Maternity HESI Questions and Answers
A+ Graded (2025)
Newborn .respiratory .rate .of .40 .breaths .per .minute .and .cyanotic .hands .and .feet:
.- .CORRECT .ANSWER-Continue .to .monitor .(normal).
20 .weeks .gestation, .gained .20 .lbs, .fundal .height .20, .clear .liquid .from .breasts.
.What .warrants .further .evaluation? .- .CORRECT .ANSWER-Too .much .weight .gain,
.gestational .weight .gain .should .only .be .approx .10.3 .lbs.
. .Neonate .under .radiant .warmer, .naso-oral .suctioned. .Which .indicates .infant .is
."vigorous"? .- .CORRECT .ANSWER-Active . movement .and .lusty .cry.
24 .hour .old .baby, .mom .is .scared .she .is .not .breastfeeding .right, .the .nurse
.should .say... .- .CORRECT .ANSWER-If . your .baby's .urine .is .straw .colored ., .then
.she .is .feeding .well.
. .12 .hours .after .birth, .mother .c/o .vaginal .pressure, .fundus .firm .@ .midline, .with
.moderate .- .CORRECT .ANSWER-Inspect .perineal .and .rectal .area.
Rheumatic .fever .hx .as .a .child, .resulted .in .heart .damage, .risk .for .CHF .post
.delivery. .Nursing .Dx? .- .CORRECT .ANSWER-Fluid .volume .excess. .
RATIONALE: .3rd .spacing.
Cesarean .- .hemorrhage .risk .assessment? .- .CORRECT .ANSWER-Check .for
.fundal .firmness .Q15 .min. .
RATIONALE: .Risk .for .postpartum .hemorrhage .is .decreased .when .uterus .is .firm
.after .delivery. .Q15 .min .checks .stimulate .fundus .to .contract .and .prevents
.bleeding.
Water .broke, .umbilical .cord .is .on .perineum, .what .does .nurse .do? .- .CORRECT
.ANSWER-Place .pt .in .trendelenburg.
RATIONALE: .Take .the .pressure .off .the .presenting .part .of .cord .by .vaginal .exam
.and .holding .up .the .presenting .part .as .much .as .possible.
Primipara .20 .week, .schedule .u/s, .what's .the .reason .for .the .u/s? .- .CORRECT
.ANSWER-To .evaluate .fetal .growth .and .to .determine .gestational .age.
,Assessing .a .3 .day .old .with .cephalohematoma. .What .intervention .is .highest
.priority? .- .CORRECT .ANSWER-Examine .Q8 .hrs .for .jaundice .(look .for
.hyperbilirubinemia). .
RATIONALE: .Bilirubin .increases .as .RBCs .in .cephalohematoma .breakdown.
40 .wks, .cesarean, .receives .anticholinergic, .atropine .0.4 .mg .IM .as .adjunct .to
.inhaled .anesthesia. .What .would .be .a .therapeutic .response .to .the .injection? .-
.CORRECT .ANSWER-Increased .HR .and .decrease .in .oral .secretions.
Newborn .assessment .that .indicates .a .cardiac .problem? .- .CORRECT .ANSWER-
RR .78/min.
RATIONALE: .Normal .respiratory .rate .for .a .newborn .is .40 .- .60.
Abacavir .(ziagen) .450 .mg .po .tid .ordered .for .HIV .positive. .Stock .is .300 .mg .tabs.
.Give? .- .CORRECT .ANSWER-Give .1.5 .tabs.
Sore .nipples .on .day .2 .of .breastfeeding. .- .CORRECT .ANSWER-Assess .infants
.position .while .feeding. .
RATIONALE: .To .make .sure .baby .is .latching .properly.
Rh .negative .refuses .Rhogam .after .delivery. .- .CORRECT .ANSWER-Rhogam
.prevents .maternal .antibody .formation .for .future .Rh .positive .babies.
