HESI REVIEW TEST-MATERNITY,
EVOLVE OBSTETRICS-MATERNITY
PRACTICE EXAM, HESI MATERNITY
QUESTIONS WITH CORRECT
ANSWERS
In developing a teaching plan for expectant parents, the nurse plans to include
information about when the parents can expect the infant's fontanels to close. The
nurse bases the explanation on knowledge that for the normal newborn, the -
ANSWER-anterior fontanel closes at 12 to 18 months and the posterior 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 by the end of the second month (D).
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-Admission weight of 4
pounds, 15 ounces (2244 grams).
Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved? -
ANSWER-A decrease in respiratory rate from 24 to 16.
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12
indicates toxic effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.) - ANSWER-A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?" - ANSWER-Lying prone with a pillow on the abdomen.
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin)
to augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions? - ANSWER-Transition labor with contractions every 2
minutes, lasting 90 seconds each.
,At 14-weeks gestation, a client arrives at the Emergency Center complaining of a
dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood
sample and initiates an IV. Thirty minutes after admission, the client reports feeling a
sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis,
a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should
the nurse implement next? - ANSWER-Increase IV rate. The client is demonstrating
symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at
approximately 14-weeks gestation when embryonic growth expands the fallopian
tube causing its rupture, and can result in hemorrage and hypovolemic shock.
Increasing the IV infusion rate (C) provides intravascular fluid to maintain blood
pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and tender
upon palpation. What action should the nurse take? - ANSWER-Apply cold
compresses to both breasts for comfort. The client is experiencing engorgement
even though she is bottle-feeding her infant, and cold compresses (A) may help
reduce discomfort. Lactation begins about the third day after delivery, so the mother
should avoid any breast stimulation,
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 sign occurs, the mother
should notify the clinic/healthcare provider and reduce her activity to conserve
energy (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 ballottable (D), 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 total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on
this finding, which intervention should the nurse implement? - ANSWER-Encourage
the mother to breastfeed frequently. The normal total bilirubin level is 6 to 12 mg/dl
after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be
monitored to prevent further complications. Breast milk provides calories and
enhances GI motility, which will assist the bowel in eliminating bilirubin (C)
A client receiving epidural anesthesia begins to experience nausea and becomes
pale and clammy. What intervention should the nurse implement first? - ANSWER-
Raise the foot of the bed. These symptoms are suggestive of hypotension which is a
side effect of epidural anesthesia. Raising the foot of the bed (A) will increase
venous return and provide blood to the vital areas. Increasing the IV fluid rate using
,a balanced non-dextrose solution and ensuring that the client is in a lateral position
are also appropriate interventions.
Immediately after birth a newborn infant is suctioned, dried, and placed under a
radiant warmer. The infant has spontaneous respirations and the nurse assesses an
apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What
action should the nurse perform next? - ANSWER-Initiate positive pressure
ventilation. The nurse should immediately begin positive pressure ventilation (A)
because this infant's vital signs are not within the normal range, and oxygen
deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100
to 160 beats/minute and respirations are 40 to 60 breaths/minute.) Waiting until the
infant is 1 minute old to intervene may worsen the infant's condition. According to
neonatal resuscitation guidelines, CPR is not begun until the heart rate is 60 or
below or between 60 and 80 and not increasing after 20 to 30 seconds of PPV.
The nurse instructs a laboring client to use accelerated-blow breathing. The client
begins to complain of tingling fingers and dizziness. What action should the nurse
take? - ANSWER-Have the client breathe into her cupped hands. 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 (C)
The nurse is counseling a woman who wants to become pregnant. The woman tells
the nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. The nurse correctly calculates that the woman's
next fertile period is - ANSWER-January 30-31
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60. What action should the nurse
take? - ANSWER-Place the woman in a lateral position. The nurse should
immediately turn the woman to a lateral position (C), place a pillow or wedge under
the right hip to deflect the uterus, increase the rate of the main line IV infusion, and
administer oxygen by face mask at 10-12 L/min.
Which maternal behavior is the nurse most likely to see when a new mother receives
her infant for the first time? - ANSWER-Her arms and hands receive the infant and
she then traces the infant's profile with her fingertips.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor.
Before initiating this prescription, it is most important for the nurse to assess the
client for which condition? - ANSWER-The nurse should evaluate the client for
gestational diabetes (A) because terbutaline (Brethine) increases blood glucose
levels.
