MATERNITY HESI EXIT EXAM– QUESTIONS AND ANSWERS |
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
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1. A nurse is caring for a client at 38 weeks of gestation who presents to the labor and
delivery unit reporting regular uterine contractions occurring every 4 minutes and lasting
60 seconds. A sterile vaginal examination reveals the cervix is 4 cm dilated, 80% effaced,
and the presenting part is at 0 station. How should the nurse classify this stage of labor?
A. Latent phase of the first stage of labor
B. Active phase of the first stage of labor
C. Transition phase of the first stage of labor
D. Second stage of labor
ANSWER: B. Active phase of the first stage of labor
The active phase of the first stage of labor is defined by cervical dilation from 6 cm to 10 cm in
contemporary guidelines, but traditionally encompasses 4 cm to 7 cm with regular, strong
contractions and progressive effacement. The latent phase spans 0 to 3 or 5 cm, transition
spans 8 to 10 cm, and the second stage begins at full dilation.
2. A nurse is monitoring a client in active labor who receives an epidural block for pain
management. Five minutes following placement of the block, the client reports feeling dizzy
and nauseated, and her blood pressure drops from 120/80 mmHg to 88/50 mmHg. What is
the priority nursing action?
A. Administer intravenous methylergonovine rapidly
B. Place the client in a lateral position and increase intravenous fluids
C. Prepare for immediate emergency cesarean section
D. Insert an indwelling urinary catheter immediately
ANSWER: B. Place the client in a lateral position and increase intravenous fluids
Sympathetic blockade from an epidural anesthesia frequently leads to maternal hypotension,
which compromises uteroplacental perfusion. Immediate interventions include repositioning
the client laterally to relieve aortocaval compression, increasing intravenous crystalloid
infusion rates, and administering ephedrine if ordered.
,3. A nurse is performing a postpartum assessment on a client who delivered a term infant 2
hours ago via spontaneous vaginal delivery. Upon palpating the uterus, the nurse finds it is
boggy, displaced to the right, and 2 cm above the umbilicus. What is the most appropriate
initial nursing intervention?
A. Administer oxytocin intravenously as prescribed
B. Assist the client to empty her urinary bladder
C. Notify the health care provider immediately
D. Perform bimanual uterine compression
ANSWER: B. Assist the client to empty her urinary bladder
A boggy uterus displaced to the right is a classic indication of a distended urinary bladder,
which prevents the uterus from contracting efficiently and increases the risk of postpartum
hemorrhage. Assisting the client to void or straight catheterizing her will allow the
myometrium to contract properly.
4. A nurse is assessing a newborn infant born at 39 weeks of gestation immediately after
birth. The infant has a pink body with blue extremities, a heart rate of 110 beats per
minute, a weak cry when stimulated, some flexion of extremities, and active sneezing when
the nasal catheter is introduced. What is the Apgar score for this infant?
A. 6
B. 7
C. 8
D. 9
ANSWER: C. 8
The Apgar score evaluates five categories: heart rate (110 bpm = 2 points), respiratory effort
(weak cry = 1 point), muscle tone (some flexion = 1 point), reflex irritability (sneezing = 2
points), and color (pink body, blue extremities = 1 point). Totaling these points gives an Apgar
score of 8.
5. A nurse is caring for a client at 32 weeks of gestation diagnosed with preeclampsia
without severe features. Which instruction should the nurse emphasize during prenatal
teaching?
A. Maintain strict complete bed rest in the prone position
,B. Monitor daily fetal movement counts and report decreases
C. Restrict all dietary sodium intake to less than 1 gram daily
D. Discontinue all prenatal antihypertensive medications immediately
ANSWER: B. Monitor daily fetal movement counts and report decreases
Daily monitoring of fetal movement is crucial for assessing fetal well-being in pregnancies
complicated by preeclampsia. Complete bed rest is no longer routinely recommended due to
thromboembolism risks, severe sodium restriction is discouraged, and medications should only
be altered by the provider.
6. A nurse is caring for a client receiving an intravenous oxytocin infusion for labor
augmentation. The fetal heart rate tracing demonstrates repetitive late decelerations with
moderate variability. What is the priority nursing action?
