Page 1 of 38
“MATERNITY HESI TEST BANK (COMBINED RED
HESI AND OTHER SOURCES)”LATEST EXAM
SOLVED QUESTIONS & ANSWERS VERIFIED
100% GRADED A+ (LATEST VERSION) WELL
REVISED 100% GUARANTEE PASS
Maternity HESI Test bank (combined red hesi and other sources)
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.
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. 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.
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 of nausea and bloating and
states that because she has had nothing to eat, she is too weak to breastfeed
her infant. Which nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
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B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
D.Fatigue related to cesarean delivery and physical care demands of infant
C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication,
and immobility is the priority nursing diagnosis and addresses the potential problem
of a paralytic ileus. Options A and B are both caused by impaired bowel motility.
Option D is not as important as impaired motility.
The nurse is counseling a client who wants to become pregnant. She tells the
nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. When will the client's next fertile period
occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7
C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first day
of her last menstrual period. Her next period would begin on February 12. Ovulation
occurs 14 days before the first day of the menstrual period. The client can expect
ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
In developing a teaching plan for expectant parents, the nurse decides to
include information about when the parents can expect the infant's fontanels
to close. Which statement is accurate regarding the timing of closure of an
infant's fontanels that should be included in this teaching plan?
A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by
the end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by
the end of the second week.
C.The anterior fontanel closes at 8 to 11 months and the posterior fontanel by
the end of the first month.
D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by
the end of the second month
D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the
end of the second month
Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age
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and the posterior fontanel closes by the end of the second month. These growth and
development milestones are frequently included in questions on the licensure
examination. Options A, B, and C are incorrect.
A client who is 3 days postpartum and breastfeeding asks the nurse how to
reduce breast engorgement. Which instruction should the nurse provide?
A.Avoid using the breast pump.
B.Breastfeed the infant every 2 hours.
C.Reduce fluid intake for 24 hours.
D.Skip feedings to let the sore breasts rest.
B.Breastfeed the infant every 2 hours.
Rationale: The mother should be instructed to attempt feeding her infant every 2
hours while massaging the breasts as the infant is feeding. If the infant does not feed
adequately and empty the breast, using a breast pump helps extract the milk and
relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping
feedings may cause further engorgement and discomfort.
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?
A.Use thread to tie off the umbilical cord.
B.Provide privacy for the woman.
C.Reassure the husband and keep him calm.
D.Put the newborn to the breast immediately.
D.Put the newborn to the breast immediately.
Rationale: Putting the newborn to the breast will help contract the uterus and prevent
a postpartum hemorrhage. This intervention has the highest priority. Option A is not
necessary; the infant can be transported attached to the placenta. Option B is an
important psychosocial need but does not have the priority of option D. Although the
husband is an important part of family-centered care, he is not the most important
concern at this time.
The nurse calls a client who is 4 days postpartum to follow up about her
transition with her newborn son at home. The woman tells the nurse, "I don't
know what is wrong. I love my son, but I feel so let down. I seem to cry for no
reason!" Which adjustment phase should the nurse determine the client is
experiencing?
A.Taking-in phase
B.Postpartum blues
C.Attachment difficulty
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D.Letting-go phase
B.Postpartum blues
Rationale: During the postpartum period, when serum hormone levels fall, women
are emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her own
psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
Which findings are of most concern to the nurse when caring for a woman in
the first trimester of pregnancy? (Select all that apply.)
A.Cramping with bright red spotting
B.Extreme tenderness of the breast
C.Lack of tenderness of the breast
D.Increased amounts of discharge
E.Increased right-side flank pain
A.Cramping with bright red spotting
C.Lack of tenderness of the breast
E.Increased right-side flank pain
Rationale: Options A and C are signs of a possible miscarriage. Cramping with bright
red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease
of tenderness in the breast is a sign that hormone levels have declined and that a
miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which
could be fatal if not discovered in time before rupture. Options B and D are normal
signs during the first trimester of a pregnancy.
On admission to the prenatal clinic, a client tells the nurse that her last
menstrual period began on February 15 and that previously her periods were
regular (28-day cycle). Her pregnancy test is positive. What is this client's
expected date of birth (EDB)?
A.November 22
B.November 8
C.December 22
D.October 22
A.November 22
Rationale: Option A correctly applies the Nägele rule for estimating the due date by
counting back 3 months from the first day of the last menstrual period (January,
“MATERNITY HESI TEST BANK (COMBINED RED
HESI AND OTHER SOURCES)”LATEST EXAM
SOLVED QUESTIONS & ANSWERS VERIFIED
100% GRADED A+ (LATEST VERSION) WELL
REVISED 100% GUARANTEE PASS
Maternity HESI Test bank (combined red hesi and other sources)
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.
