Page 1 of 50
“HESI PRACTICE EXAM MATERNAL NEWBORN “
NEWEST UPDATED EXAM 2025 – 2026 SOLVED
QUESTIONS & ANSWERS VERIFIED 100% GRADED A+
(LATEST VERSION)
HESI Practice Exam Maternal Newborn
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most
important for the nurse to report to the healthcare provider?
Bruising.
Oral intake.
Hemoglobin.
Bilirubin.
Bilirubin.
Rationale
Neonatal erythrolysis due to Rh incompatibility causes rapid release of
unconjugated bilirubin (D), which results in serum levels (hyperbilirubinemia)
that place the infant at risk for neurological damage (kernicterus). (A, B, and C)
may influence the serum bilirubin level, but the most significant finding is the
serial bilirubin levels that determines the need for early intervention.
The nurse is giving discharge instructions for a client following a suction
curettage for hydatidiform mole. The client asks why oral contraceptives are
being recommended for the next 12 months. What information should the
nurse provide?
-Oral contraceptives prevent a reoccurrence of a molar pregnancy.
-Pregnancy within 1 year decreases the chances of a future successful
pregnancy.
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-Diagnostic testing for human chorionic gonadotropin (hCG) levels are
elevated by pregnancy.
-Molar reoccurrences are higher if conception occurs within 1 year after an
initial mutation.
Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by
pregnancy.
Rationale
The major risk after a molar pregnancy is the development of
choriocarcinoma, which is detected by measuring the same hormone (hCG)
that the body produces during pregnancy. Continued elevated hCG levels may
be either from choriocarcinoma or a subsequent pregnancy making diagnosis
and treatment difficult, so oral contraceptives are prescribed to prevent
pregnancy for a year since it interferes with monitoring the return of hCG
levels (C) to normal. (A, B, and D) are inaccurate.
Which finding in the medical history of a post-partum client should the nurse
withhold the administration of a routine standing order for methylergonovine
maleate (Methergine)?
Pregnancy induced hypertension.
Placenta previa.
Gestational diabetes.
Postpartum hemorrhage.
Pregnancy induced hypertension.
Rationale
Methergine is used for post-partum bleeding. A client's history of pregnancy-
induced hypertension (A) is a contraindication for Methergine which causes
vasoconstriction and increases blood pressure, so the routine standing order
should be withheld and reported to the healthcare provider. (B, C, and D) are
not contraindications for the use of Methergine.
The nurse prepares to administer an injection of vitamin K to a newborn infant.
The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which
response would be best for the nurse to make?
-Inform the mother that the injection was prescribed by the healthcare
provider.
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-Explore the mother's concerns about the infant receiving an injection of
vitamin K.
-Explain that vitamin K is required by state law and compliance is mandatory.
-Remind the mother that all babies receive this shot and it is relatively
painless.
Explore the mother's concerns about the infant receiving an injection of vitamin K.
Rationale
This mother's concerns should be explored (B) and any misconceptions
cleared up before the vitamin K is injected. (A and C) are true but do not
communicate the importance of vitamin K administration. Also, parents have
the right to refuse the injection by signing a refusal form. (D) is providing false
reassurance--all injections cause pain
What action should the nurse implement when caring for a newborn receiving
phototherapy?
Reposition every 6 hours.
Place an eyeshield over the eyes.
Limit the intake of formula.
Apply an oil-based lotion to the skin
Place an eyeshield over the eyes.
Rationale
Phototherapy converts unconjugated bilirubin, which is deposited in the skin,
to a water-soluble form that is more easily excreted by the liver. Exposure to
the light source can increase the risk for ocular damage, so an eyeshield (B) is
placed while the infant is under the light source. To ensure all body surfaces
are exposed to the lights, the newborn should be reposition every 2 to 4 hours,
not every 6 hours (A). Phototherapy can increase insensible water loss, and to
prevent dehydration, fluid intake should be encouraged, not restricted (C).