A. Increase the oxytocin infusion rate by 2 milliunits/minute
B. Discontinue the oxytocin infusion immediately and administer oxygen
C. Assist the client into a supine position flat on her back
D. Prepare the client for immediate artificial rupture of membranes
ANSWER: B. Discontinue the oxytocin infusion immediately and administer oxygen
Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. The immediate
priority is to stop uterotonic stimulation (oxytocin) to reduce uterine activity, reposition the
client to a side-lying position, administer oxygen via non-rebreather mask, and increase IV
fluids.
7. A nurse is assessing a newborn infant at 12 hours of life and notes yellowish discoloration
of the skin and sclera. Total serum bilirubin levels are rising. What underlying
physiological mechanism contributes to neonatal physiological jaundice?
A. Enhanced hepatic glucuronyl transferase activity
B. Rapid breakdown of fetal red blood cells combined with immature liver conjugation
C. Complete biliary ductal atresia present from birth
D. Severe maternal-fetal ABO blood group incompatibility
ANSWER: B. Rapid breakdown of fetal red blood cells combined with immature liver
conjugation
, Physiological jaundice appears after 24 hours of life due to the accelerated destruction of
short-lived fetal erythrocytes and the transiently low activity of the hepatic enzyme glucuronyl
transferase required for bilirubin conjugation.
8. A nurse is caring for a client at 28 weeks of gestation who presents with painless, bright
red vaginal bleeding. Vital signs are stable, and the fetal heart rate is reassuring. Which
diagnostic procedure is strictly contraindicated for this client?
A. Transabdominal ultrasound scan
B. Sterile vaginal examination
C. Complete blood count and coagulation profile
D. Type and crossmatch for packed red blood cells
ANSWER: B. Sterile vaginal examination
Painless bright red bleeding in the third trimester strongly suggests placenta previa. A digital
vaginal examination is strictly contraindicated because disturbing the placenta can precipitate
sudden, massive, life-threatening hemorrhage.
9. A nurse is providing discharge instructions to a postpartum client who is formula
feeding her infant. Which instruction regarding postpartum lactation suppression is most
appropriate?
A. Express breast milk manually every two hours to relieve pressure
B. Apply warm compresses to both breasts continuously throughout the day
C. Wear a supportive, snug-fitting bra and avoid breast stimulation
D. Restrict all fluid intake to less than 500 mL per 24 hours
ANSWER: C. Wear a supportive, snug-fitting bra and avoid breast stimulation
Lactation suppression is achieved by avoiding any mechanical stimulation or expression of
milk, which signals the pituitary gland to decrease prolactin production. Wearing a firm,
supportive bra and applying ice packs help reduce engorgement and discomfort.
10. A nurse is evaluating a client at 36 weeks of gestation who is suspected of having
abruptio placentae. Which clinical manifestation differentiates abruptio placentae from
placenta previa?
A. Painless, bright red vaginal bleeding
VERIFIED AND WELL DETAILED ANSWERS PLUS RATIONALES |
GUARANTEED PASS | LATEST EXAM UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST| DOWNLOAD INSTANT PDF
1. A nurse is caring for a client at 38 weeks of gestation who presents to the labor and
delivery unit reporting regular uterine contractions occurring every 4 minutes and lasting
60 seconds. A sterile vaginal examination reveals the cervix is 4 cm dilated, 80% effaced,
and the presenting part is at 0 station. How should the nurse classify this stage of labor?
A. Latent phase of the first stage of labor
B. Active phase of the first stage of labor
C. Transition phase of the first stage of labor
D. Second stage of labor
ANSWER: B. Active phase of the first stage of labor
The active phase of the first stage of labor is defined by cervical dilation from 6 cm to 10 cm in
contemporary guidelines, but traditionally encompasses 4 cm to 7 cm with regular, strong
contractions and progressive effacement. The latent phase spans 0 to 3 or 5 cm, transition
spans 8 to 10 cm, and the second stage begins at full dilation.
2. A nurse is monitoring a client in active labor who receives an epidural block for pain
management. Five minutes following placement of the block, the client reports feeling dizzy
and nauseated, and her blood pressure drops from 120/80 mmHg to 88/50 mmHg. What is
the priority nursing action?
A. Administer intravenous methylergonovine rapidly
B. Place the client in a lateral position and increase intravenous fluids
C. Prepare for immediate emergency cesarean section
D. Insert an indwelling urinary catheter immediately
ANSWER: B. Place the client in a lateral position and increase intravenous fluids
Sympathetic blockade from an epidural anesthesia frequently leads to maternal hypotension,
which compromises uteroplacental perfusion. Immediate interventions include repositioning
the client laterally to relieve aortocaval compression, increasing intravenous crystalloid
infusion rates, and administering ephedrine if ordered.
