HESI Review Test-Maternity Exam GRADED A+ QUESTIONS AND CORRECT ANSWERS
100% VERIFIED 2025-2026
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the
symptoms. Which assessment finding indicates the therapeutic drug level has
been achieved?
A decrease in respiratory rate from 24 to 16.
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12
indicates toxic effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for
an amniotomy. What equipment should the nurse have available at the client's
bedside? (Select all that apply.)
A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
Lying prone with a pillow on the abdomen. Lying prone (A) keeps the fundus
contracted and is especially useful with multiparas, who commonly experience
afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin
(Pitocin) to augment early labor. The nurse should discontinue the oxytocin
infusion for which pattern of contractions?
Transition labor with contractions every 2 minutes, lasting 90 seconds each.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of
a dull pain in the right lower quadrant of her abdomen. The nurse obtains a
blood sample and initiates an IV. Thirty minutes after admission, the client
reports feeling a sharp abdominal pain and a shoulder pain. Assessment
findings include diaphoresis, a heart rate of 120 beats/minute, and a blood
pressure of 86/48. Which action should the nurse implement next?
, Increase IV rate. The client is demonstrating symptoms of blood loss, probably the
result of an ectopic pregnancy, which occurs at approximately 14-weeks gestation
when embryonic growth expands the fallopian tube causing its rupture, and can
result in hemorrage and hypovolemic shock. Increasing the IV infusion rate (C)
provides intravascular fluid to maintain blood pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and
tender upon palpation. What action should the nurse take?
Apply cold compresses to both breasts for comfort. The client is experiencing
engorgement even though she is bottle-feeding her infant, and cold compresses (A)
may help reduce discomfort. Lactation begins about the third day after delivery, so
the mother should avoid any breast stimulation,
The nurse is providing discharge teaching for a client who is 24 hours
postpartum. The nurse explains to the client that her vaginal discharge will
change from red to pink and then to white. The client asks, "What if I start
having red bleeding after it changes?" What should the nurse instruct the
client to do?
Reduce activity level and notify the healthcare provider. Lochia should progress in
stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red.
The return to rubra usually indicates subinvolution or infection. If such a sign occurs,
the mother should notify the clinic/healthcare provider and reduce her activity to
conserve energy (A).
The nurse is preparing to give an enema to a laboring client. Which client
requires the most caution when carrying out this procedure?
A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is
not engaged. When the presenting part is ballottable (D), it is floating out of the
pelvis. In such a situation, the cord can descend before the fetus causing a
prolapsed cord, which is an emergency situation.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based
on this finding, which intervention should the nurse implement?
Encourage the mother to breastfeed frequently. The normal total bilirubin level is 6 to
12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant
should be monitored to prevent further complications. Breast milk provides calories
and enhances GI motility, which will assist the bowel in eliminating bilirubin (C)
100% VERIFIED 2025-2026
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the
symptoms. Which assessment finding indicates the therapeutic drug level has
been achieved?
A decrease in respiratory rate from 24 to 16.
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12
indicates toxic effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for
an amniotomy. What equipment should the nurse have available at the client's
bedside? (Select all that apply.)
A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?"
Lying prone with a pillow on the abdomen. Lying prone (A) keeps the fundus
contracted and is especially useful with multiparas, who commonly experience
afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin
(Pitocin) to augment early labor. The nurse should discontinue the oxytocin
infusion for which pattern of contractions?
Transition labor with contractions every 2 minutes, lasting 90 seconds each.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of
a dull pain in the right lower quadrant of her abdomen. The nurse obtains a
blood sample and initiates an IV. Thirty minutes after admission, the client
reports feeling a sharp abdominal pain and a shoulder pain. Assessment
findings include diaphoresis, a heart rate of 120 beats/minute, and a blood
pressure of 86/48. Which action should the nurse implement next?
, Increase IV rate. The client is demonstrating symptoms of blood loss, probably the
result of an ectopic pregnancy, which occurs at approximately 14-weeks gestation
when embryonic growth expands the fallopian tube causing its rupture, and can
result in hemorrage and hypovolemic shock. Increasing the IV infusion rate (C)
provides intravascular fluid to maintain blood pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and
tender upon palpation. What action should the nurse take?
Apply cold compresses to both breasts for comfort. The client is experiencing
engorgement even though she is bottle-feeding her infant, and cold compresses (A)
may help reduce discomfort. Lactation begins about the third day after delivery, so
the mother should avoid any breast stimulation,
The nurse is providing discharge teaching for a client who is 24 hours
postpartum. The nurse explains to the client that her vaginal discharge will
change from red to pink and then to white. The client asks, "What if I start
having red bleeding after it changes?" What should the nurse instruct the
client to do?
Reduce activity level and notify the healthcare provider. Lochia should progress in
stages from rubra (red) to serosa (pinkish) to alba (whitish), and not return to red.
The return to rubra usually indicates subinvolution or infection. If such a sign occurs,
the mother should notify the clinic/healthcare provider and reduce her activity to
conserve energy (A).
The nurse is preparing to give an enema to a laboring client. Which client
requires the most caution when carrying out this procedure?
A 40-week primigravida who is at 6 cm cervical dilatation and the presenting part is
not engaged. When the presenting part is ballottable (D), it is floating out of the
pelvis. In such a situation, the cord can descend before the fetus causing a
prolapsed cord, which is an emergency situation.
The total bilirubin level of a 36-hour, breastfeeding newborn is 14 mg/dl. Based
on this finding, which intervention should the nurse implement?
Encourage the mother to breastfeed frequently. The normal total bilirubin level is 6 to
12 mg/dl after Day 1 of life. This infant's bilirubin is beginning to climb and the infant
should be monitored to prevent further complications. Breast milk provides calories
and enhances GI motility, which will assist the bowel in eliminating bilirubin (C)