Lotions (D) absorb heat and can potentially cause burns and should not be
used on the skin while phototherapy is in progress.
An infant with hyperbilirubinaemia is receiving phototherapy. What
intervention should the nurse implement?
Maintain NPO status.
Monitor temperature.
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Apply skin lotion as prescribed.
Change T-shirt every 3 hours.
Monitor temperature.
Rationale
Minor side effects of phototherapy include loose, green stools, transient
rashes, hyperthermia, increased metabolic rate, dehydration, electrolyte
disturbances, and priapism. Regular monitoring of the infant's temperature (B)
allows evaluation of hyperthermia and dehydration. Extra oral fluids are
provided to reduce the risk of dehydration, so NPO status is not necessary (A).
Skin lotion is contraindicated (C) to prevent increased tanning or an increase
in heat or skin "frying" effect. Clothing reduces the area of exposed skin to the
lights, so T-shirts (D) should not be worn during phototherapy
The nurse is caring for a client whose labor is being augmented with oxytocin
(Pitocin). Which finding indicates that the nurse should discontinue the
oxytocin infusion?
The client needs to void.
Amniotic membranes rupture.
Uterine contractions occur every 8 to 10 minutes.
The fetal heart rate is 180 bpm without variability.
The fetal heart rate is 180 bpm without variability.
Rationale
A fetal heart rate (FHR) without variability (D) is a non-reassuring finding that
indicates the oxytocin should be discontinued, and the healthcare provider
should be notified. A client's urge to void (A) is not an indication to
discontinue the oxytocin infusion used for induction. The oxytocin infusion
should not be discontinued when the amniotic membranes rupture (B) unless
there are non-reassuring changes in the FHR pattern or uterine
hyperstimulation occurs, and (C) does not qualify as uterine hyperstimulation.
While inspecting a newborn’s head, the nurse identifies a swelling of the scalp
that does not cross the suture line. Which finding should the nurse document?
Molding.
Cephalohematoma.
Caput succedaneum.
“HESI PRACTICE EXAM MATERNAL NEWBORN “
NEWEST UPDATED EXAM 2025 – 2026 SOLVED
QUESTIONS & ANSWERS VERIFIED 100% GRADED A+
(LATEST VERSION)
HESI Practice Exam Maternal Newborn
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most
important for the nurse to report to the healthcare provider?
Bruising.
Oral intake.
Hemoglobin.
Bilirubin.
Bilirubin.
Rationale
Neonatal erythrolysis due to Rh incompatibility causes rapid release of
unconjugated bilirubin (D), which results in serum levels (hyperbilirubinemia)
that place the infant at risk for neurological damage (kernicterus). (A, B, and C)
may influence the serum bilirubin level, but the most significant finding is the
serial bilirubin levels that determines the need for early intervention.
The nurse is giving discharge instructions for a client following a suction
curettage for hydatidiform mole. The client asks why oral contraceptives are
being recommended for the next 12 months. What information should the
nurse provide?
-Oral contraceptives prevent a reoccurrence of a molar pregnancy.
-Pregnancy within 1 year decreases the chances of a future successful
pregnancy.
, Page 2 of 50
-Diagnostic testing for human chorionic gonadotropin (hCG) levels are
elevated by pregnancy.
-Molar reoccurrences are higher if conception occurs within 1 year after an
initial mutation.
Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by
pregnancy.
Rationale
The major risk after a molar pregnancy is the development of
choriocarcinoma, which is detected by measuring the same hormone (hCG)
that the body produces during pregnancy. Continued elevated hCG levels may
be either from choriocarcinoma or a subsequent pregnancy making diagnosis
and treatment difficult, so oral contraceptives are prescribed to prevent
pregnancy for a year since it interferes with monitoring the return of hCG
levels (C) to normal. (A, B, and D) are inaccurate.
Which finding in the medical history of a post-partum client should the nurse
withhold the administration of a routine standing order for methylergonovine
maleate (Methergine)?
Pregnancy induced hypertension.
Placenta previa.
Gestational diabetes.