24 .hours .after .birth, .cephalohematoma, .what .intervention? .- .CORRECT
.ANSWER-Examine .jaundice .Q8 .hours.
RATIONALE: .Bilirubin .increases .as .RBCs .in .cephalohematoma .breakdown.
. .Patient .had .twins .born .to .multigravida, .12 .hours .ago. .Nursing .Dx? .- .CORRECT
.ANSWER-Assess .fundal .tone .and .lochia .flow.
. .Primigravida, .36 .week, .admitted, .water .broke, .2cm .dilated, .50% .effaced, .-2
.station, .vertex .presentation, .greenish .colored .amniotic .fluid, .contractions .Q3-5
.min .with .deceased .in .FHR .after .the .last .4 .contraction .peaks. .What .to .do .FIRST?
.- .CORRECT .ANSWER-02 .via .facemask.
Terbutaline .(Brethine) .injections .for .preterm .labor. .When .do .you .hold .and .call
.the .MD? .- .CORRECT .ANSWER-Bilateral .crackles .in .lungs .on .auscultation
.(critical .complication).
RATIONALE: .Could .indicate .pulmonary .edema.
APGAR .3. .Intervention? .- .CORRECT .ANSWER-Continue .resuscitation .efforts.
In .PACU, .the .most .important .assessment .for .first .8 .hours .after .cesarean: .-
.CORRECT .ANSWER-Uterine .atony.
RATIONALE: .Uterine .atony .can .lead .to .hemorrhage.
Cytotec .(Misoprostol) .for .peptic .ulcer .(Synthetic .Prostaglandin .E .Drug). .Nurse
.response? .- .CORRECT .ANSWER-Increased .risk .for .spontaneous .miscarriage. .
,RATIONALE: .Cytotec .(Misoprostol) .can .induce .uterine .contractions .resulting .in
.miscarriage.
Multigravida .at .term .with .back .labor, .cervix .is .3 .cm .dilated, .50% .effaced, .-1
.station. .- .CORRECT .ANSWER-Apply .counter .pressure .to .sacral .area. .
RATIONALE: .Caused .by .malposition .of .the .fetus.
Not .Rubella .immune .(negative .titer) .and .6 .weeks .pregnant. .When .should .the
.vaccine .be .given? .- .CORRECT .ANSWER-Give .early .postpartum .within .72 . hours.
HESI .HINT: ."Rubella .is .teratogenic .to .the .fetus .during .the .first .trimester, .causing
.congenital .heart .disease, .congenital .cataracts, .or .both. .All .women .should .have
.their .titers .checked .during .pregnancy. . If .a .woman's .titers .are .low, .she .should
.receive .the . vaccine .after .delivery .and .be .instructed .not .to .get .pregnant .within .3
.months. .Breast-feeding .mothers .may .take .the .vaccine" .(p. .288).
Gravida .1, .para .0, .cervix .dilated .8 .cm, .contractions .Q2 .min, .bloody .show, .and
.nausea. .Nurse .Dx? .- .CORRECT .ANSWER-Pain .r/t .transitional .phase .of .labor.
Baby .weighs .7.5 .lbs .today, .tomorrow .7 .lbs .(5 .lb .weight .loss). .What .does .the
.nurse .do? .- .CORRECT .ANSWER-Tell .mother .it .is .normal.
RATIONALE: .Newborns .can .lose .10% .of .their .wt .and .regain .it .later.
Receiving .report .on .laboring .pt .from .ER. .Water .broke .and .didn't .know .it. .First
.thing .the .nurse .does? .- .CORRECT .ANSWER-Take .temperature. .
RATIONALE: .Length .of .time .membranes .ruptured .is .important .to .monitor .for
.infection.
Postpartum .temporary .bed-rest .should .be .placed .if? .- .CORRECT .ANSWER-
Positive .Homan's .sign.
. .Fundus .hand .placement: .1 .massages .the .fundus .the .other .is .for... .- .CORRECT
.ANSWER-The .other .hand .anchors .the .lower .uterine .section.
