HESI Comprehensive NCLEX-RN Practice
(Maternity) COMPLETE SOLUTION
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. Which is the correct description of this client that should be documented in the
medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1 - ANSWER-C) Gravida 2, para 0
Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0.
Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth - ANSWER-C) Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the
drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of
nervousness.
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. - 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.
,HESI Comprehensive NCLEX-RN Practice
(Maternity) COMPLETE SOLUTION
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and
occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each
contraction and returns to baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER-B) Determine cervical dilation and
effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.
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. -
ANSWER-A) Breastfeed the infant, ensuring that both breasts are completely emptied.
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.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a
small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She
further states that she is not experiencing any uterine contractions or abdominal pain. What
instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI). -
ANSWER-A) Come to the clinic today for an ultrasound.
Rationale: Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous.
, HESI Comprehensive NCLEX-RN Practice
(Maternity) COMPLETE SOLUTION
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The
home health nurse has taught her how to take her own blood pressure and gave her parameters to
judge a significant increase in blood pressure. When the client calls the clinic complaining of
indigestion, which instruction should the nurse provide?
A.Lie on your left side and call 911 for emergency assistance.
B.Take an antacid and call back if the pain has not subsided.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D.See your health care provider to obtain a prescription for a histamine blocking agent. - ANSWER-C)
Take your blood pressure now, and if it is seriously elevated, go to the hospital.
Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A
blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign
of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.
A client in active labor is becoming increasingly fearful because her contractions are occurring more
often than she had expected. Her partner is also becoming anxious. Which of the following should be
the focus of the nurse's response?
A.Telling the client and her partner that the labor process is often unpredictable
B.Informing the client that this means she will give birth sooner than expected
C.Asking the client and her partner if they would like the nurse to stay in the room
D.Affirming that the fetal heart rate is remaining within normal limits - ANSWER-C) Asking the client
and her partner if they would like the nurse to stay in the room
Rationale: Offering to remain with the client and her partner offers support without providing false
reassurance.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is
getting lighter in color. Which action should the nurse take?
A.Instruct the client to go to the emergency room.
B.Recommend vaginal douching.
C.Explain this is a normal finding.
D.Determine if ovulation has occurred. - ANSWER-C)Explain this is a normal finding.
Rationale:The client is describing lochia serosa, a normal change in the lochial flow.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA)
pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining
(Maternity) COMPLETE SOLUTION
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. Which is the correct description of this client that should be documented in the
medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1 - ANSWER-C) Gravida 2, para 0
Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0.
Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth - ANSWER-C) Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the
drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of
nervousness.
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. - 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.
,HESI Comprehensive NCLEX-RN Practice
(Maternity) COMPLETE SOLUTION
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and
occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each
contraction and returns to baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER-B) Determine cervical dilation and
effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress.
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. -
ANSWER-A) Breastfeed the infant, ensuring that both breasts are completely emptied.
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.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a
small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She
further states that she is not experiencing any uterine contractions or abdominal pain. What
instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection (UTI). -
ANSWER-A) Come to the clinic today for an ultrasound.
Rationale: Third-trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous.
, HESI Comprehensive NCLEX-RN Practice
(Maternity) COMPLETE SOLUTION
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The
home health nurse has taught her how to take her own blood pressure and gave her parameters to
judge a significant increase in blood pressure. When the client calls the clinic complaining of
indigestion, which instruction should the nurse provide?
A.Lie on your left side and call 911 for emergency assistance.
B.Take an antacid and call back if the pain has not subsided.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D.See your health care provider to obtain a prescription for a histamine blocking agent. - ANSWER-C)
Take your blood pressure now, and if it is seriously elevated, go to the hospital.
Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A
blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign
of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.
A client in active labor is becoming increasingly fearful because her contractions are occurring more
often than she had expected. Her partner is also becoming anxious. Which of the following should be
the focus of the nurse's response?
A.Telling the client and her partner that the labor process is often unpredictable
B.Informing the client that this means she will give birth sooner than expected
C.Asking the client and her partner if they would like the nurse to stay in the room
D.Affirming that the fetal heart rate is remaining within normal limits - ANSWER-C) Asking the client
and her partner if they would like the nurse to stay in the room
Rationale: Offering to remain with the client and her partner offers support without providing false
reassurance.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is
getting lighter in color. Which action should the nurse take?
A.Instruct the client to go to the emergency room.
B.Recommend vaginal douching.
C.Explain this is a normal finding.
D.Determine if ovulation has occurred. - ANSWER-C)Explain this is a normal finding.
Rationale:The client is describing lochia serosa, a normal change in the lochial flow.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA)
pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining
