Maternity HESI Questions EXAM GRADED A+ QUESTIONS AND CORRECT ANSWERS
100% VERIFIED
While inspecting a newborn’s head, the nurse identifies a swelling of the scalp
that does not cross the suture line. Which finding should the nurse document?
Cephalohematoma
A cephalohematoma (B) should be documented because it is a collection of
blood beneath the periosteum of the cranial bone causing scalp swelling that
does not cross the suture line. Molding (A) is overlapping of cranial bones that
occurs as the fetal head accommodates for the descent through the vaginal
vault. Caput succedaneum (C) is differentiated from a cephalohematoma by
generalized edematous swelling of the presenting part of the head. Fontanel
tension should feel slightly concave and well defined against the edges of the
cranial bones, whereas a bulging anterior fontanel (D) is tense and distends
from an increased intracranial pressure, such as seen in congenital
hydrocephalus.
What assessment finding should the nurse report to the healthcare provider
that is consistent with concealed hemorrhage in an abruptio placenta?
Hard, board-like abdomen
Abruptio placenta causes concealed intrauterine hemorrhage when the
placenta separates and its edges do not. The formation of a hematoma behind
the placenta and subsequent infiltration of the blood manifests as a firm,
board-like abdomen (B), which should be reported immediately to the
healthcare provider. As bleeding occurs, fetal oxygenation and maternal
stability are compromised leading to fetal and maternal tachycardia, not (A).
With abruptio placenta, fundal height and abdominal pain increase, not (C and
D).
While assessing a newborn the nurse observes diffuse edema of the soft
tissues of the scalp that cross the suture lines. How should the nurse
document this finding?
Caput succedaneum
Caput succedaneum (D) is characterized by swelling of the soft tissues of the
scalp that extends across suture lines. Molding (A) of the head results from
adjustment of the infant’s skull structure, which allows for the passage of the
,infant’s head through the birth canal and is a common occurence in vaginal
deliveries. Hemangioma (B) is a collection of blood vessels close to the skin.
Cephalohematoma (C) is an edematous area caused by extravasation of blood
between the skull bone and periosteum and does not cross the suture lines,
which differentiates it from caput succedaneum.
The nurse notes an irregular bluish hue on the sacral area of a 1-day old
Hispanic infant. How should the nurse document this finding?
Mongolian spots
Mongolian spots (usually in the sacral, lumbar, and gluteal regions) are a
common skin variation in newborns of African, Asian, Native American, and
Hispanic descent (B). (A) refers to cyanosis of the hands and feet, a normal
finding in newborns soon after birth. (C) is a pink, papular rash that may
appear on the thorax, back, buttocks, and abdomen within 24 to 48 hours after
birth. (D) is visible when an infant lies on the side and the lower half of the
body is pink or red and the upper half is pale.
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her
obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks
gestation. Using the GTPAL system, which designation is the most accurate
summary of this client's obstetrical history?
4-1-2-0-3
The client with 3 previous gravid experiences and this current pregnancy
totals 4 gravid experiences, and 1 term delivery (37-weeks or greater), 2
preterm deliveries (20 to 37 weeks, whether viable or not viable), no
spontaneous abortions and 3 living children. (B) best designates this client's
obstetrical history. (A, C, and D) are inaccurate for this client's history using
the TPAL system.
An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a
nuchal cord after a 30-minute second stage. The nurse identifies petechiae
over the face and upper back of the newborn. What information should the
nurse provide the parents about this finding?
The pinpoint spots are benign and disappear within 48 hours.
Rapid delivery and a tight nuchal cord cause the presenting parts (head) to
have bruising and pin point hemorrhages (petechiae), which are benign and
usually disappear within two days after birth (D). (A) is not indicated. Birth
, injuries caused by forceps (B) present as linear configuration across both
sides of the face and outline the placement of the forceps. (C) is inaccurate.
A client in early labor is having uterine contractions every 3 to 4 minutes,
lasting an average of 55 to 60 seconds. An internal uterine pressure catheter
(IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a
contraction and the resting tone is 6 to 10 mm Hg. Based on this information,
what action should the nurse implement?
Document the findings in the client's record.
This labor pattern indicates that the client is in the active phase of the first
stage of labor and has a normal labor pattern, so the findings should be
documented in the client’s medical record (D). There is no indication to notify
the healthcare provider (A) or bring the delivery table into the room (B) at this
time. Oxytocin augmentation (C) is not needed for this labor pattern.
Which prescription should the nurse administer to a newborn to reduce
complications related to birth trauma?
Vitamin K
The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin
levels and reduce the risk of neonatal bleeding, newborns receive a single
injection of vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic
ophthalmic agents used to prevent neonatal ophthalmia. (C) is an antibiotic
used to treat neonatal infections.
A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water"
has broken. While inspecting the client's perineum, the nurse notes the
umbilical cord protruding from the vagina. What action should the nurse
implement first?
Place the client in a knee-chest position.
Until an emergency delivery is accomplished, the client should be placed in a
knee-chest position (C) to relieve compression of the presenting part on the
umbilical cord, which can compromise fetal oxygenation. (A, B, and C) are
implemented after the client is positioned to relieve pressure on the umbilical
cord.
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most
important for the nurse to report to the healthcare provider?