DM .I, .HbgA1c .level .7.8 .at .10 .weeks .pregnant. .What .should .the .nurse .do? .-
.CORRECT .ANSWER-Contact .MD .for .BPP . (BioPhysical .Profile).
Symptoms .of .hemorrhage/bleeding .out: .- .CORRECT .ANSWER-LR .200 .mL/hr
.using .18 .gauge .needle.
Most .accurate .way .to .determine .fetal .position .at .29 .weeks .gestation. .- .CORRECT
.ANSWER-Ultrasound.
RATIONALE: .Provides .direct .view .of .the .fetus.
To .measure .contractions... .- .CORRECT .ANSWER-From .beginning .of .a
.contraction, .to .the .beginning .of .the .next .contractions.
. .Newborn .assessment .for .respiratory .distress. .- .CORRECT .ANSWER-Flaring .of
.the .nares.
, RATIONALE: .Forced .inspiration, .grunting, .tachy .(respirations .>60), .cyanosis,
.and .retractions .over .chest .wall).
40 .weeks .pregnant, .laboring, .patient .states .supine .is .position .of .comfort, .the
.nurse .should? .- .CORRECT .ANSWER-Place .pillow .wedge .under .right .hip.
RATIONALE: .Hypotension .from .pressure .on .vena .cava .is .risk, .the .wedge
.relieves .the .pressure .on .the .vena .cava.
MVA, .36 .weeks, .BP .80/50, .HR .130, .what .does .the .nurse .do? .- .CORRECT
.ANSWER-Tilt .the .backboard .to .displace .uterus.
. .Patient .concerned .about .yellow .nipple .discharge. .- .CORRECT .ANSWER-Tell .the
.patient .it .is .normal.
Nutrition .teaching .for .pregnant .teens. .- .CORRECT .ANSWER-Iron-deficient
.anemia.
38 .weeks, .laboring, .which .finding .(condition) .warrants .a .cesarean? .- .CORRECT
.ANSWER-Active . herpes .lesions .on .perineum.
. .Second .stage .of .labor, .what .does .nurse .do .first? .- .CORRECT .ANSWER-Let .pt
.know .that .birth .is .imminent. .
RATIONALE: .Second .stage .pt .is .fully .dilated .and .fetus .is .crowning.
Baby .born .breech, .in .the .NICU .they .assess? .- .CORRECT .ANSWER-Ortolani's
.test.
RATIONALE: .(from .Saunders, .couldn't .find .it .in .HESI). .It .is .a .test .of .hip .laxity,
.used .to .diagnose .hip .dysplasia.
IV .LR .1000 .mL .with .oxytocin .(Pitocin) .40 .units .to .deliver .15mL/hr. .How .many
.milli-units/minute .is .the .client .receiving? .- .CORRECT .ANSWER-10 .mu/min.
38 .week .(IDM) .infant .of .diabetic .mother .admitted .to .NICU .@ .8.2 .lbs. .What .is .the
.priority .Nursing .Dx? .- .CORRECT .ANSWER-Hypoglycemia.
FHR .decreases .after .each .contraction. .What .should .the .nurse .do? .- .CORRECT
.ANSWER-Give .10 .lpm .02 .via .mask.
. .Post .partum .teaching .to .prevent .pregnancy. .- .CORRECT .ANSWER-Use .condom
.and .spermicidal .gel.
1st .trimester, .Hgb .8.6, .Hct .25.1, .what .food .should .the .nurse .encourage? .-
.CORRECT .ANSWER-Chicken.
Oxytocin .(Pitocin) .20 .units .in .1000 .LR .after .delivery .is .for? .- .CORRECT
.ANSWER-To .stimulate .uterine .contractions .to .prevent .hemorrhage.
RATIONALE: .Admin .after .placenta .delivery. .Prior .to .placental .delivery .would
.cause .uterus .to .contract .and .retain .placenta.
