REVISED MATERNITY HESI
QUESTIONS AND VERIFIED
ANSWERS
The nurse observes a new mother avoiding eye contact with her newborn. Which action
should the nurse take? - CORRECT ANSWER -Observe the mother for other attachment
behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose? - CORRECT ANSWER -Screen for neural tube defects.
What action should the nurse implement to decrease the client's risk for hemorrhage after a
cesarean section? - CORRECT ANSWER -Check the firmness of the uterus every 15 minutes.
The nurse attempts to help an unmarried teenager deal with her feelings following a
spontaneous abortion at 8-weeks gestation. What type of emotional response should the
nurse anticipate? - CORRECT ANSWER -Grief related to her perceptions about the loss of
this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider? - CORRECT
ANSWER -Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and
her husband consider attending childbirth preparation classes. When is the best time for the
couple to attend these classes? - CORRECT ANSWER -At 30-weeks gestation is closest to the
time parents would be ready for such classes. Learning is facilitated by an interested pupil!
The couple is most interested in childbirth toward the end of the pregnancy when they are
psychologically ready for the termination of the pregnancy, and the birth of their child is
an immediate concern.
,A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion? - CORRECT ANSWER -Epigastric pain (C) is
indicative of an edematous liver or pancreas which is an early warning sign of an impending
convulsion (eclampsia) and requires immediate attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is most
important for the nurse to report to the healthcare provider immediately? - CORRECT
ANSWER -Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use
herbal therapy. Which response is best for the nurse to provide? - CORRECT ANSWER -It is
important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is referred to a
healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which
postprocedure complaint indicates that the fallopian tubes are patent? - CORRECT ANSWER -
If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic
collection of peritoneal dye/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath
her buttock. The nurse notes that both perineal pads are completely saturated and the
client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement
next? - CORRECT ANSWER -Palpate the firmness of the fundus.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from
small to large and her fundus is boggy despite massage. The client's pulse is 84
beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine
0.2 mg IM × 1. What action should the nurse take immediately? - CORRECT ANSWER -
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should
contact the healthcare provider and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask
this client? - CORRECT ANSWER -Do you have a history of rheumatic fever? Clients with a
history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for
cardiac decompensation due to the increased
,blood volume that occurs during pregnancy, so obtaining information about this client's health
history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin? - CORRECT
ANSWER -Pitocin causes the uterine myofibril to contract, so unless the infusion is closely
monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic
contractions, uterine rupture, and fetal distress or demise.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity? - CORRECT ANSWER -Urine output 90 ml/4 hours.
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less
than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which information should the
nurse provide the client? - CORRECT ANSWER -Encourage healthy lifestyles for families desiring
pregnancy. Planning for pregnancy begins with healthy lifestyles in the family (D) which is an
intervention in preconception care that targets an overall goal for a client preparing for
pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-
stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic
test should the nurse prepare the client for additional information about fetal status? - CORRECT
ANSWER -Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by
examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal
tone and heart rate.
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!"
The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated
and 75% effaced. What additional information is most important for the nurse to obtain? -
CORRECT ANSWER -Date of last normal menstrual period. Evaluating the gestation of the
pregnancy (C) takes priority. If the fetus is preterm and the fetal heart pattern is
reassuring, the healthcare provider may attempt to prolong the pregnancy and administer
corticosteroids to mature the lungs of the fetus.
, A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing
a small amount of vaginal bleeding which she describes as bright red. She further states
that she is not experiencing any uterine contractions or abdominal pain. What instruction
should the nurse provide? - CORRECT ANSWER -Come to the clinic today for an ultrasound.
Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-
threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal
ultrasound (A).
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."
Which explanation should the nurse give to this anxious client? - CORRECT ANSWER -There's
a strong, tough membrane there to protect the baby so you need not be afraid to wash
or comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing actions?
(Arrange in order.) - CORRECT ANSWER - Reposition the client.
Provide oxygen via face
mask. Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest
priority? - CORRECT ANSWER -Put the newborn to breast. Putting the newborn to breast
(D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has
the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary
infusion and complains of pain in her lower back. Which intervention should the nurse
implement? - CORRECT ANSWER -Apply firm pressure to sacral area. The discomfort of back
labor can be minimized by the application of firm pressure to the sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag
of water has broken. The nurse identifies the presence of meconium fluid on the perineum
and determines the fetal heart rate is between 140 to 150 beats/minute. What action
should the nurse implement next? -
QUESTIONS AND VERIFIED
ANSWERS
The nurse observes a new mother avoiding eye contact with her newborn. Which action
should the nurse take? - CORRECT ANSWER -Observe the mother for other attachment
behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose? - CORRECT ANSWER -Screen for neural tube defects.