Postpartum hemorrhage.
Pregnancy induced hypertension.
Rationale
Methergine is used for post-partum bleeding. A client's history of pregnancy-
induced hypertension (A) is a contraindication for Methergine which causes
vasoconstriction and increases blood pressure, so the routine standing order
should be withheld and reported to the healthcare provider. (B, C, and D) are
not contraindications for the use of Methergine.
The nurse prepares to administer an injection of vitamin K to a newborn infant.
The mother tells the nurse, "Wait! I don't want my baby to have a shot." Which
response would be best for the nurse to make?
-Inform the mother that the injection was prescribed by the healthcare
provider.
, Page 3 of 50
-Explore the mother's concerns about the infant receiving an injection of
vitamin K.
-Explain that vitamin K is required by state law and compliance is mandatory.
-Remind the mother that all babies receive this shot and it is relatively
painless.
Explore the mother's concerns about the infant receiving an injection of vitamin K.
Rationale
This mother's concerns should be explored (B) and any misconceptions
cleared up before the vitamin K is injected. (A and C) are true but do not
communicate the importance of vitamin K administration. Also, parents have
the right to refuse the injection by signing a refusal form. (D) is providing false
reassurance--all injections cause pain
What action should the nurse implement when caring for a newborn receiving
phototherapy?
Reposition every 6 hours.
Place an eyeshield over the eyes.
Limit the intake of formula.
Apply an oil-based lotion to the skin
Place an eyeshield over the eyes.
Rationale
Phototherapy converts unconjugated bilirubin, which is deposited in the skin,
to a water-soluble form that is more easily excreted by the liver. Exposure to
the light source can increase the risk for ocular damage, so an eyeshield (B) is
placed while the infant is under the light source. To ensure all body surfaces
are exposed to the lights, the newborn should be reposition every 2 to 4 hours,
not every 6 hours (A). Phototherapy can increase insensible water loss, and to
prevent dehydration, fluid intake should be encouraged, not restricted (C).
Lotions (D) absorb heat and can potentially cause burns and should not be
used on the skin while phototherapy is in progress.
An infant with hyperbilirubinaemia is receiving phototherapy. What
intervention should the nurse implement?
Maintain NPO status.
Monitor temperature.
, Page 4 of 50
Apply skin lotion as prescribed.
Change T-shirt every 3 hours.
Monitor temperature.
Rationale
Minor side effects of phototherapy include loose, green stools, transient
rashes, hyperthermia, increased metabolic rate, dehydration, electrolyte
disturbances, and priapism. Regular monitoring of the infant's temperature (B)
allows evaluation of hyperthermia and dehydration. Extra oral fluids are
provided to reduce the risk of dehydration, so NPO status is not necessary (A).
Skin lotion is contraindicated (C) to prevent increased tanning or an increase
in heat or skin "frying" effect. Clothing reduces the area of exposed skin to the
lights, so T-shirts (D) should not be worn during phototherapy
The nurse is caring for a client whose labor is being augmented with oxytocin
(Pitocin). Which finding indicates that the nurse should discontinue the
oxytocin infusion?
The client needs to void.
Amniotic membranes rupture.
Uterine contractions occur every 8 to 10 minutes.
The fetal heart rate is 180 bpm without variability.
The fetal heart rate is 180 bpm without variability.
Rationale
A fetal heart rate (FHR) without variability (D) is a non-reassuring finding that
indicates the oxytocin should be discontinued, and the healthcare provider
should be notified. A client's urge to void (A) is not an indication to
discontinue the oxytocin infusion used for induction. The oxytocin infusion
should not be discontinued when the amniotic membranes rupture (B) unless
there are non-reassuring changes in the FHR pattern or uterine
hyperstimulation occurs, and (C) does not qualify as uterine hyperstimulation.
While inspecting a newborn’s head, the nurse identifies a swelling of the scalp
that does not cross the suture line. Which finding should the nurse document?
Molding.
Cephalohematoma.
Caput succedaneum.
