ne
lOMoAR cPSD| 24448587
HESI MATERNITY 1&2 TEST BANK 2023-2024
sh
QUESTIONS AND CORRECT DETAILED
ne
ANSWERS
la
tz
sh
Sp
Maternity HESI 1 Test Bank
ne
la
1. A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
sh
each day tells the nurse that her feet have begun to swell. Which instruction would be
Sp
most effective in preventing pooling of blood in the lower extremities?
ne
la
Move about every hour
tz
sh
Sp
Pooling of blood in the lower extremities results from the enlarged uterus exerting
ne
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
la
2. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
sh
Sp
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
ne
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
la
tz
sh
Tachycardia and a feeling of nervousness
Sp
ne
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
la
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
sh
headache, and a feeling of "nervousness".
Sp
ne
3. When do the anterior and posterior fontanels close?
la
tz
sh
anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
Sp
month.
ne
la
4. When assessing a client who is at 12-weeks gestation, the nurse recommends that she
and her husband consider attending childbirth preparation classes. When is the best
sh
Sp
time for the couple to attend these classes?
ne
30 weeks gestation
a
tz
l
sh
at 30 weeks gestation is closest (of the options) to the time parents would be ready for
Sp
such classes. Learning is facilitated by an interested pupil! The couple is most
ne
interested in childbirth toward the end of the pregnancy when they are psychologically
la
sh
Sp
la
Sp
, ne
ready for the termination of the pregnancy, and the birth of their child is an immediate
sh
concern.
ne
5. The nurse should encourage the laboring client to begin pushing when...
la
tz
the cervix is completely dilated.
sh
Sp
ne
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix
la
can become edematous and may never completely dilate, necessitating an operative
sh
delivery. Many primigravida’s begin active labor 100% effaced and then proceed to
Sp
dilate.
ne
la
6. The nurse instructs a laboring client to use accelerated-blow breathing. The client
tz
begins to complain of tingling fingers and dizziness. What action should the nurse take?
sh
Sp
ne
Have the client breathe into her cupped hands
la
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
sh
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
Sp
facilitated by breathing into a paper bag or cupped hands.
ne
la
7. Twenty-four hours after admission to the newborn nursery, a full-term male infant
tz
develops localized edema on the right side of his head. The nurse knows that, in the
sh
Sp
newborn, an accumulation of blood between the periosteum and skull which does not
ne
cross the suture line is a newborn variation known as...
la
a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
sh
Sp
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the
ne
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
la
periosteum and the skull.
tz
sh
Sp
8. When does the head return to its normal shape?
ne
7-10 days
la
sh
9. What did Nurse theorist Reva Rubin describe?
Sp
ne
The initial postpartum period as the "taking-in phase," which is characterized by
a
maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and
tz
closeness to families and the newborn.
l
sh
Sp
ne
10. A couple, concerned because the woman has not been able to conceive, is referred to
a healthcare provider for a fertility workup and a hysterosalpingography is scheduled.
la
Which post procedure complaint indicates that the fallopian tubes are patent?
sh
Sp
la
Sp
, ne
sh
Shoulder pain
ne
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
la
collection of peritoneal dye/gas.
tz
sh
Sp
11. Which nursing intervention is most helpful in relieving postpartum uterine contractions
or "afterpains?"
ne
la
Lying prone with a pillow on the abdomen
sh
Sp
ne
Lying prone keeps the fundus contracted and is especially useful with multiparas, who
la
tz
commonly experience afterpains due to lack of uterine tone.
sh
Sp
12. Which maternal behavior is the nurse most likely to see when a new mother receives
ne
her infant for the first time?
la
Her arms and hands receive the infant and she then traces the infant's profile with her
sh
Sp
fingertips.
ne
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
la
described in during the first visit with the newborn, which may be at delivery or later.
tz
sh
Sp
13. A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
ne
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
la
Which assessment finding indicates the therapeutic drug level has been achieved?
sh
A decreased in respiratory rate from 24 to 16
Sp
ne
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory
la
rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic
tz
effects.)
sh
Sp
ne
14. Urinary output must be monitored when administering magnesium sulfate and should
la
be at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client
is 4.8 to 9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
sh
Sp
ne
The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
What does it help prevent? helps prevent seizures What
a
indicates toxic levels? 3
tz
l
sh
Sp
Respiratory rate below 12 indicates toxic effects.