What action should the nurse implement to decrease the client's risk for hemorrhage after a
cesarean section? - CORRECT ANSWER -Check the firmness of the uterus every 15 minutes.
The nurse attempts to help an unmarried teenager deal with her feelings following a
spontaneous abortion at 8-weeks gestation. What type of emotional response should the
nurse anticipate? - CORRECT ANSWER -Grief related to her perceptions about the loss of
this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider? - CORRECT
ANSWER -Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and
her husband consider attending childbirth preparation classes. When is the best time for the
couple to attend these classes? - CORRECT ANSWER -At 30-weeks gestation is closest to the
time parents would be ready for such classes. Learning is facilitated by an interested pupil!
The couple is most interested in childbirth toward the end of the pregnancy when they are
psychologically ready for the termination of the pregnancy, and the birth of their child is
an immediate concern.
,A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion? - CORRECT ANSWER -Epigastric pain (C) is
indicative of an edematous liver or pancreas which is an early warning sign of an impending
convulsion (eclampsia) and requires immediate attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is most
important for the nurse to report to the healthcare provider immediately? - CORRECT
ANSWER -Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use
herbal therapy. Which response is best for the nurse to provide? - CORRECT ANSWER -It is
important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is referred to a
healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which
postprocedure complaint indicates that the fallopian tubes are patent? - CORRECT ANSWER -
If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic
collection of peritoneal dye/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath
her buttock. The nurse notes that both perineal pads are completely saturated and the
client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement
next? - CORRECT ANSWER -Palpate the firmness of the fundus.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from
small to large and her fundus is boggy despite massage. The client's pulse is 84
beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine
0.2 mg IM × 1. What action should the nurse take immediately? - CORRECT ANSWER -
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should
contact the healthcare provider and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask
this client? - CORRECT ANSWER -Do you have a history of rheumatic fever? Clients with a
history of rheumatic fever (D) may develop mitral valve prolapse, which increases the risk for
cardiac decompensation due to the increased
,blood volume that occurs during pregnancy, so obtaining information about this client's health
history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin? - CORRECT
ANSWER -Pitocin causes the uterine myofibril to contract, so unless the infusion is closely
monitored, the client is at risk for hyperstimulation (B) which can lead to tetanic
contractions, uterine rupture, and fetal distress or demise.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity? - CORRECT ANSWER -Urine output 90 ml/4 hours.
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less
than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which information should the
nurse provide the client? - CORRECT ANSWER -Encourage healthy lifestyles for families desiring
pregnancy. Planning for pregnancy begins with healthy lifestyles in the family (D) which is an
intervention in preconception care that targets an overall goal for a client preparing for
pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-
stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic
test should the nurse prepare the client for additional information about fetal status? - CORRECT
ANSWER -Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by
examining 5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal
tone and heart rate.
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!"
The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated
and 75% effaced. What additional information is most important for the nurse to obtain? -
CORRECT ANSWER -Date of last normal menstrual period. Evaluating the gestation of the
pregnancy (C) takes priority. If the fetus is preterm and the fetal heart pattern is
reassuring, the healthcare provider may attempt to prolong the pregnancy and administer
corticosteroids to mature the lungs of the fetus.
, A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing
a small amount of vaginal bleeding which she describes as bright red. She further states
that she is not experiencing any uterine contractions or abdominal pain. What instruction
should the nurse provide? - CORRECT ANSWER -Come to the clinic today for an ultrasound.
Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-
threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal
ultrasound (A).
A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot."
Which explanation should the nurse give to this anxious client? - CORRECT ANSWER -There's
a strong, tough membrane there to protect the baby so you need not be afraid to wash
or comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing actions?
(Arrange in order.) - CORRECT ANSWER - Reposition the client.
Provide oxygen via face
mask. Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest
priority? - CORRECT ANSWER -Put the newborn to breast. Putting the newborn to breast
(D) will help contract the uterus and prevent a postpartum hemorrhage--this intervention has
the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary
infusion and complains of pain in her lower back. Which intervention should the nurse
implement? - CORRECT ANSWER -Apply firm pressure to sacral area. The discomfort of back
labor can be minimized by the application of firm pressure to the sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag
of water has broken. The nurse identifies the presence of meconium fluid on the perineum
and determines the fetal heart rate is between 140 to 150 beats/minute. What action
should the nurse implement next? -
