Maternity HESI 1,2 Test Bank |Questions, Answers & Rationale
(Summer 2025/2026) 100% CORRECT/Grade A+ Assured
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the
baby when it moves too much. Which recommendation should the nurse make to this expectant
father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - (Correct Answer) - D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal movement,
occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during
the second trimester. Options A and C are not necessary because the behaviors displayed
are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
,[Type here]
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - (Correct Answer) - C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and consistency. Option A should be
assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is
monitored hourly after the membranes are ruptured to detect the development of
amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
,[Type here]
D.Red patches on the cheeks and trunk - (Correct Answer) - B. Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of
the hands and feet) is a common finding in newborns; it occurs because the capillary
system is immature. Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on
the cheeks and trunk are called erythema toxicum neonatorum, a common finding in
newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed.
Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. -
(Correct Answer) - A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
, [Type here]
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not
facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement
on the affected side. Option D will not decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells
the nurse that her feet have begun to swell. Which instruction will aid in the prevention of
pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - (Correct Answer) - C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure
on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and
increase venous return. Option A would increase venous return from varicose veins in the
lower extremities but would be of little help with swelling. Option B might be helpful with
generalized edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive clothing
is a problem.
(Summer 2025/2026) 100% CORRECT/Grade A+ Assured
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the
baby when it moves too much. Which recommendation should the nurse make to this expectant
father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - (Correct Answer) - D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal movement,
occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal bonding during
the second trimester. Options A and C are not necessary because the behaviors displayed
are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
,[Type here]
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - (Correct Answer) - C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and consistency. Option A should be
assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is
monitored hourly after the membranes are ruptured to detect the development of
amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
,[Type here]
D.Red patches on the cheeks and trunk - (Correct Answer) - B. Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of
the hands and feet) is a common finding in newborns; it occurs because the capillary
system is immature. Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on
the cheeks and trunk are called erythema toxicum neonatorum, a common finding in
newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed.
Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. -
(Correct Answer) - A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
, [Type here]
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not
facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement
on the affected side. Option D will not decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells
the nurse that her feet have begun to swell. Which instruction will aid in the prevention of
pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - (Correct Answer) - C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure
on the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and
increase venous return. Option A would increase venous return from varicose veins in the
lower extremities but would be of little help with swelling. Option B might be helpful with
generalized edema but is not specific for edematous lower extremities. Option D does not
address venous return, and there is no indication in the question that constrictive clothing
is a problem.