ne
Urine output of less than 100 ml/4 hours Absent
la
DTRs
sh
Sp
la
Sp
, ne
sh
15. Twenty minutes after a continuous epidural anesthetic is administered, a laboring
ne
client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?
la
Place woman in a lateral position
tz
sh
Sp
The nurse should immediately turn the woman to a lateral position, place a pillow or
ne
wedge under the right hip to deflect the uterus, increase the rate of the main line IV
la
infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure
remains low, especially if it further decreases, the anesthesiologist/healthcare provider
sh
Sp
should be notified immediately.
ne
16. A client at 28-weeks gestation calls the antepartum clinic and states that she is
la
experiencing a small amount of vaginal bleeding which she describes as bright red. She
tz
further states that she is not experiencing any uterine contractions or abdominal pain.
sh
Sp
What instruction should the nurse provide?
ne
Come to the clinic today for an ultrasound
la
Third trimester painless bleeding is characteristic of a placenta previa. Bright red
sh
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
Sp
ne
incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound.
la
tz
17. An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while
sh
Sp
her husband is screaming for someone to help his wife. Which intervention has the
ne
highest priority?
la
Put the newborn to breast
sh
Sp
Putting the newborn to breast will help contract the uterus and prevent a postpartum
ne
hemorrhage--this intervention has the highest priority.
la
tz
18. A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client
sh
Sp
asks the nurse, "Why must I stay in bed all the time?" Which response is best for the
ne
nurse to provide this client?
la
Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
sh
Sp
To help preserve cardiac reserves, the woman may need to restrict her activities and
ne
complete bedrest is often prescribed.
a
tz
19. The nurse is teaching care of the newborn to a group of prospective parents and
l
sh
Sp
describes the need for administering antibiotic ointment into the eyes of the newborn.
ne
Which infectious organism will this treatment prevent from harming the infant?
la
Gonorrhea
sh
Sp
la
Sp
lOMoAR cPSD| 24448587
HESI MATERNITY 1&2 TEST BANK 2023-2024
sh
QUESTIONS AND CORRECT DETAILED
ne
ANSWERS
la
tz
sh
Sp
Maternity HESI 1 Test Bank
ne
la
1. A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
sh
each day tells the nurse that her feet have begun to swell. Which instruction would be
Sp
most effective in preventing pooling of blood in the lower extremities?
ne
la
Move about every hour
tz
sh
Sp
Pooling of blood in the lower extremities results from the enlarged uterus exerting
ne
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
la
2. A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
sh
Sp
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
ne
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
la
tz
sh
Tachycardia and a feeling of nervousness
Sp
ne
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
la
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
sh
headache, and a feeling of "nervousness".
Sp
ne
3. When do the anterior and posterior fontanels close?
la
tz
sh
anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
Sp
month.
ne
la
4. When assessing a client who is at 12-weeks gestation, the nurse recommends that she
and her husband consider attending childbirth preparation classes. When is the best
sh
Sp
time for the couple to attend these classes?
ne
30 weeks gestation
a
tz
l
sh
at 30 weeks gestation is closest (of the options) to the time parents would be ready for
Sp
such classes. Learning is facilitated by an interested pupil! The couple is most
ne
interested in childbirth toward the end of the pregnancy when they are psychologically
la
sh
Sp
la
Sp
, ne
ready for the termination of the pregnancy, and the birth of their child is an immediate
sh
concern.
ne
5. The nurse should encourage the laboring client to begin pushing when...
la
tz
the cervix is completely dilated.
sh
Sp
ne
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix
la
can become edematous and may never completely dilate, necessitating an operative
sh
delivery. Many primigravida’s begin active labor 100% effaced and then proceed to
Sp
dilate.
ne
la
6. The nurse instructs a laboring client to use accelerated-blow breathing. The client
tz
begins to complain of tingling fingers and dizziness. What action should the nurse take?
sh
Sp
ne
Have the client breathe into her cupped hands
la
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
sh
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
Sp
facilitated by breathing into a paper bag or cupped hands.