A client in active labor is admitted with preeclampsia. Which assessment finding is
most significant in planning this client's care? - ANSWER-Patellar reflex 4+
A 4+ reflex in a client with pregnancy-induced hypertension (A) indicates
hyperreflexia, which is an indication of an impending seizure.
, A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding indicates to the nurse that the drug is
effective? - ANSWER-Changes in apical heart rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
resulting in an increase in RBCs. Since the body has not had to compensate for
anemia with an increased heart rate, changes in heart rate from high to normal (C) is
one indicator that Epogen is effective.
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral
hypoglycemic agents are discontinued. Which intervention is most important for the
nurse to implement? - ANSWER-Describe diet changes that can improve the
management of her diabetes.
Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy,
and describing the necessary diet changes is the most important intervention for the
nurse to implement with this client.
28 year old client in active labor complains of cramps in her leg.What intervention
should the nurse implement.
A. massage the calf and foot
B. extend the leg and dorsiflex the foot
C. lower the leg off the side of the bed
D. elevate the leg above the heart. - ANSWER-B. Extend the leg and dorsiflex the
foot.
The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling finger and dizziness. What action should the nurse
take?
a. administer o2 by face mask
b. notify the HCP for the client's syndrome
c. have the client breathe into her cupped hands
d. check the client's BP and fetal HR/ - ANSWER-c. have the client breathe into her
cupped hands.
When assessing a client who is at 12 week gestation, the nurse recommends that
she and her husband consider attending childbirth preparation classes. When is the
best time for the couple to attend these classes?
A. at 16 weeks gestation
B.at 20 weeks gestation
C. at 24 weeks gestation
D. at 30 weeks gestation - ANSWER-D. At 30 weeks gestation.
In developing a teaching plan for expectant parents the nurse plans to include
formation about when the parents can expect the infants fontanels to close. The
nurse bases the explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first
week.
B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the
second week.
C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first
month.
EVOLVE OBSTETRICS-MATERNITY
PRACTICE EXAM, HESI MATERNITY
QUESTIONS WITH CORRECT
ANSWERS
In developing a teaching plan for expectant parents, the nurse plans to include
information about when the parents can expect the infant's fontanels to close. The
nurse bases the explanation on knowledge that for the normal newborn, the -
ANSWER-anterior fontanel closes at 12 to 18 months and the posterior 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 by the end of the second month (D).
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-Admission weight of 4
pounds, 15 ounces (2244 grams).
Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved? -
ANSWER-A decrease in respiratory rate from 24 to 16.
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12
indicates toxic effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.) - ANSWER-A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?" - ANSWER-Lying prone with a pillow on the abdomen.
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin)
to augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions? - ANSWER-Transition labor with contractions every 2
minutes, lasting 90 seconds each.
,At 14-weeks gestation, a client arrives at the Emergency Center complaining of a
dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood
sample and initiates an IV. Thirty minutes after admission, the client reports feeling a
sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis,
a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should
the nurse implement next? - ANSWER-Increase IV rate. The client is demonstrating
symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at
approximately 14-weeks gestation when embryonic growth expands the fallopian
tube causing its rupture, and can result in hemorrage and hypovolemic shock.
Increasing the IV infusion rate (C) provides intravascular fluid to maintain blood
pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and tender
upon palpation. What action should the nurse take? - ANSWER-Apply cold
compresses to both breasts for comfort. The client is experiencing engorgement
even though she is bottle-feeding her infant, and cold compresses (A) may help
reduce discomfort. Lactation begins about the third day after delivery, so the mother
should avoid any breast stimulation,
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 sign occurs, the mother
should notify the clinic/healthcare provider and reduce her activity to conserve
energy (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 ballottable (D), 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 total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based on
this finding, which intervention should the nurse implement? - ANSWER-Encourage
the mother to breastfeed frequently. The normal total bilirubin level is 6 to 12 mg/dl
after Day 1 of life. This infant's bilirubin is beginning to climb and the infant should be
monitored to prevent further complications. Breast milk provides calories and
enhances GI motility, which will assist the bowel in eliminating bilirubin (C)
A client receiving epidural anesthesia begins to experience nausea and becomes
pale and clammy. What intervention should the nurse implement first? - ANSWER-
Raise the foot of the bed. These symptoms are suggestive of hypotension which is a
side effect of epidural anesthesia. Raising the foot of the bed (A) will increase
venous return and provide blood to the vital areas. Increasing the IV fluid rate using
,a balanced non-dextrose solution and ensuring that the client is in a lateral position
are also appropriate interventions.
