HESI Maternity Questions
During stage two of labor, what assessments must the labor nurse perform? (Select all that apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - (correct Answer) - A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions to determine the
fetal response to the contractions. Frequency may slow during the second stage. Duration will help
facilitate decent of the presenting part. The uterine tone between contractions should be soft to
facilitate placental filling after the contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and occurring every
5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and
returns to baseline after the contraction. What is the next nursing action?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin infusion. - (correct Answer) - D. Increase the rate of the oxytocin
infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a
duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal
response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate
the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed when the client
exhibits signs of progressing labor, which is not indicated at this time.
,The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in
the presentation. Which statements will the nurse include in the teaching plan? (Select all that apply.)
A. "The baby has to pass through the true pelvis."
B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - (correct Answer) - A, B, C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining statements are true.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours each day. She tells the
nurse that her feet have begun to swell. Which instruction 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. - (correct Answer) - C. Move about every hour.
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.
In developing a teaching plan for expectant parents, the nurse decides to include information about
when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the
timing of closure of an infant's fontanels that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second
week.
,C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first
month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second
month. - (correct Answer) - D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel
by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel
closes by the end of the second month. These growth and development milestones are frequently
included in questions on the licensure examination. Options A, B, and C are incorrect.
The laboring client at term states to the nurse, "I think my water just broke." The nurse observes a shiny,
gelatinous, rope-like structure protruding from the client's vaginal area. What is the next nursing action?
A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - (correct Answer) - B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical cord. Compression of the
cord can lead to fetal anoxia. Placing the client in knee-chest position reduces the weight of the
presenting part off of the cord. The nurse will need to complete the remaining options, but oxygenation
of the fetus takes priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term infant who has
developed localized swelling on the right side of the 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. Cephalohematoma, 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 - (correct Answer) - A. Cephalohematoma,
which is caused by forceps trauma
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours
after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option
, C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery,
and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could
not be detected by physical assessment alone.
The postpartum client is preparing for discharge. She states to the nurse, "I have not had a bowel
movement yet." What are the nurse's recommendations for this client? (Select all that apply.)
A. "Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per day."
B. "Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears."
C. "Increase the frequency of breast-feeding to no less than every two hours."
D. "Since it is nice outside, take a 15-minute walk two to three times a day."
E. "Take your narcotic pain medications as prescribed, every 3 to 4 hours." - (correct Answer) - A, B, D
For post-partum constipation, drink at least 2000 mL of water every day. Eating foods high in fiber will
help with constipation. Ambulation also helps with constipation. Increasing the frequency of
breastfeeding helps with uterine involution, but not with constipation. Frequent use of narcotic pain
medication can be constipating.
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes the student
understands the teaching when which statements are made? (Select all that apply.)
A. The umbilical cord contains two veins and one artery.
B. Umbilical arterial blood has the highest oxygenation.
C. Fetal oxygenation occurs through the placenta.
D. The foramen ovale is open in the fetal state.
E. Blood flows from the placenta to the fetal heart. - (correct Answer) - C, D, E
The umbilical cord contains one vein and 2 arteries. Umbilical venous blood has the highest level of
oxygenation. The remaining statements are true.
The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted client. The order
reads, place 30 units of oxytocin in 500 mL of normal saline and start at 1 mL/hour. Increase by 1 mL
every 30 minutes until contractions are every 3 to 4 minutes. Oxytoxin is packaged in a glass vial that
reads, 1 mL contains 10 units. What supplies will the nurse need to gather to start the infusion? (Select
all that apply.)
During stage two of labor, what assessments must the labor nurse perform? (Select all that apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - (correct Answer) - A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions to determine the
fetal response to the contractions. Frequency may slow during the second stage. Duration will help
facilitate decent of the presenting part. The uterine tone between contractions should be soft to
facilitate placental filling after the contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are firm and occurring every
5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and
returns to baseline after the contraction. What is the next nursing action?
A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin infusion. - (correct Answer) - D. Increase the rate of the oxytocin
infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a
duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal
response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate
the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed when the client
exhibits signs of progressing labor, which is not indicated at this time.
,The nurse is teaching a prenatal class about the structure of the pelvis and is using a model of a pelvis in
the presentation. Which statements will the nurse include in the teaching plan? (Select all that apply.)
A. "The baby has to pass through the true pelvis."
B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - (correct Answer) - A, B, C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining statements are true.
A 38-week primigravida works as an office assistant and sits at a computer 8 hours each day. She tells the
nurse that her feet have begun to swell. Which instruction 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. - (correct Answer) - C. Move about every hour.
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.
In developing a teaching plan for expectant parents, the nurse decides to include information about
when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the
timing of closure of an infant's fontanels that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second
week.
,C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first
month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second
month. - (correct Answer) - D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel
by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel
closes by the end of the second month. These growth and development milestones are frequently
included in questions on the licensure examination. Options A, B, and C are incorrect.
The laboring client at term states to the nurse, "I think my water just broke." The nurse observes a shiny,
gelatinous, rope-like structure protruding from the client's vaginal area. What is the next nursing action?
A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - (correct Answer) - B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical cord. Compression of the
cord can lead to fetal anoxia. Placing the client in knee-chest position reduces the weight of the
presenting part off of the cord. The nurse will need to complete the remaining options, but oxygenation
of the fetus takes priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a full-term infant who has
developed localized swelling on the right side of the 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. Cephalohematoma, 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 - (correct Answer) - A. Cephalohematoma,
which is caused by forceps trauma
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24 hours
after delivery. Trauma from delivery causes capillary bleeding between the periosteum and skull. Option
, C is a cranial distortion lasting 5 to 7 days, caused by pressure on the cranium during vaginal delivery,
and is a common variation of the newborn. Options B and D both involve intracranial bleeding and could
not be detected by physical assessment alone.
The postpartum client is preparing for discharge. She states to the nurse, "I have not had a bowel
movement yet." What are the nurse's recommendations for this client? (Select all that apply.)
A. "Drink no less than 5, 8-ounce glasses of water or non-caffeine beverages per day."
B. "Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears."
C. "Increase the frequency of breast-feeding to no less than every two hours."
D. "Since it is nice outside, take a 15-minute walk two to three times a day."
E. "Take your narcotic pain medications as prescribed, every 3 to 4 hours." - (correct Answer) - A, B, D
For post-partum constipation, drink at least 2000 mL of water every day. Eating foods high in fiber will
help with constipation. Ambulation also helps with constipation. Increasing the frequency of
breastfeeding helps with uterine involution, but not with constipation. Frequent use of narcotic pain
medication can be constipating.
The nurse is reviewing fetal circulation with a nursing student. The nurse concludes the student
understands the teaching when which statements are made? (Select all that apply.)
A. The umbilical cord contains two veins and one artery.
B. Umbilical arterial blood has the highest oxygenation.
C. Fetal oxygenation occurs through the placenta.
D. The foramen ovale is open in the fetal state.
E. Blood flows from the placenta to the fetal heart. - (correct Answer) - C, D, E
The umbilical cord contains one vein and 2 arteries. Umbilical venous blood has the highest level of
oxygenation. The remaining statements are true.
The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted client. The order
reads, place 30 units of oxytocin in 500 mL of normal saline and start at 1 mL/hour. Increase by 1 mL
every 30 minutes until contractions are every 3 to 4 minutes. Oxytoxin is packaged in a glass vial that
reads, 1 mL contains 10 units. What supplies will the nurse need to gather to start the infusion? (Select
all that apply.)
