HESI-FOCUS ON MATERNITY EXAM
QUESTIONS AND ANSWERS
a 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 -
ANSWER-contractions that begin in the lower abdomen and back and radiate over
the entire abdomen
a nurse is preparing to assess the FHR in a pregnant woman who is at gestational
week 12. Which piece of equipment does the nurse use to assess the FHR -
ANSWER-electronic dopple
a pregnant client is positive for HIV. The client asks the nurse whether her newborn
will contract the virus. The appropriate response is - ANSWER-the newborn does
have a risk of contraction the infection
A delivery room nurse performing an initial assessment on a newborn notes that the
ears are low set. Based on this finding, which nursing action is appropriate initially -
ANSWER-notifying the HCP
a nurse is reviewing the medical record of a pregnant client with sickle cell anemia.
To which information related by the client would the nurse give the highest priority -
ANSWER-drinking less than 4 glasses of fluid daily
A nurse is caring for a client receiving an IV infusion of oxytocin to stimulate labor.
Which finding would prompt the nurse to stop the infusion - ANSWER-nonreassuring
FHR patter
A nurse is assessing a woman in labor and notes the presence of accelerations on
the fetal monitor tracing. Which action should the nurse perform in response to this
observation - ANSWER-document the finding
a nurse assessing a pregnant woman in labor notes the presence of early
decelerations on the fetal monitor tracing. Which situation wold the nurse suspect
based on this observation - ANSWER-pressure on the fetal head during a
contraction
a nurse caring for a client in the active stage of labor assesses the fetal status and
notes a late deceleration on the monitor strip. Based on this finding, which nursing
action is the priority - ANSWER-administering oxygen by way of face mask
placental abruption is suspected in a client who is experiencing vaginal bleeding. On
assessment, which finding would the nurse expect to note - ANSWER-uterine tender
to palpitation
a PP nurse instructs a new mother in how to bathe her newborn. Which statement by
the mother indicates a need for further instruction - ANSWER-I should bathe him
after a feeding
, a nurse is monitoring a pregnant client with sepsis for DIC. Which lab finding causes
the nurse to suspect DIC - ANSWER-increased fibrin degradation products
a nurse caring for a hospitalized client with a dx of abruptio placentae and develops
a nursing care plan incorporating interventions to be implemented in the event of
shock. If signs of shock develop, to promote tissue oxygenation, the nurse would
immediately - ANSWER-turn the client on her side
a multigravida asks a nurse when she will be able to start feeling the fetus move.
The nurse responds by telling the mother that fetal movements will be noted as early
as - ANSWER-14-16 weeks gestation
A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result
of 155 mg/dL (8.6 mmol/L). The nurse tells the client that: - ANSWER-additional
tests will likely be performed to confirm gestational diabetes
A Hepatitis B screen is performed on a pregnant client, and the results indicate the
presence of antigens in the maternal blood. The nurse tells the client that -
ANSWER-the infant should receive both the vaccine and hepatitis immune globulin
soon after birth
a client in the first trimester of pregnancy arrives at the clinic and reports that she
has been experiencing vaginal bleeding. Threatened abortion is suspected and the
nurse provides instructions to the client regarding care. Which statement by the
client indicates the need for further instruction - ANSWER-I need to stay in bed for
the rest of my pregnancy
a 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 - ANSWER-document the findings
a 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 -
ANSWER-prone
a 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 - ANSWER-do you have sharp pain on the right or left side of your
pelvis
a nurse is conducting a home visit with a mother and her 1 week old infant, who is at
risk for acquired neonatal congenital syphillis. Which finding specific to this disease
does the nurse look for while assessing the infant - ANSWER-a copper colored rash
a nurse provides instructions regarding prenatal care to a client with a hx of heart
disease. The nurse tells the client that - ANSWER-physical activity should be limited
QUESTIONS AND ANSWERS
a 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 -
ANSWER-contractions that begin in the lower abdomen and back and radiate over
the entire abdomen
a nurse is preparing to assess the FHR in a pregnant woman who is at gestational
week 12. Which piece of equipment does the nurse use to assess the FHR -
ANSWER-electronic dopple
a pregnant client is positive for HIV. The client asks the nurse whether her newborn
will contract the virus. The appropriate response is - ANSWER-the newborn does
have a risk of contraction the infection
A delivery room nurse performing an initial assessment on a newborn notes that the
ears are low set. Based on this finding, which nursing action is appropriate initially -
ANSWER-notifying the HCP
a nurse is reviewing the medical record of a pregnant client with sickle cell anemia.
To which information related by the client would the nurse give the highest priority -
ANSWER-drinking less than 4 glasses of fluid daily
A nurse is caring for a client receiving an IV infusion of oxytocin to stimulate labor.
Which finding would prompt the nurse to stop the infusion - ANSWER-nonreassuring
FHR patter
A nurse is assessing a woman in labor and notes the presence of accelerations on
the fetal monitor tracing. Which action should the nurse perform in response to this
observation - ANSWER-document the finding
a nurse assessing a pregnant woman in labor notes the presence of early
decelerations on the fetal monitor tracing. Which situation wold the nurse suspect
based on this observation - ANSWER-pressure on the fetal head during a
contraction
a nurse caring for a client in the active stage of labor assesses the fetal status and
notes a late deceleration on the monitor strip. Based on this finding, which nursing
action is the priority - ANSWER-administering oxygen by way of face mask
placental abruption is suspected in a client who is experiencing vaginal bleeding. On
assessment, which finding would the nurse expect to note - ANSWER-uterine tender
to palpitation
a PP nurse instructs a new mother in how to bathe her newborn. Which statement by
the mother indicates a need for further instruction - ANSWER-I should bathe him
after a feeding
, a nurse is monitoring a pregnant client with sepsis for DIC. Which lab finding causes
the nurse to suspect DIC - ANSWER-increased fibrin degradation products
a nurse caring for a hospitalized client with a dx of abruptio placentae and develops
a nursing care plan incorporating interventions to be implemented in the event of
shock. If signs of shock develop, to promote tissue oxygenation, the nurse would
immediately - ANSWER-turn the client on her side
a multigravida asks a nurse when she will be able to start feeling the fetus move.
The nurse responds by telling the mother that fetal movements will be noted as early
as - ANSWER-14-16 weeks gestation
A 1-hour oral glucose tolerance test is performed on a pregnant client, with a result
of 155 mg/dL (8.6 mmol/L). The nurse tells the client that: - ANSWER-additional
tests will likely be performed to confirm gestational diabetes
A Hepatitis B screen is performed on a pregnant client, and the results indicate the
presence of antigens in the maternal blood. The nurse tells the client that -
ANSWER-the infant should receive both the vaccine and hepatitis immune globulin
soon after birth
a client in the first trimester of pregnancy arrives at the clinic and reports that she
has been experiencing vaginal bleeding. Threatened abortion is suspected and the
nurse provides instructions to the client regarding care. Which statement by the
client indicates the need for further instruction - ANSWER-I need to stay in bed for
the rest of my pregnancy
a 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 - ANSWER-document the findings
a 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 -
ANSWER-prone
a 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 - ANSWER-do you have sharp pain on the right or left side of your
pelvis
a nurse is conducting a home visit with a mother and her 1 week old infant, who is at
risk for acquired neonatal congenital syphillis. Which finding specific to this disease
does the nurse look for while assessing the infant - ANSWER-a copper colored rash
a nurse provides instructions regarding prenatal care to a client with a hx of heart
disease. The nurse tells the client that - ANSWER-physical activity should be limited
