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HESI Maternity & OB Test Bank 2025–2026 |
Questions 140| NCLEX-Style Labor, Postpartum,
Newborn Q&A with Detailed Rationales
1. A laboring client at 6 cm dilation begins to report back pain with
each contraction. What is the nurse’s priority action?
A. Administer IV fluids
B. Apply counter-pressure to the sacral area
C. Reposition the client to lithotomy
D. Encourage the client to bear down
Correct Answer: B. Apply counter-pressure to the sacral area
Rationale: Back labor pain is often caused by the fetus in the occiput
posterior (OP) position, where the back of the baby’s head presses against
the mother’s sacrum. Counter-pressure applied to the sacrum helps alleviate
this intense pain by reducing pressure and creating comfort through physical
support. This non-pharmacological pain relief technique is safe and effective
during active labor. Options A and C do not directly address pain relief and
, 2
may worsen discomfort. Option D is inappropriate since the client is not yet
in the second stage of labor.
2. A client in labor is receiving oxytocin (Pitocin). Which assessment
requires immediate intervention?
A. Contractions every 3 minutes, lasting 60 seconds
B. Fetal heart rate 110 bpm
C. Late decelerations on fetal monitor
D. Cervical dilation of 5 cm
Correct Answer: C. Late decelerations on fetal monitor
Rationale: Late decelerations indicate uteroplacental insufficiency, which
can result from excessive uterine contractions or reduced placental perfusion
—both risks associated with oxytocin use. This pattern reflects fetal hypoxia
and requires immediate intervention, such as stopping oxytocin,
repositioning the mother, and administering oxygen. Options A, B, and D
are normal or expected findings in labor.
3. A newborn has acrocyanosis at 5 minutes of life. What is the nurse’s
best response?
A. Begin resuscitative measures
B. Continue routine monitoring
C. Initiate blow-by oxygen
D. Call the provider urgently
, 3
Correct Answer: B. Continue routine monitoring
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is a normal
finding in newborns during the first 24–48 hours due to immature peripheral
circulation. It is not indicative of central hypoxia. Therefore, no emergency
intervention is needed, and the nurse should continue monitoring. Options
A, C, and D are inappropriate as they suggest pathologic hypoxia, which is
not present here.
4. Which finding in a postpartum client 12 hours after delivery requires
immediate follow-up?
A. Firm uterus at the midline
B. Moderate lochia rubra
C. Elevated white blood cell count
D. Saturating a peripad every 15 minutes
Correct Answer: D. Saturating a peripad every 15 minutes
Rationale: This indicates postpartum hemorrhage, a life-threatening
condition. Blood loss greater than 500 mL (vaginal) or 1,000 mL (cesarean)
or rapid peripad saturation warrants immediate evaluation. While a firm
uterus and lochia rubra are normal, and WBC elevation is common
postpartum due to stress, heavy bleeding suggests uterine atony or laceration
and must be treated emergently.
5. A multiparous woman arrives fully dilated and crowning. What is the
priority nursing intervention?
, 4
A. Prepare the room for delivery
B. Transfer her to the delivery suite
C. Apply fetal monitor leads
D. Encourage her to stop pushing
Correct Answer: A. Prepare the room for delivery
Rationale: In precipitous labor, birth may occur within minutes. Immediate
preparation to assist with a safe delivery is crucial. Delaying for transfers or
monitoring wastes critical time. Telling the woman to stop pushing is not
realistic during crowning. The focus is safe, immediate delivery.
6. Which newborn assessment at birth requires priority intervention?
A. Respiratory rate of 64
B. Nasal flaring
C. Acrocyanosis
D. Positive Babinski reflex
Correct Answer: B. Nasal flaring
Rationale: Nasal flaring is a sign of respiratory distress, indicating that the
newborn is working harder to breathe. This may be due to transient
tachypnea, meconium aspiration, or sepsis. Immediate evaluation and
support are required. A RR of 64 and acrocyanosis are normal in the first
hour. Babinski is a normal newborn reflex.