Bilirubin
100% VERIFIED
While inspecting a newborn’s head, the nurse identifies a swelling of the scalp
that does not cross the suture line. Which finding should the nurse document?
Cephalohematoma
A cephalohematoma (B) should be documented because it is a collection of
blood beneath the periosteum of the cranial bone causing scalp swelling that
does not cross the suture line. Molding (A) is overlapping of cranial bones that
occurs as the fetal head accommodates for the descent through the vaginal
vault. Caput succedaneum (C) is differentiated from a cephalohematoma by
generalized edematous swelling of the presenting part of the head. Fontanel
tension should feel slightly concave and well defined against the edges of the
cranial bones, whereas a bulging anterior fontanel (D) is tense and distends
from an increased intracranial pressure, such as seen in congenital
hydrocephalus.
What assessment finding should the nurse report to the healthcare provider
that is consistent with concealed hemorrhage in an abruptio placenta?
Hard, board-like abdomen
Abruptio placenta causes concealed intrauterine hemorrhage when the
placenta separates and its edges do not. The formation of a hematoma behind
the placenta and subsequent infiltration of the blood manifests as a firm,
board-like abdomen (B), which should be reported immediately to the
healthcare provider. As bleeding occurs, fetal oxygenation and maternal
stability are compromised leading to fetal and maternal tachycardia, not (A).
With abruptio placenta, fundal height and abdominal pain increase, not (C and
D).
While assessing a newborn the nurse observes diffuse edema of the soft
tissues of the scalp that cross the suture lines. How should the nurse
document this finding?
Caput succedaneum
Caput succedaneum (D) is characterized by swelling of the soft tissues of the
scalp that extends across suture lines. Molding (A) of the head results from
adjustment of the infant’s skull structure, which allows for the passage of the
,infant’s head through the birth canal and is a common occurence in vaginal
deliveries. Hemangioma (B) is a collection of blood vessels close to the skin.
Cephalohematoma (C) is an edematous area caused by extravasation of blood
between the skull bone and periosteum and does not cross the suture lines,
which differentiates it from caput succedaneum.
The nurse notes an irregular bluish hue on the sacral area of a 1-day old
Hispanic infant. How should the nurse document this finding?
Mongolian spots
Mongolian spots (usually in the sacral, lumbar, and gluteal regions) are a
common skin variation in newborns of African, Asian, Native American, and
Hispanic descent (B). (A) refers to cyanosis of the hands and feet, a normal
finding in newborns soon after birth. (C) is a pink, papular rash that may
appear on the thorax, back, buttocks, and abdomen within 24 to 48 hours after
birth. (D) is visible when an infant lies on the side and the lower half of the
body is pink or red and the upper half is pale.
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her
obstetrical history includes 3 live births at 39-weeks, 34-weeks, and 35-weeks
gestation. Using the GTPAL system, which designation is the most accurate
summary of this client's obstetrical history?
4-1-2-0-3
The client with 3 previous gravid experiences and this current pregnancy
totals 4 gravid experiences, and 1 term delivery (37-weeks or greater), 2
preterm deliveries (20 to 37 weeks, whether viable or not viable), no
spontaneous abortions and 3 living children. (B) best designates this client's
obstetrical history. (A, C, and D) are inaccurate for this client's history using
the TPAL system.
An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a
nuchal cord after a 30-minute second stage. The nurse identifies petechiae
over the face and upper back of the newborn. What information should the
nurse provide the parents about this finding?
The pinpoint spots are benign and disappear within 48 hours.
Rapid delivery and a tight nuchal cord cause the presenting parts (head) to
have bruising and pin point hemorrhages (petechiae), which are benign and
usually disappear within two days after birth (D). (A) is not indicated. Birth
, injuries caused by forceps (B) present as linear configuration across both
sides of the face and outline the placement of the forceps. (C) is inaccurate.
A client in early labor is having uterine contractions every 3 to 4 minutes,
lasting an average of 55 to 60 seconds. An internal uterine pressure catheter
(IUPC) is inserted. The intrauterine pressure is 65 to 70 mm Hg at the peak of a
contraction and the resting tone is 6 to 10 mm Hg. Based on this information,
what action should the nurse implement?
Document the findings in the client's record.
This labor pattern indicates that the client is in the active phase of the first
stage of labor and has a normal labor pattern, so the findings should be
documented in the client’s medical record (D). There is no indication to notify
the healthcare provider (A) or bring the delivery table into the room (B) at this
time. Oxytocin augmentation (C) is not needed for this labor pattern.
Which prescription should the nurse administer to a newborn to reduce
complications related to birth trauma?
Vitamin K
The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin
levels and reduce the risk of neonatal bleeding, newborns receive a single
injection of vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic
ophthalmic agents used to prevent neonatal ophthalmia. (C) is an antibiotic
used to treat neonatal infections.
A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water"
has broken. While inspecting the client's perineum, the nurse notes the
umbilical cord protruding from the vagina. What action should the nurse
implement first?
Place the client in a knee-chest position.
Until an emergency delivery is accomplished, the client should be placed in a
knee-chest position (C) to relieve compression of the presenting part on the
umbilical cord, which can compromise fetal oxygenation. (A, B, and C) are
implemented after the client is positioned to relieve pressure on the umbilical
cord.
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most
important for the nurse to report to the healthcare provider?
Bilirubin
