nurse to ask this client? -
ANSWER-Do you have a history of rheumatic fever?
Clients with a history of rheumatic fever may develop mitral
valve prolapse, which increases the risk for cardiac
decompensation due to the increased blood volume that
occurs during pregnancy, so obtaining information about
this client's health history is a priority.
After each feeding, a 3-day-old newborn is spitting up large
amounts of Enfamil® Newborn Formula, a nonfat cow's milk
formula. The pediatric healthcare provider changes the neonate's
formula to Similac® Soy Isomil® Formula, a soy protein isolate
based infant formula. What information should the nurse provide
to the mother about the newly prescribed formula? - ANSWER-
Similac® Soy Isomil® Formula is a soy protein-based formula that
contains sucrose
The nurse should explain that the newborn's feeding
intolerance may be related to the lactose found in cow's milk
formula and is being replaced with the soy-based formula
that contains sucrose, which is well-tolerated in infants with
milk allergies and lactose intolerance.
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The nurse is performing a gestational age assessment on a full-
term newborn during the first hour of transition using the Ballard
(Dubowitz) scale. Based on this assessment, the nurse
determines that the neonate has a maturity rating of 40-weeks.
What findings should the nurse identify to determine if the
neonate is small for gestational age (SGA)? (Select all that apply.)
- ANSWER-Frontal occipital circumference of 12.5 inches (31.25
cm) Head to heel length of 17 inches (42.5 cm)Admission weight
of 4 pounds, 15 ounces (2244 grams)
The normal full-term, appropriate for gestational age (AGA)
newborn should fall between the measurement ranges of
weight, 6-9 pounds (2700-4000 grams); length, 19-21 inches
(48-53 cm); FOC, 13-14 inches (33-35 cm). This neonate's
parameters plot below the 10% percentile, which indicate that
the infant is SGA.
The nurse is assessing a client who is having a non-stress test
(NST) at 41-weeks gestation. The nurse determines that the client
is not having contractions, the fetal heart rate (FHR) baseline is
144 bpm, and no FHR accelerations are occurring. What action
2023 OB Maternity HESI EXIT VERSION 1 TEST BANK
ACTUAL EXAM WITH ALL UPDATED QUESTIONS AND
CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) WITH
RATIONALES (ALREADY GRADED A+)
The nurse is preparing to give an enema to a laboring client.
Which client requires the most caution when carrying out this
procedure? - ANSWER-A 40-week primigravida who is at 6 cm
cervical dilatation and the presenting part is not engaged.
When the presenting part is ballotable, it is floating out of the
pelvis. In such a situation, the cord can descend before the
fetus causing a prolapsed cord, which is an emergency
situation.
The nurse is providing discharge teaching for a client who is 24
hours postpartum. The nurse explains to the client that her
vaginal discharge will change from red to pink and then to white.
The client asks, "What if I start having red bleeding AFTER it
changes?" What should the nurse instruct the client to do? -
ANSWER-Reduce activity level and notify the healthcare provider.
Lochia should progress in stages from rubra (red) to serosa
(pinkish) to alba (whitish), and not return to red. The return to
rubra usually indicates subinvolution or infection. If such a
,2|Page
sign occurs, the mother should notify the clinic/healthcare
provider and reduce her activity to conserve energy
One hour after giving birth to an 8-pound infant, a client's lochia
rubra has increased from small to large and her fundus is boggy
despite massage. The client's pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes
Methergine 0.2 mg IM × 1. What action should the nurse take
immediately? - ANSWER-Contact the healthcare provider and
question the prescription
Methergine is contraindicated for clients with elevated blood
pressure, so the nurse should contact the healthcare
provider and question the prescription
A client at 32-weeks' gestation is diagnosed with preeclampsia.
Which assessment finding is most indicative of an impending
convulsion? - ANSWER-3+ deep tendon reflexes and hyper
clonus
A client at 32-weeks' gestation comes to the prenatal clinic with
complaints of pedal edema, dyspnea, fatigue, and a moist cough.
,3|Page
Which question is most important for the nurse to ask this client? -
ANSWER-Do you have a history of rheumatic fever?
Clients with a history of rheumatic fever may develop mitral
valve prolapse, which increases the risk for cardiac
decompensation due to the increased blood volume that
occurs during pregnancy, so obtaining information about
this client's health history is a priority.
After each feeding, a 3-day-old newborn is spitting up large
amounts of Enfamil® Newborn Formula, a nonfat cow's milk
formula. The pediatric healthcare provider changes the neonate's
formula to Similac® Soy Isomil® Formula, a soy protein isolate
based infant formula. What information should the nurse provide
to the mother about the newly prescribed formula? - ANSWER-
Similac® Soy Isomil® Formula is a soy protein-based formula that
contains sucrose
The nurse should explain that the newborn's feeding
intolerance may be related to the lactose found in cow's milk
formula and is being replaced with the soy-based formula
that contains sucrose, which is well-tolerated in infants with
milk allergies and lactose intolerance.
, 4|Page
The nurse is performing a gestational age assessment on a full-
term newborn during the first hour of transition using the Ballard
(Dubowitz) scale. Based on this assessment, the nurse
determines that the neonate has a maturity rating of 40-weeks.
What findings should the nurse identify to determine if the
neonate is small for gestational age (SGA)? (Select all that apply.)
- ANSWER-Frontal occipital circumference of 12.5 inches (31.25
cm) Head to heel length of 17 inches (42.5 cm)Admission weight
of 4 pounds, 15 ounces (2244 grams)
The normal full-term, appropriate for gestational age (AGA)
newborn should fall between the measurement ranges of
weight, 6-9 pounds (2700-4000 grams); length, 19-21 inches
(48-53 cm); FOC, 13-14 inches (33-35 cm). This neonate's
parameters plot below the 10% percentile, which indicate that
the infant is SGA.
The nurse is assessing a client who is having a non-stress test
(NST) at 41-weeks gestation. The nurse determines that the client
is not having contractions, the fetal heart rate (FHR) baseline is
144 bpm, and no FHR accelerations are occurring. What action
