RN HESI Maternity
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis
of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to
include in this client's nursing care plan? - ANS-Monitor Blood pressure, pulse, and
respirations q4h.
\A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to
prevent urinary retention. The home health nurse notes that the child has developed
episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is
most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change - ANS-C. Change to latex-free
gloves when handling infant
\A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's
Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many
ml/hour should the nurse program the infusion pump? (Enter numeric value only)
A. 120
B. 70
C. 65
D. 75 - ANS-D. 75
\A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and
bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate
FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action
should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - ANS-B. Notify the healthcare
provider from the client's bedside
\A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a
non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin (
Pitocin ) infusion. Which finding is most important for the nurse to report to the health care
provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - ANS-D. A pattern of late fetal decelerations
\A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test
(NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin) infusion.
Which finding is most important for the nurse to report to the healthcare provider?
A. Spontaneous rupture of membranes.
B. Fetal heart rate accelerations with fetal movement.
C. Absences of uterine contraction of 20 minutes.
,D. A pattern of fetal late decelerations. - ANS-D. A pattern of fetal late decelerations.
\A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she
does not know if she can continue to breastfeed her infant. What instruction is best for the
nurse to provide? - ANS-Apply hot packs just before each feeding.
\A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing
intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises - ANS-D. remove restraints
one at a time to provide ROM exercises
\A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile
vomiting. Which assessment finding indicates to the nurse that the infant is becoming
dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant - ANS-A. Weak cry without any tears
\A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels
of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the best
explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
D. The TSH is high because of the low production of T4 by the thyroid. - ANS-D. The TSH is
high because of the low production of T4 by the thyroid.
\A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
- ANS-A. Breastfeed the infant, ensuring that both breasts are completely emptied.
\A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in
a motor vehicle collision. While stabilizing the patient , the nurse obtains fetal monitor
reading. Which action should the nurse take if the fetus is tachycardic is on the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - ANS-D. Contact
the healthcare provider after initiating oxygen per face mask
\A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure and
gave her parameters to judge a significant increase in blood pressure. When the client calls
the clinic complaining of indigestion, which instruction should the nurse provide?
, A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent. -
ANS-C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
\A client at 35-weeks gestation complains of a "pain whenever the baby moves." On
assessment, the nurse notes the client's temperature to be 101.2F, with severe abdominal or
uterine tenderness on palpation. The nurse knows that these findings are indicative of what
condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection. - ANS-B. Chorioamnionitis
\A client at 40-weeks' gestation presents to the obstetrical floor and indicates that the
amniotic membranes ruptured spontaneously at home. She is in active labor and feels the
need to bear down and push. What information is most important for the nurse to obtain
first?
A. the estimated amount of fluid
B. time the membranes ruptured
C. color and consistency of the fluid
D. any odor noted when membranes ruptured. - ANS-C. color and consistency of the fluid
\A client delivers a viable infant , but begins to have excessive uncontrolled vaginal ..
notifying the healthcare provider of the clients condition ,What information is most important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused - ANS-A. Maternal blood pressure.
\A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious. Which
of the following should be the focus of the nurse's response?
A. Telling the client and her partner that the labor process is often unpredictable
B. Informing the client that this means she will give birth sooner than expected
C. Asking the client and her partner if they would like the nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within normal limits - ANS-C. Asking the
client and her partner if they would like the nurse to stay in the room
\A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern - ANS-D. Contraction pattern.
\A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her
lochia is getting lighter in color and asks when the flow will stop. How should the nurse
respond?
A. 2 weeks
B. 10 days
C. When the placental site has healed
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis
of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to
include in this client's nursing care plan? - ANS-Monitor Blood pressure, pulse, and
respirations q4h.
\A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to
prevent urinary retention. The home health nurse notes that the child has developed
episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is
most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change - ANS-C. Change to latex-free
gloves when handling infant
\A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's
Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many
ml/hour should the nurse program the infusion pump? (Enter numeric value only)
A. 120
B. 70
C. 65
D. 75 - ANS-D. 75
\A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and
bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate
FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action
should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - ANS-B. Notify the healthcare
provider from the client's bedside
\A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a
non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin (
Pitocin ) infusion. Which finding is most important for the nurse to report to the health care
provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - ANS-D. A pattern of late fetal decelerations
\A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test
(NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin) infusion.
Which finding is most important for the nurse to report to the healthcare provider?
A. Spontaneous rupture of membranes.
B. Fetal heart rate accelerations with fetal movement.
C. Absences of uterine contraction of 20 minutes.
,D. A pattern of fetal late decelerations. - ANS-D. A pattern of fetal late decelerations.
\A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she
does not know if she can continue to breastfeed her infant. What instruction is best for the
nurse to provide? - ANS-Apply hot packs just before each feeding.
\A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing
intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises - ANS-D. remove restraints
one at a time to provide ROM exercises
\A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile
vomiting. Which assessment finding indicates to the nurse that the infant is becoming
dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant - ANS-A. Weak cry without any tears
\A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels
of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the best
explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
D. The TSH is high because of the low production of T4 by the thyroid. - ANS-D. The TSH is
high because of the low production of T4 by the thyroid.
\A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.
- ANS-A. Breastfeed the infant, ensuring that both breasts are completely emptied.
\A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in
a motor vehicle collision. While stabilizing the patient , the nurse obtains fetal monitor
reading. Which action should the nurse take if the fetus is tachycardic is on the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - ANS-D. Contact
the healthcare provider after initiating oxygen per face mask
\A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure and
gave her parameters to judge a significant increase in blood pressure. When the client calls
the clinic complaining of indigestion, which instruction should the nurse provide?
, A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent. -
ANS-C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
\A client at 35-weeks gestation complains of a "pain whenever the baby moves." On
assessment, the nurse notes the client's temperature to be 101.2F, with severe abdominal or
uterine tenderness on palpation. The nurse knows that these findings are indicative of what
condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection. - ANS-B. Chorioamnionitis
\A client at 40-weeks' gestation presents to the obstetrical floor and indicates that the
amniotic membranes ruptured spontaneously at home. She is in active labor and feels the
need to bear down and push. What information is most important for the nurse to obtain
first?
A. the estimated amount of fluid
B. time the membranes ruptured
C. color and consistency of the fluid
D. any odor noted when membranes ruptured. - ANS-C. color and consistency of the fluid
\A client delivers a viable infant , but begins to have excessive uncontrolled vaginal ..
notifying the healthcare provider of the clients condition ,What information is most important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused - ANS-A. Maternal blood pressure.
\A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious. Which
of the following should be the focus of the nurse's response?
A. Telling the client and her partner that the labor process is often unpredictable
B. Informing the client that this means she will give birth sooner than expected
C. Asking the client and her partner if they would like the nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within normal limits - ANS-C. Asking the
client and her partner if they would like the nurse to stay in the room
\A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern - ANS-D. Contraction pattern.
\A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her
lochia is getting lighter in color and asks when the flow will stop. How should the nurse
respond?
A. 2 weeks
B. 10 days
C. When the placental site has healed
