HESI MATERNITY QUESTIONS AND 100% VERIFIED
ANSWERS | GRADED A+ | GUARANTEED PASS!!
A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. What will the nurse document in
the client's chart regarding her GTPAL?
A. 11001
B. 10010
C. 20010
D. 20100
- answer-C. 20010
This is the client's second pregnancy or second gravid event, so option C is correct.
The notation includes number of pregnancies, full term, pre-term (between 20 and
37 weeks), miscarriages before 20 weeks and living children. 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. Option A does not take into account the current pregnancy, nor does
option B, which also counts the miscarriage as a "para," an incorrect recording.
Although option D is correct concerning gravidity, para 1 is incorrect.-answer-A
38-week primigravida works as an office assistant and sits at a computer 8 hours
each day. She 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.
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.-answer-A
41-week multigravida is receiving oxytocin 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. What is the next nursing action?
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 infusion.
- answer-D. Increase the rate of the oxytocin infusion.
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. FHR accelerations are a normal response to contractions, so the oxytocin
(Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed
when the client exhibits signs of progressing labor, which is not indicated at this
time.-answer-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.
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.-answer-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.
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
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed
by transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta, which is life
threatening to the mother and fetus. If those symptoms were described, option B
would be appropriate. Option C does not address the cause of the symptoms. The
client is not describing symptoms of a UTI.-answer-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.
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. Additional data are needed to
confirm an emergency situation as described in option A. Options B and D ignore
the threat to client safety posed by a significant increase in blood pressure.-answer-
A client at 34 weeks gestation arrives to the clinic and says to the nurse that she
thinks she is having contractions. What actions will the nurse include in this
client's plan of care? (Select all that apply.)
, A. State to her, "Let me know if you have a contraction during your visit today."
B. Ask the client, "Are the contractions painful?"
C. Tell the client, "You have nothing to worry about."
D. Ask her, "Do they come a frequently as every 5 minutes?"
E. Tell the client, "It is time for you to go directly to labor and delivery."
F. Inform her, "Those could be Braxton-Hicks contractions."
- answer-A, B, D, F
Braxton Hicks contractions are painless, irregular contractions that often occur in
pregnancy. Asking the client to inform the nurse would allow the nurse to palpate
the contraction for intensity and determine the duration. Do not dismiss the client's
concerns. Contraction that is regular, e.g. every 5 minutes for more than an hour,
may be a sign of preterm labor and requires further assessment. There is no need to
go to labor and delivery until further assessments determine she is in preterm
labor.-answer-A client at 34 weeks gestation reports to the clinic nurse that she has
frequent indigestion. What should the nurse include in the client's teaching plan?
(Select all that apply.)
A. "I'll ask your health care provider to prescribe ondansetron for you."
B. "Have you tried taking Tums for your indigestion?"
C. "The baby is getting big, which reduces the size of the stomach."
D. "Try eating small meals, 6 times per day."
E. "You have no cause to be worried."
- answer-B, C, D
Calcium carbonate (Tums) is safe to take during pregnancy and is effective over-
the-counter treatment for indigestion. At 34 weeks the fetus is about 4 cm below
the xiphoid and crowding the abdominal contents. Since the stomach is smaller,
eating small and frequent meals may help the indigestion. Ondansetron, or Zofran,
can be used in pregnancy, but is not an initial treatment. Reassure the client, not
dismiss her concern with "You have no cause to be worried."-answer-A client at 36
weeks gestation presents to labor and delivery and states to the nurse, "I have been
leaking fluid for about 2 days now. At first I thought it was urine. Now, I am not so
sure." Which nursing actions are most appropriate for this client? (Select all that
apply.)
A. Assess maternal vital signs.
B. Place an electronic fetal monitor.
C. Place a peri pad.
ANSWERS | GRADED A+ | GUARANTEED PASS!!
A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. What will the nurse document in
the client's chart regarding her GTPAL?
A. 11001
B. 10010
C. 20010
D. 20100
- answer-C. 20010
This is the client's second pregnancy or second gravid event, so option C is correct.
The notation includes number of pregnancies, full term, pre-term (between 20 and
37 weeks), miscarriages before 20 weeks and living children. 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. Option A does not take into account the current pregnancy, nor does
option B, which also counts the miscarriage as a "para," an incorrect recording.
Although option D is correct concerning gravidity, para 1 is incorrect.-answer-A
38-week primigravida works as an office assistant and sits at a computer 8 hours
each day. She 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.
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.-answer-A
41-week multigravida is receiving oxytocin 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. What is the next nursing action?
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 infusion.
- answer-D. Increase the rate of the oxytocin infusion.
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. FHR accelerations are a normal response to contractions, so the oxytocin
(Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed
when the client exhibits signs of progressing labor, which is not indicated at this
time.-answer-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.
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.-answer-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.
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
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed
by transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta, which is life
threatening to the mother and fetus. If those symptoms were described, option B
would be appropriate. Option C does not address the cause of the symptoms. The
client is not describing symptoms of a UTI.-answer-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.
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. Additional data are needed to
confirm an emergency situation as described in option A. Options B and D ignore
the threat to client safety posed by a significant increase in blood pressure.-answer-
A client at 34 weeks gestation arrives to the clinic and says to the nurse that she
thinks she is having contractions. What actions will the nurse include in this
client's plan of care? (Select all that apply.)
, A. State to her, "Let me know if you have a contraction during your visit today."
B. Ask the client, "Are the contractions painful?"
C. Tell the client, "You have nothing to worry about."
D. Ask her, "Do they come a frequently as every 5 minutes?"
E. Tell the client, "It is time for you to go directly to labor and delivery."
F. Inform her, "Those could be Braxton-Hicks contractions."
- answer-A, B, D, F
Braxton Hicks contractions are painless, irregular contractions that often occur in
pregnancy. Asking the client to inform the nurse would allow the nurse to palpate
the contraction for intensity and determine the duration. Do not dismiss the client's
concerns. Contraction that is regular, e.g. every 5 minutes for more than an hour,
may be a sign of preterm labor and requires further assessment. There is no need to
go to labor and delivery until further assessments determine she is in preterm
labor.-answer-A client at 34 weeks gestation reports to the clinic nurse that she has
frequent indigestion. What should the nurse include in the client's teaching plan?
(Select all that apply.)
A. "I'll ask your health care provider to prescribe ondansetron for you."
B. "Have you tried taking Tums for your indigestion?"
C. "The baby is getting big, which reduces the size of the stomach."
D. "Try eating small meals, 6 times per day."
E. "You have no cause to be worried."
- answer-B, C, D
Calcium carbonate (Tums) is safe to take during pregnancy and is effective over-
the-counter treatment for indigestion. At 34 weeks the fetus is about 4 cm below
the xiphoid and crowding the abdominal contents. Since the stomach is smaller,
eating small and frequent meals may help the indigestion. Ondansetron, or Zofran,
can be used in pregnancy, but is not an initial treatment. Reassure the client, not
dismiss her concern with "You have no cause to be worried."-answer-A client at 36
weeks gestation presents to labor and delivery and states to the nurse, "I have been
leaking fluid for about 2 days now. At first I thought it was urine. Now, I am not so
sure." Which nursing actions are most appropriate for this client? (Select all that
apply.)
A. Assess maternal vital signs.
B. Place an electronic fetal monitor.
C. Place a peri pad.