ne
la
7. Twenty-four hours after admission to the newborn nursery, a full-term male infant
tz
develops localized edema on the right side of his head. The nurse knows that, in the
sh
Sp
newborn, an accumulation of blood between the periosteum and skull which does not
ne
cross the suture line is a newborn variation known as...
la
a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
sh
Sp
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the
ne
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
la
periosteum and the skull.
tz
sh
Sp
8. When does the head return to its normal shape?
ne
7-10 days
la
sh
9. What did Nurse theorist Reva Rubin describe?
Sp
ne
The initial postpartum period as the "taking-in phase," which is characterized by
a
maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and
tz
closeness to families and the newborn.
l
sh
Sp
ne
10. A couple, concerned because the woman has not been able to conceive, is referred to
a healthcare provider for a fertility workup and a hysterosalpingography is scheduled.
la
Which post procedure complaint indicates that the fallopian tubes are patent?
sh
Sp
la
Sp
, ne
sh
Shoulder pain
ne
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
la
collection of peritoneal dye/gas.
tz
sh
Sp
11. Which nursing intervention is most helpful in relieving postpartum uterine contractions
or "afterpains?"
ne
la
Lying prone with a pillow on the abdomen
sh
Sp
ne
Lying prone keeps the fundus contracted and is especially useful with multiparas, who
la
tz
commonly experience afterpains due to lack of uterine tone.
sh
Sp
12. Which maternal behavior is the nurse most likely to see when a new mother receives
ne
her infant for the first time?
la
Her arms and hands receive the infant and she then traces the infant's profile with her
sh
Sp
fingertips.
ne
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
la
described in during the first visit with the newborn, which may be at delivery or later.
tz
sh
Sp
13. A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
ne
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
la
Which assessment finding indicates the therapeutic drug level has been achieved?
sh
A decreased in respiratory rate from 24 to 16
Sp
ne
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory
la
rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic
tz
effects.)
sh
Sp
ne
14. Urinary output must be monitored when administering magnesium sulfate and should
la
be at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client
is 4.8 to 9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
sh
Sp
ne
The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
What does it help prevent? helps prevent seizures What
a
indicates toxic levels? 3
tz
l
sh
Sp
Respiratory rate below 12 indicates toxic effects.
ne
Urine output of less than 100 ml/4 hours Absent
la
DTRs
sh
Sp
la
Sp
, ne
sh
15. Twenty minutes after a continuous epidural anesthetic is administered, a laboring
ne
client's blood pressure drops from 120/80 to 90/60. What action should the nurse take?
la
Place woman in a lateral position
tz
sh
Sp
The nurse should immediately turn the woman to a lateral position, place a pillow or
ne
wedge under the right hip to deflect the uterus, increase the rate of the main line IV
la
infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure
remains low, especially if it further decreases, the anesthesiologist/healthcare provider
sh
Sp
should be notified immediately.
ne
16. A client at 28-weeks gestation calls the antepartum clinic and states that she is
la
experiencing a small amount of vaginal bleeding which she describes as bright red. She
tz
further states that she is not experiencing any uterine contractions or abdominal pain.
sh
Sp
What instruction should the nurse provide?
ne
Come to the clinic today for an ultrasound
la
Third trimester painless bleeding is characteristic of a placenta previa. Bright red
sh
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
Sp
ne
incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound.
la
tz
17. An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while
sh
Sp
her husband is screaming for someone to help his wife. Which intervention has the
ne
highest priority?
la
Put the newborn to breast
sh
Sp
Putting the newborn to breast will help contract the uterus and prevent a postpartum
ne
hemorrhage--this intervention has the highest priority.
la
tz
18. A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client
sh
Sp
asks the nurse, "Why must I stay in bed all the time?" Which response is best for the
ne
nurse to provide this client?
la
Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
sh
Sp
To help preserve cardiac reserves, the woman may need to restrict her activities and
ne
complete bedrest is often prescribed.
a
tz
19. The nurse is teaching care of the newborn to a group of prospective parents and
l
sh
Sp
describes the need for administering antibiotic ointment into the eyes of the newborn.
ne
Which infectious organism will this treatment prevent from harming the infant?
la
Gonorrhea
sh
Sp
la
Sp