A+ Graded (2025)
Newborn .respiratory .rate .of .40 .breaths .per .minute .and .cyanotic .hands .and .feet:
.- .CORRECT .ANSWER-Continue .to .monitor .(normal).
20 .weeks .gestation, .gained .20 .lbs, .fundal .height .20, .clear .liquid .from .breasts.
.What .warrants .further .evaluation? .- .CORRECT .ANSWER-Too .much .weight .gain,
.gestational .weight .gain .should .only .be .approx .10.3 .lbs.
. .Neonate .under .radiant .warmer, .naso-oral .suctioned. .Which .indicates .infant .is
."vigorous"? .- .CORRECT .ANSWER-Active . movement .and .lusty .cry.
24 .hour .old .baby, .mom .is .scared .she .is .not .breastfeeding .right, .the .nurse
.should .say... .- .CORRECT .ANSWER-If . your .baby's .urine .is .straw .colored ., .then
.she .is .feeding .well.
. .12 .hours .after .birth, .mother .c/o .vaginal .pressure, .fundus .firm .@ .midline, .with
.moderate .- .CORRECT .ANSWER-Inspect .perineal .and .rectal .area.
Rheumatic .fever .hx .as .a .child, .resulted .in .heart .damage, .risk .for .CHF .post
.delivery. .Nursing .Dx? .- .CORRECT .ANSWER-Fluid .volume .excess. .
RATIONALE: .3rd .spacing.
Cesarean .- .hemorrhage .risk .assessment? .- .CORRECT .ANSWER-Check .for
.fundal .firmness .Q15 .min. .
RATIONALE: .Risk .for .postpartum .hemorrhage .is .decreased .when .uterus .is .firm
.after .delivery. .Q15 .min .checks .stimulate .fundus .to .contract .and .prevents
.bleeding.
Water .broke, .umbilical .cord .is .on .perineum, .what .does .nurse .do? .- .CORRECT
.ANSWER-Place .pt .in .trendelenburg.
RATIONALE: .Take .the .pressure .off .the .presenting .part .of .cord .by .vaginal .exam
.and .holding .up .the .presenting .part .as .much .as .possible.
Primipara .20 .week, .schedule .u/s, .what's .the .reason .for .the .u/s? .- .CORRECT
.ANSWER-To .evaluate .fetal .growth .and .to .determine .gestational .age.
,Assessing .a .3 .day .old .with .cephalohematoma. .What .intervention .is .highest
.priority? .- .CORRECT .ANSWER-Examine .Q8 .hrs .for .jaundice .(look .for
.hyperbilirubinemia). .
RATIONALE: .Bilirubin .increases .as .RBCs .in .cephalohematoma .breakdown.
40 .wks, .cesarean, .receives .anticholinergic, .atropine .0.4 .mg .IM .as .adjunct .to
.inhaled .anesthesia. .What .would .be .a .therapeutic .response .to .the .injection? .-
.CORRECT .ANSWER-Increased .HR .and .decrease .in .oral .secretions.
Newborn .assessment .that .indicates .a .cardiac .problem? .- .CORRECT .ANSWER-
RR .78/min.
RATIONALE: .Normal .respiratory .rate .for .a .newborn .is .40 .- .60.
Abacavir .(ziagen) .450 .mg .po .tid .ordered .for .HIV .positive. .Stock .is .300 .mg .tabs.
.Give? .- .CORRECT .ANSWER-Give .1.5 .tabs.
Sore .nipples .on .day .2 .of .breastfeeding. .- .CORRECT .ANSWER-Assess .infants
.position .while .feeding. .
RATIONALE: .To .make .sure .baby .is .latching .properly.
Rh .negative .refuses .Rhogam .after .delivery. .- .CORRECT .ANSWER-Rhogam
.prevents .maternal .antibody .formation .for .future .Rh .positive .babies.
