Maternity HESI T
CORRECT DET
RATIONALES
1.An expectant father tells the nurse he fears that his wife is
"losing her mind." He states that she is constantly rubbing her
abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with
her symp- toms.
B. Explain that his wife is exhibiting ambivalence about the
pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenat
visit.
1/
,D. Reassure him that normal maternal-fetal bonding is occurring.
Answer> D) Reassure him that normal maternal-fetal bonding is
occurring.
Rationale
These behaviors are positive signs of maternal-fetal bonding and do not
reflect ambivalence. No intervention is needed. Quickening, the first
perception of fetal movement, occurs at 17 to 20 weeks of gestation and
begins a new phase of prenatal bonding during the second trimester.
Options A and C are not necessary because the behaviors displayed are
normal.
2.The nurse is preparing a laboring client for an amniotomy.
Immediately after the procedure is completed, it is most
important for the nurse to obtain which information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)
2/
, Answer> C. Fetal heart rate (FHR)
Rationale
The FHR should be assessed before and after the procedure to detect
changes that may indicate the presence of cord compression or prolapse.
An amniotomy (artificial rupture of membranes [AROM]) is used to
stimulate labor when the condition of the cervix is favorable. The fluid
should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is n
specific
for AROM. Option B is monitored hourly after the membranes are ruptured
to detect the development of amnionitis. Option D should be determined
for all clients in labor.
3.A nurse receives a shift change report for a newborn who is 12
hours post-vaginal delivery. In developing a plan of care, the
nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
3/
, C.Tiny white papules on the nose or
chin
D.Red patches on the cheeks and trunk
Answer> B. Skin color that is slightly jaundiced
Rationale Jaundice, a yellow skin coloration, is caused by elevated levels of
bilirubin, which should be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet) is a common finding in
newborns; it occurs because the capillary system is immature. Milia are
small white papules present on the nose and chin that are caused by
sebaceous gland blockage and disappear in a few weeks. Small red
patches on the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
4.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
4/
CORRECT DET
RATIONALES
1.An expectant father tells the nurse he fears that his wife is
"losing her mind." He states that she is constantly rubbing her
abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with
her symp- toms.
B. Explain that his wife is exhibiting ambivalence about the
pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenat
visit.
1/
,D. Reassure him that normal maternal-fetal bonding is occurring.
Answer> D) Reassure him that normal maternal-fetal bonding is
occurring.
Rationale
These behaviors are positive signs of maternal-fetal bonding and do not
reflect ambivalence. No intervention is needed. Quickening, the first
perception of fetal movement, occurs at 17 to 20 weeks of gestation and
begins a new phase of prenatal bonding during the second trimester.
Options A and C are not necessary because the behaviors displayed are
normal.
2.The nurse is preparing a laboring client for an amniotomy.
Immediately after the procedure is completed, it is most
important for the nurse to obtain which information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)
2/
, Answer> C. Fetal heart rate (FHR)
Rationale
The FHR should be assessed before and after the procedure to detect
changes that may indicate the presence of cord compression or prolapse.
An amniotomy (artificial rupture of membranes [AROM]) is used to
stimulate labor when the condition of the cervix is favorable. The fluid
should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is n
specific
for AROM. Option B is monitored hourly after the membranes are ruptured
to detect the development of amnionitis. Option D should be determined
for all clients in labor.
3.A nurse receives a shift change report for a newborn who is 12
hours post-vaginal delivery. In developing a plan of care, the
nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
3/
, C.Tiny white papules on the nose or
chin
D.Red patches on the cheeks and trunk
Answer> B. Skin color that is slightly jaundiced
Rationale Jaundice, a yellow skin coloration, is caused by elevated levels of
bilirubin, which should be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet) is a common finding in
newborns; it occurs because the capillary system is immature. Milia are
small white papules present on the nose and chin that are caused by
sebaceous gland blockage and disappear in a few weeks. Small red
patches on the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
4.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
4/