7. Which intervention helps prevent postpartum hemorrhage?
HESI Maternity & OB Test Bank 2025–2026 |
Questions 140| NCLEX-Style Labor, Postpartum,
Newborn Q&A with Detailed Rationales
1. A laboring client at 6 cm dilation begins to report back pain with
each contraction. What is the nurse’s priority action?
A. Administer IV fluids
B. Apply counter-pressure to the sacral area
C. Reposition the client to lithotomy
D. Encourage the client to bear down
Correct Answer: B. Apply counter-pressure to the sacral area
Rationale: Back labor pain is often caused by the fetus in the occiput
posterior (OP) position, where the back of the baby’s head presses against
the mother’s sacrum. Counter-pressure applied to the sacrum helps alleviate
this intense pain by reducing pressure and creating comfort through physical
support. This non-pharmacological pain relief technique is safe and effective
during active labor. Options A and C do not directly address pain relief and
, 2
may worsen discomfort. Option D is inappropriate since the client is not yet
in the second stage of labor.
2. A client in labor is receiving oxytocin (Pitocin). Which assessment
requires immediate intervention?
A. Contractions every 3 minutes, lasting 60 seconds
B. Fetal heart rate 110 bpm
C. Late decelerations on fetal monitor
D. Cervical dilation of 5 cm
Correct Answer: C. Late decelerations on fetal monitor
Rationale: Late decelerations indicate uteroplacental insufficiency, which
can result from excessive uterine contractions or reduced placental perfusion
—both risks associated with oxytocin use. This pattern reflects fetal hypoxia
and requires immediate intervention, such as stopping oxytocin,
repositioning the mother, and administering oxygen. Options A, B, and D
are normal or expected findings in labor.
3. A newborn has acrocyanosis at 5 minutes of life. What is the nurse’s
best response?
A. Begin resuscitative measures
B. Continue routine monitoring
C. Initiate blow-by oxygen
D. Call the provider urgently
, 3
Correct Answer: B. Continue routine monitoring
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is a normal
finding in newborns during the first 24–48 hours due to immature peripheral
circulation. It is not indicative of central hypoxia. Therefore, no emergency
intervention is needed, and the nurse should continue monitoring. Options
A, C, and D are inappropriate as they suggest pathologic hypoxia, which is
not present here.
4. Which finding in a postpartum client 12 hours after delivery requires
immediate follow-up?
A. Firm uterus at the midline
B. Moderate lochia rubra
C. Elevated white blood cell count
D. Saturating a peripad every 15 minutes
Correct Answer: D. Saturating a peripad every 15 minutes
Rationale: This indicates postpartum hemorrhage, a life-threatening
condition. Blood loss greater than 500 mL (vaginal) or 1,000 mL (cesarean)
or rapid peripad saturation warrants immediate evaluation. While a firm
uterus and lochia rubra are normal, and WBC elevation is common
postpartum due to stress, heavy bleeding suggests uterine atony or laceration
and must be treated emergently.
5. A multiparous woman arrives fully dilated and crowning. What is the
priority nursing intervention?
, 4
A. Prepare the room for delivery
B. Transfer her to the delivery suite
C. Apply fetal monitor leads
D. Encourage her to stop pushing
Correct Answer: A. Prepare the room for delivery
Rationale: In precipitous labor, birth may occur within minutes. Immediate
preparation to assist with a safe delivery is crucial. Delaying for transfers or
monitoring wastes critical time. Telling the woman to stop pushing is not
realistic during crowning. The focus is safe, immediate delivery.
6. Which newborn assessment at birth requires priority intervention?
A. Respiratory rate of 64
B. Nasal flaring
C. Acrocyanosis
D. Positive Babinski reflex
Correct Answer: B. Nasal flaring
Rationale: Nasal flaring is a sign of respiratory distress, indicating that the
newborn is working harder to breathe. This may be due to transient
tachypnea, meconium aspiration, or sepsis. Immediate evaluation and
support are required. A RR of 64 and acrocyanosis are normal in the first
hour. Babinski is a normal newborn reflex.
7. Which intervention helps prevent postpartum hemorrhage?