24 .hours .after .birth, .cephalohematoma, .what .intervention? .- .CORRECT
.ANSWER-Examine .jaundice .Q8 .hours.
RATIONALE: .Bilirubin .increases .as .RBCs .in .cephalohematoma .breakdown.
. .Patient .had .twins .born .to .multigravida, .12 .hours .ago. .Nursing .Dx? .- .CORRECT
.ANSWER-Assess .fundal .tone .and .lochia .flow.
. .Primigravida, .36 .week, .admitted, .water .broke, .2cm .dilated, .50% .effaced, .-2
.station, .vertex .presentation, .greenish .colored .amniotic .fluid, .contractions .Q3-5
.min .with .deceased .in .FHR .after .the .last .4 .contraction .peaks. .What .to .do .FIRST?
.- .CORRECT .ANSWER-02 .via .facemask.
Terbutaline .(Brethine) .injections .for .preterm .labor. .When .do .you .hold .and .call
.the .MD? .- .CORRECT .ANSWER-Bilateral .crackles .in .lungs .on .auscultation
.(critical .complication).
RATIONALE: .Could .indicate .pulmonary .edema.
APGAR .3. .Intervention? .- .CORRECT .ANSWER-Continue .resuscitation .efforts.
In .PACU, .the .most .important .assessment .for .first .8 .hours .after .cesarean: .-
.CORRECT .ANSWER-Uterine .atony.
RATIONALE: .Uterine .atony .can .lead .to .hemorrhage.
Cytotec .(Misoprostol) .for .peptic .ulcer .(Synthetic .Prostaglandin .E .Drug). .Nurse
.response? .- .CORRECT .ANSWER-Increased .risk .for .spontaneous .miscarriage. .
,RATIONALE: .Cytotec .(Misoprostol) .can .induce .uterine .contractions .resulting .in
.miscarriage.
Multigravida .at .term .with .back .labor, .cervix .is .3 .cm .dilated, .50% .effaced, .-1
.station. .- .CORRECT .ANSWER-Apply .counter .pressure .to .sacral .area. .
RATIONALE: .Caused .by .malposition .of .the .fetus.
Not .Rubella .immune .(negative .titer) .and .6 .weeks .pregnant. .When .should .the
.vaccine .be .given? .- .CORRECT .ANSWER-Give .early .postpartum .within .72 . hours.
HESI .HINT: ."Rubella .is .teratogenic .to .the .fetus .during .the .first .trimester, .causing
.congenital .heart .disease, .congenital .cataracts, .or .both. .All .women .should .have
.their .titers .checked .during .pregnancy. . If .a .woman's .titers .are .low, .she .should
.receive .the . vaccine .after .delivery .and .be .instructed .not .to .get .pregnant .within .3
.months. .Breast-feeding .mothers .may .take .the .vaccine" .(p. .288).
Gravida .1, .para .0, .cervix .dilated .8 .cm, .contractions .Q2 .min, .bloody .show, .and
.nausea. .Nurse .Dx? .- .CORRECT .ANSWER-Pain .r/t .transitional .phase .of .labor.
Baby .weighs .7.5 .lbs .today, .tomorrow .7 .lbs .(5 .lb .weight .loss). .What .does .the
.nurse .do? .- .CORRECT .ANSWER-Tell .mother .it .is .normal.
RATIONALE: .Newborns .can .lose .10% .of .their .wt .and .regain .it .later.
Receiving .report .on .laboring .pt .from .ER. .Water .broke .and .didn't .know .it. .First
.thing .the .nurse .does? .- .CORRECT .ANSWER-Take .temperature. .
RATIONALE: .Length .of .time .membranes .ruptured .is .important .to .monitor .for
.infection.
Postpartum .temporary .bed-rest .should .be .placed .if? .- .CORRECT .ANSWER-
Positive .Homan's .sign.
. .Fundus .hand .placement: .1 .massages .the .fundus .the .other .is .for... .- .CORRECT
.ANSWER-The .other .hand .anchors .the .lower .uterine .section.
