HESI Comprehensive NCLEX-RN Practice (Maternity)
Study online at https://quizlet.com/_5a7uvn
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 prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring.: 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 prenata
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): 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 not specific
, HESI Comprehensive NCLEX-RN Practice (Maternity)
Study online at https://quizlet.com/_5a7uvn
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
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk: 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 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.: A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement,
and breastfeeding during mastitis facilitates the complete emptying of engorged
breasts, eliminating the pressure on the inflamed breast tissue. Option B is less
, HESI Comprehensive NCLEX-RN Practice (Maternity)
Study online at https://quizlet.com/_5a7uvn
painful but does not facilitate complete emptying of the breast tissue. Option C
will not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
5. A 38-week primigravida who works as a secretary and sits at a computer 8
hours each day tells the nurse that her feet have begun to swell. Which instruc-
tion will aid in the prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing.: C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will relieve pressure on the
pelvic veins and increase venous return. Option A would increase venous return from
varicose veins in the lower extremities but would be of little help with swelling. Option
B might be helpful with generalized edema but is not specific for edematous lower
extremities. Option D does not address venous return, and there is no indication in
the question that constrictive clothing is a problem.
6. Twenty-four hours after admission to the newborn nursery, a full-term male
infant develops localized swelling on the right side of his head. In a newborn,
what is the most likely cause of this accumulation of blood between the
periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage: A.Cephalhe-
matoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually
arises within the first 24 hours after delivery. Trauma from delivery causes capillary
Study online at https://quizlet.com/_5a7uvn
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 prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring.: 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 prenata
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): 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 not specific
, HESI Comprehensive NCLEX-RN Practice (Maternity)
Study online at https://quizlet.com/_5a7uvn
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
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk: 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 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.: A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement,
and breastfeeding during mastitis facilitates the complete emptying of engorged
breasts, eliminating the pressure on the inflamed breast tissue. Option B is less
, HESI Comprehensive NCLEX-RN Practice (Maternity)
Study online at https://quizlet.com/_5a7uvn
painful but does not facilitate complete emptying of the breast tissue. Option C
will not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
5. A 38-week primigravida who works as a secretary and sits at a computer 8
hours each day tells the nurse that her feet have begun to swell. Which instruc-
tion will aid in the prevention of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing.: C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will relieve pressure on the
pelvic veins and increase venous return. Option A would increase venous return from
varicose veins in the lower extremities but would be of little help with swelling. Option
B might be helpful with generalized edema but is not specific for edematous lower
extremities. Option D does not address venous return, and there is no indication in
the question that constrictive clothing is a problem.
6. Twenty-four hours after admission to the newborn nursery, a full-term male
infant develops localized swelling on the right side of his head. In a newborn,
what is the most likely cause of this accumulation of blood between the
periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage: A.Cephalhe-
matoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually
arises within the first 24 hours after delivery. Trauma from delivery causes capillary