Immediately after birth a newborn infant is suctioned, dried, and placed under a
radiant warmer. The infant has spontaneous respirations and the nurse assesses an
apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What
action should the nurse perform next? - ANSWER-Initiate positive pressure
ventilation. The nurse should immediately begin positive pressure ventilation (A)
because this infant's vital signs are not within the normal range, and oxygen
deprivation leads to cardiac depression in infants. (The normal newborn pulse is 100
to 160 beats/minute and respirations are 40 to 60 breaths/minute.) Waiting until the
infant is 1 minute old to intervene may worsen the infant's condition. According to
neonatal resuscitation guidelines, CPR is not begun until the heart rate is 60 or
below or between 60 and 80 and not increasing after 20 to 30 seconds of PPV.
The nurse instructs a laboring client to use accelerated-blow breathing. The client
begins to complain of tingling fingers and dizziness. What action should the nurse
take? - ANSWER-Have the client breathe into her cupped hands. 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 (C)
The nurse is counseling a woman who wants to become pregnant. The woman tells
the nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. The nurse correctly calculates that the woman's
next fertile period is - ANSWER-January 30-31
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60. What action should the nurse
take? - ANSWER-Place the woman in a lateral position. The nurse should
immediately turn the woman to a lateral position (C), place a pillow or wedge under
the right hip to deflect the uterus, increase the rate of the main line IV infusion, and
administer oxygen by face mask at 10-12 L/min.
Which maternal behavior is the nurse most likely to see when a new mother receives
her infant for the first time? - ANSWER-Her arms and hands receive the infant and
she then traces the infant's profile with her fingertips.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor.
Before initiating this prescription, it is most important for the nurse to assess the
client for which condition? - ANSWER-The nurse should evaluate the client for
gestational diabetes (A) because terbutaline (Brethine) increases blood glucose
levels.
A client in active labor is admitted with preeclampsia. Which assessment finding is
most significant in planning this client's care? - ANSWER-Patellar reflex 4+
A 4+ reflex in a client with pregnancy-induced hypertension (A) indicates
hyperreflexia, which is an indication of an impending seizure.
, A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding indicates to the nurse that the drug is
effective? - ANSWER-Changes in apical heart rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production,
resulting in an increase in RBCs. Since the body has not had to compensate for
anemia with an increased heart rate, changes in heart rate from high to normal (C) is
one indicator that Epogen is effective.
A woman with Type 2 diabetes mellitus becomes pregnant, and her oral
hypoglycemic agents are discontinued. Which intervention is most important for the
nurse to implement? - ANSWER-Describe diet changes that can improve the
management of her diabetes.
Diet modifications (A) are effective in managing Type 2 diabetes during pregnancy,
and describing the necessary diet changes is the most important intervention for the
nurse to implement with this client.
28 year old client in active labor complains of cramps in her leg.What intervention
should the nurse implement.
A. massage the calf and foot
B. extend the leg and dorsiflex the foot
C. lower the leg off the side of the bed
D. elevate the leg above the heart. - ANSWER-B. Extend the leg and dorsiflex the
foot.
The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling finger and dizziness. What action should the nurse
take?
a. administer o2 by face mask
b. notify the HCP for the client's syndrome
c. have the client breathe into her cupped hands
d. check the client's BP and fetal HR/ - ANSWER-c. have the client breathe into her
cupped hands.
When assessing a client who is at 12 week gestation, the nurse recommends that
she and her husband consider attending childbirth preparation classes. When is the
best time for the couple to attend these classes?
A. at 16 weeks gestation
B.at 20 weeks gestation
C. at 24 weeks gestation
D. at 30 weeks gestation - ANSWER-D. At 30 weeks gestation.
In developing a teaching plan for expectant parents the nurse plans to include
formation about when the parents can expect the infants fontanels to close. The
nurse bases the explanation on knowledge that for the normal newborn, the
A. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first
week.
B. anterior fontanel closes at 5 to 7 months and the posterior by the end of the
second week.
C. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first
month.