DM .I, .HbgA1c .level .7.8 .at .10 .weeks .pregnant. .What .should .the .nurse .do? .-
.CORRECT .ANSWER-Contact .MD .for .BPP . (BioPhysical .Profile).
Symptoms .of .hemorrhage/bleeding .out: .- .CORRECT .ANSWER-LR .200 .mL/hr
.using .18 .gauge .needle.
Most .accurate .way .to .determine .fetal .position .at .29 .weeks .gestation. .- .CORRECT
.ANSWER-Ultrasound.
RATIONALE: .Provides .direct .view .of .the .fetus.
To .measure .contractions... .- .CORRECT .ANSWER-From .beginning .of .a
.contraction, .to .the .beginning .of .the .next .contractions.
. .Newborn .assessment .for .respiratory .distress. .- .CORRECT .ANSWER-Flaring .of
.the .nares.
, RATIONALE: .Forced .inspiration, .grunting, .tachy .(respirations .>60), .cyanosis,
.and .retractions .over .chest .wall).
40 .weeks .pregnant, .laboring, .patient .states .supine .is .position .of .comfort, .the
.nurse .should? .- .CORRECT .ANSWER-Place .pillow .wedge .under .right .hip.
RATIONALE: .Hypotension .from .pressure .on .vena .cava .is .risk, .the .wedge
.relieves .the .pressure .on .the .vena .cava.
MVA, .36 .weeks, .BP .80/50, .HR .130, .what .does .the .nurse .do? .- .CORRECT
.ANSWER-Tilt .the .backboard .to .displace .uterus.
. .Patient .concerned .about .yellow .nipple .discharge. .- .CORRECT .ANSWER-Tell .the
.patient .it .is .normal.
Nutrition .teaching .for .pregnant .teens. .- .CORRECT .ANSWER-Iron-deficient
.anemia.
38 .weeks, .laboring, .which .finding .(condition) .warrants .a .cesarean? .- .CORRECT
.ANSWER-Active . herpes .lesions .on .perineum.
. .Second .stage .of .labor, .what .does .nurse .do .first? .- .CORRECT .ANSWER-Let .pt
.know .that .birth .is .imminent. .
RATIONALE: .Second .stage .pt .is .fully .dilated .and .fetus .is .crowning.
Baby .born .breech, .in .the .NICU .they .assess? .- .CORRECT .ANSWER-Ortolani's
.test.
RATIONALE: .(from .Saunders, .couldn't .find .it .in .HESI). .It .is .a .test .of .hip .laxity,
.used .to .diagnose .hip .dysplasia.
IV .LR .1000 .mL .with .oxytocin .(Pitocin) .40 .units .to .deliver .15mL/hr. .How .many
.milli-units/minute .is .the .client .receiving? .- .CORRECT .ANSWER-10 .mu/min.
38 .week .(IDM) .infant .of .diabetic .mother .admitted .to .NICU .@ .8.2 .lbs. .What .is .the
.priority .Nursing .Dx? .- .CORRECT .ANSWER-Hypoglycemia.
FHR .decreases .after .each .contraction. .What .should .the .nurse .do? .- .CORRECT
.ANSWER-Give .10 .lpm .02 .via .mask.
. .Post .partum .teaching .to .prevent .pregnancy. .- .CORRECT .ANSWER-Use .condom
.and .spermicidal .gel.
1st .trimester, .Hgb .8.6, .Hct .25.1, .what .food .should .the .nurse .encourage? .-
.CORRECT .ANSWER-Chicken.
Oxytocin .(Pitocin) .20 .units .in .1000 .LR .after .delivery .is .for? .- .CORRECT
.ANSWER-To .stimulate .uterine .contractions .to .prevent .hemorrhage.
RATIONALE: .Admin .after .placenta .delivery. .Prior .to .placental .delivery .would
.cause .uterus .to .contract .and .retain .placenta.
