HESI PN Maternity Exit Exam 2025/2026 –
Labor, Postpartum & Neonatal Questions &
Answers in Full with Rationales | 100%
Verified | Graded A+
Key Topics Covered
1. Antepartum Care: Prenatal assessments, complications, and client education.
2. Intrapartum Care: Labor stages, fetal monitoring, and interventions.
3. Postpartum Care: Maternal recovery, complications, and breastfeeding support.
4. Neonatal Care: Newborn assessments, interventions, and infection prevention.
Questions with Verified Answers and Rationales
Multiple-Choice Questions
1. A primigravida at 38 weeks gestation arrives at the labor unit with contractions
every 5 minutes. The fetal heart rate (FHR) is 140 bpm. What should the nurse
assess first to confirm labor?
o a. Cervical dilation and effacement
o b. Maternal blood pressure
o c. Contraction intensity
o d. Fetal position
o ANS: a. Cervical dilation and effacement
▪ Rationale: Cervical dilation and effacement are the primary indicators of
true labor progression.
2. A client in active labor receives an epidural. What is the priority nursing action?
o a. Monitor fetal heart rate
o b. Check maternal blood pressure
o c. Assess pain level
o d. Encourage ambulation
o ANS: b. Check maternal blood pressure
▪ Rationale: Epidurals can cause hypotension, requiring frequent blood
pressure monitoring to ensure maternal and fetal safety.
3. A client at 36 weeks gestation reports leaking fluid. What should the nurse do first?
o a. Perform a vaginal exam
o b. Assess the fluid with nitrazine paper
o c. Monitor fetal heart rate
, o d. Notify the healthcare provider
o ANS: b. Assess the fluid with nitrazine paper
▪ Rationale: Nitrazine paper confirms rupture of membranes by detecting
amniotic fluid’s alkaline pH, guiding further interventions.
4. A multiparous client in labor has a non-reassuring FHR pattern. What should the
nurse do first?
o a. Administer oxygen via face mask
o b. Reposition the client to the left side
o c. Increase IV fluid rate
o d. Notify the healthcare provider
o ANS: b. Reposition the client to the left side
▪ Rationale: Repositioning to the left side improves uteroplacental
perfusion, addressing potential fetal distress.
5. A postpartum client reports heavy vaginal bleeding 24 hours after delivery. What
should the nurse assess first?
o a. Fundal height and firmness
o b. Lochia color
o c. Blood pressure
o d. Perineal pain
o ANS: a. Fundal height and firmness
▪ Rationale: Heavy bleeding may indicate uterine atony, requiring
immediate fundal assessment to ensure contraction.
6. A newborn is placed under a radiant warmer due to an axillary temperature of
97.2°F. What is the rationale for this action?
o a. Promotes weight gain
o b. Prevents infection
o c. Maintains thermoregulation
o d. Enhances bonding
o ANS: c. Maintains thermoregulation
▪ Rationale: Newborns have poor insulation due to minimal subcutaneous
fat, requiring external heat to maintain body temperature.
7. A breastfeeding mother reports breast engorgement. What should the nurse
recommend?
o a. Apply cold compresses between feedings
o b. Gently massage breasts during feeding
o c. Stop breastfeeding for 24 hours
o d. Use a breast pump every 6 hours
o ANS: b. Gently massage breasts during feeding
▪ Rationale: Massaging during feeding promotes milk flow, relieving
engorgement without interrupting breastfeeding.
8. A client at 39 weeks gestation reports severe abdominal pain and no fetal movement.
What should the nurse do first?
o a. Perform a non-stress test
o b. Assess fetal heart rate
o c. Notify the healthcare provider
o d. Prepare for an ultrasound
, o ANS: b. Assess fetal heart rate
▪ Rationale: Decreased fetal movement and pain suggest fetal distress,
requiring immediate FHR assessment.
9. A newborn with a suspected herpes infection is admitted to the nursery. What
should the nurse do first?
o a. Administer vitamin K injection
o b. Place the newborn in isolation
o c. Obtain a blood glucose level
o d. Document the temperature
o ANS: b. Place the newborn in isolation
▪ Rationale: Isolation prevents transmission of herpes to other newborns,
prioritizing infection control.
10. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates
toxicity?
o a. Respiratory rate of 10/min
o b. Blood pressure of 140/90 mmHg
o c. Deep tendon reflexes of 2+
o d. Urine output of 50 mL/hr
o ANS: a. Respiratory rate of 10/min
▪ Rationale: Magnesium sulfate toxicity can cause respiratory depression
(<12/min), requiring immediate intervention.
Select-All-That-Apply Questions
11. A nurse is teaching a prenatal class about signs of labor. Which findings should the
nurse include? (Select all that apply.)
o a. Regular, frequent contractions
o b. Bloody show
o c. Increased appetite
o d. Rupture of membranes
o e. Elevated blood pressure
o ANS: a, b, d
▪ Rationale: Regular contractions (a), bloody show (b), and rupture of
membranes (d) indicate labor onset. Appetite (c) and blood pressure (e)
are not specific signs.