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. 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.
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 of nausea and bloating and
states that because she has had nothing to eat, she is too weak to breastfeed
her infant. Which nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
, Page 2 of 38
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
D.Fatigue related to cesarean delivery and physical care demands of infant
C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication,
and immobility is the priority nursing diagnosis and addresses the potential problem
of a paralytic ileus. Options A and B are both caused by impaired bowel motility.
Option D is not as important as impaired motility.
The nurse is counseling a client who wants to become pregnant. She tells the
nurse that she has a 36-day menstrual cycle and the first day of her last
menstrual period was January 8. When will the client's next fertile period
occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7
C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first day
of her last menstrual period. Her next period would begin on February 12. Ovulation
occurs 14 days before the first day of the menstrual period. The client can expect
ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
In developing a teaching plan for expectant parents, the nurse decides to
include information about when the parents can expect the infant's fontanels
to close. Which statement is accurate regarding the timing of closure of an
infant's fontanels that should be included in this teaching plan?
A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by
the end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by
the end of the second week.
C.The anterior fontanel closes at 8 to 11 months and the posterior fontanel by
the end of the first month.
D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by
the end of the second month
D.The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the
end of the second month
Rationale: In the normal infant, the anterior fontanel closes at 12 to 18 months of age
, Page 3 of 38
and the posterior fontanel closes by the end of the second month. These growth and
development milestones are frequently included in questions on the licensure
examination. Options A, B, and C are incorrect.
A client who is 3 days postpartum and breastfeeding asks the nurse how to
reduce breast engorgement. Which instruction should the nurse provide?
A.Avoid using the breast pump.
B.Breastfeed the infant every 2 hours.
C.Reduce fluid intake for 24 hours.
D.Skip feedings to let the sore breasts rest.
B.Breastfeed the infant every 2 hours.
Rationale: The mother should be instructed to attempt feeding her infant every 2
hours while massaging the breasts as the infant is feeding. If the infant does not feed
adequately and empty the breast, using a breast pump helps extract the milk and
relieve some of the discomfort. Dehydration irritates swollen breast tissue. Skipping
feedings may cause further engorgement and discomfort.
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?
A.Use thread to tie off the umbilical cord.
B.Provide privacy for the woman.
C.Reassure the husband and keep him calm.
D.Put the newborn to the breast immediately.
D.Put the newborn to the breast immediately.
Rationale: Putting the newborn to the breast will help contract the uterus and prevent
a postpartum hemorrhage. This intervention has the highest priority. Option A is not
necessary; the infant can be transported attached to the placenta. Option B is an
important psychosocial need but does not have the priority of option D. Although the
husband is an important part of family-centered care, he is not the most important
concern at this time.
The nurse calls a client who is 4 days postpartum to follow up about her
transition with her newborn son at home. The woman tells the nurse, "I don't
know what is wrong. I love my son, but I feel so let down. I seem to cry for no
reason!" Which adjustment phase should the nurse determine the client is
experiencing?
A.Taking-in phase
B.Postpartum blues
C.Attachment difficulty
, Page 4 of 38
D.Letting-go phase
B.Postpartum blues
Rationale: During the postpartum period, when serum hormone levels fall, women
are emotionally labile, often crying easily for no apparent reason. This phase is
commonly called postpartum blues, which peaks around the fifth postpartum day.
The taking-in phase is the period following birth when the mother focuses on her own
psychological needs; typically, this period lasts for 24 hours. Crying is not a
maladaptive attachment response. It indicates a normal physical and emotional
response. The letting-go phase is when the mother sees the child as a separate
individual.
Which findings are of most concern to the nurse when caring for a woman in
the first trimester of pregnancy? (Select all that apply.)
A.Cramping with bright red spotting
B.Extreme tenderness of the breast
C.Lack of tenderness of the breast
D.Increased amounts of discharge
E.Increased right-side flank pain
A.Cramping with bright red spotting
C.Lack of tenderness of the breast
E.Increased right-side flank pain
Rationale: Options A and C are signs of a possible miscarriage. Cramping with bright
red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease
of tenderness in the breast is a sign that hormone levels have declined and that a
miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which
could be fatal if not discovered in time before rupture. Options B and D are normal
signs during the first trimester of a pregnancy.
On admission to the prenatal clinic, a client tells the nurse that her last
menstrual period began on February 15 and that previously her periods were
regular (28-day cycle). Her pregnancy test is positive. What is this client's
expected date of birth (EDB)?
A.November 22
B.November 8
C.December 22
D.October 22
A.November 22
Rationale: Option A correctly applies the Nägele rule for estimating the due date by
counting back 3 months from the first day of the last menstrual period (January,