12. A postpartum client is at risk for infection. Which interventions should the nurse
implement? (Select all that apply.)
o a. Teach hand hygiene
o b. Monitor lochia for foul odor
o c. Encourage early ambulation
o d. Administer antibiotics prophylactically
o e. Assess perineal integrity
o ANS: a, b, e
▪ Rationale: Hand hygiene (a) prevents infection; foul lochia (b) indicates
infection; perineal assessment (e) detects issues. Prophylactic antibiotics
Labor, Postpartum & Neonatal Questions &
Answers in Full with Rationales | 100%
Verified | Graded A+
Key Topics Covered
1. Antepartum Care: Prenatal assessments, complications, and client education.
2. Intrapartum Care: Labor stages, fetal monitoring, and interventions.
3. Postpartum Care: Maternal recovery, complications, and breastfeeding support.
4. Neonatal Care: Newborn assessments, interventions, and infection prevention.
Questions with Verified Answers and Rationales
Multiple-Choice Questions
1. A primigravida at 38 weeks gestation arrives at the labor unit with contractions
every 5 minutes. The fetal heart rate (FHR) is 140 bpm. What should the nurse
assess first to confirm labor?
o a. Cervical dilation and effacement
o b. Maternal blood pressure
o c. Contraction intensity
o d. Fetal position
o ANS: a. Cervical dilation and effacement
▪ Rationale: Cervical dilation and effacement are the primary indicators of
true labor progression.
2. A client in active labor receives an epidural. What is the priority nursing action?
o a. Monitor fetal heart rate
o b. Check maternal blood pressure
o c. Assess pain level
o d. Encourage ambulation
o ANS: b. Check maternal blood pressure
▪ Rationale: Epidurals can cause hypotension, requiring frequent blood
pressure monitoring to ensure maternal and fetal safety.
3. A client at 36 weeks gestation reports leaking fluid. What should the nurse do first?
o a. Perform a vaginal exam
o b. Assess the fluid with nitrazine paper
o c. Monitor fetal heart rate
, o d. Notify the healthcare provider
o ANS: b. Assess the fluid with nitrazine paper
▪ Rationale: Nitrazine paper confirms rupture of membranes by detecting
amniotic fluid’s alkaline pH, guiding further interventions.
4. A multiparous client in labor has a non-reassuring FHR pattern. What should the
nurse do first?
o a. Administer oxygen via face mask
o b. Reposition the client to the left side
o c. Increase IV fluid rate
o d. Notify the healthcare provider
o ANS: b. Reposition the client to the left side
▪ Rationale: Repositioning to the left side improves uteroplacental
perfusion, addressing potential fetal distress.
5. A postpartum client reports heavy vaginal bleeding 24 hours after delivery. What
should the nurse assess first?
o a. Fundal height and firmness
o b. Lochia color
o c. Blood pressure
o d. Perineal pain
o ANS: a. Fundal height and firmness
▪ Rationale: Heavy bleeding may indicate uterine atony, requiring
immediate fundal assessment to ensure contraction.
6. A newborn is placed under a radiant warmer due to an axillary temperature of
97.2°F. What is the rationale for this action?
o a. Promotes weight gain
o b. Prevents infection
o c. Maintains thermoregulation
o d. Enhances bonding
o ANS: c. Maintains thermoregulation
▪ Rationale: Newborns have poor insulation due to minimal subcutaneous
fat, requiring external heat to maintain body temperature.
7. A breastfeeding mother reports breast engorgement. What should the nurse
recommend?
o a. Apply cold compresses between feedings
o b. Gently massage breasts during feeding
o c. Stop breastfeeding for 24 hours
o d. Use a breast pump every 6 hours
o ANS: b. Gently massage breasts during feeding
▪ Rationale: Massaging during feeding promotes milk flow, relieving
engorgement without interrupting breastfeeding.
8. A client at 39 weeks gestation reports severe abdominal pain and no fetal movement.
What should the nurse do first?
o a. Perform a non-stress test
o b. Assess fetal heart rate
o c. Notify the healthcare provider
o d. Prepare for an ultrasound
, o ANS: b. Assess fetal heart rate
▪ Rationale: Decreased fetal movement and pain suggest fetal distress,
requiring immediate FHR assessment.
9. A newborn with a suspected herpes infection is admitted to the nursery. What
should the nurse do first?
o a. Administer vitamin K injection
o b. Place the newborn in isolation
o c. Obtain a blood glucose level
o d. Document the temperature
o ANS: b. Place the newborn in isolation
▪ Rationale: Isolation prevents transmission of herpes to other newborns,
prioritizing infection control.
10. A client with preeclampsia is receiving magnesium sulfate. Which finding indicates
toxicity?
o a. Respiratory rate of 10/min
o b. Blood pressure of 140/90 mmHg
o c. Deep tendon reflexes of 2+
o d. Urine output of 50 mL/hr
o ANS: a. Respiratory rate of 10/min
▪ Rationale: Magnesium sulfate toxicity can cause respiratory depression
(<12/min), requiring immediate intervention.
Select-All-That-Apply Questions
11. A nurse is teaching a prenatal class about signs of labor. Which findings should the
nurse include? (Select all that apply.)
o a. Regular, frequent contractions
o b. Bloody show
o c. Increased appetite
o d. Rupture of membranes
o e. Elevated blood pressure
o ANS: a, b, d
▪ Rationale: Regular contractions (a), bloody show (b), and rupture of
membranes (d) indicate labor onset. Appetite (c) and blood pressure (e)
are not specific signs.
12. A postpartum client is at risk for infection. Which interventions should the nurse
implement? (Select all that apply.)
o a. Teach hand hygiene
o b. Monitor lochia for foul odor
o c. Encourage early ambulation
o d. Administer antibiotics prophylactically
o e. Assess perineal integrity
o ANS: a, b, e
▪ Rationale: Hand hygiene (a) prevents infection; foul lochia (b) indicates
infection; perineal assessment (e) detects issues. Prophylactic antibiotics