,3. A nurse is performing a postpartum assessment on a client who delivered a term infant 2
hours ago via spontaneous vaginal delivery. Upon palpating the uterus, the nurse finds it is
boggy, displaced to the right, and 2 cm above the umbilicus. What is the most appropriate
initial nursing intervention?
A. Administer oxytocin intravenously as prescribed
B. Assist the client to empty her urinary bladder
C. Notify the health care provider immediately
D. Perform bimanual uterine compression
ANSWER: B. Assist the client to empty her urinary bladder
A boggy uterus displaced to the right is a classic indication of a distended urinary bladder,
which prevents the uterus from contracting efficiently and increases the risk of postpartum
hemorrhage. Assisting the client to void or straight catheterizing her will allow the
myometrium to contract properly.
4. A nurse is assessing a newborn infant born at 39 weeks of gestation immediately after
birth. The infant has a pink body with blue extremities, a heart rate of 110 beats per
minute, a weak cry when stimulated, some flexion of extremities, and active sneezing when
the nasal catheter is introduced. What is the Apgar score for this infant?
A. 6
B. 7
C. 8
D. 9
ANSWER: C. 8
The Apgar score evaluates five categories: heart rate (110 bpm = 2 points), respiratory effort
(weak cry = 1 point), muscle tone (some flexion = 1 point), reflex irritability (sneezing = 2
points), and color (pink body, blue extremities = 1 point). Totaling these points gives an Apgar
score of 8.
5. A nurse is caring for a client at 32 weeks of gestation diagnosed with preeclampsia
without severe features. Which instruction should the nurse emphasize during prenatal
teaching?
A. Maintain strict complete bed rest in the prone position
,B. Monitor daily fetal movement counts and report decreases
C. Restrict all dietary sodium intake to less than 1 gram daily
D. Discontinue all prenatal antihypertensive medications immediately
ANSWER: B. Monitor daily fetal movement counts and report decreases
Daily monitoring of fetal movement is crucial for assessing fetal well-being in pregnancies
complicated by preeclampsia. Complete bed rest is no longer routinely recommended due to
thromboembolism risks, severe sodium restriction is discouraged, and medications should only
be altered by the provider.
6. A nurse is caring for a client receiving an intravenous oxytocin infusion for labor
augmentation. The fetal heart rate tracing demonstrates repetitive late decelerations with
moderate variability. What is the priority nursing action?
A. Increase the oxytocin infusion rate by 2 milliunits/minute
B. Discontinue the oxytocin infusion immediately and administer oxygen
C. Assist the client into a supine position flat on her back
D. Prepare the client for immediate artificial rupture of membranes
ANSWER: B. Discontinue the oxytocin infusion immediately and administer oxygen
Late decelerations indicate uteroplacental insufficiency and fetal hypoxia. The immediate
priority is to stop uterotonic stimulation (oxytocin) to reduce uterine activity, reposition the
client to a side-lying position, administer oxygen via non-rebreather mask, and increase IV
fluids.
7. A nurse is assessing a newborn infant at 12 hours of life and notes yellowish discoloration
of the skin and sclera. Total serum bilirubin levels are rising. What underlying
physiological mechanism contributes to neonatal physiological jaundice?
A. Enhanced hepatic glucuronyl transferase activity
B. Rapid breakdown of fetal red blood cells combined with immature liver conjugation
C. Complete biliary ductal atresia present from birth
D. Severe maternal-fetal ABO blood group incompatibility
ANSWER: B. Rapid breakdown of fetal red blood cells combined with immature liver
conjugation
, Physiological jaundice appears after 24 hours of life due to the accelerated destruction of
short-lived fetal erythrocytes and the transiently low activity of the hepatic enzyme glucuronyl
transferase required for bilirubin conjugation.
8. A nurse is caring for a client at 28 weeks of gestation who presents with painless, bright
red vaginal bleeding. Vital signs are stable, and the fetal heart rate is reassuring. Which
diagnostic procedure is strictly contraindicated for this client?
A. Transabdominal ultrasound scan
B. Sterile vaginal examination
C. Complete blood count and coagulation profile
D. Type and crossmatch for packed red blood cells
ANSWER: B. Sterile vaginal examination
Painless bright red bleeding in the third trimester strongly suggests placenta previa. A digital
vaginal examination is strictly contraindicated because disturbing the placenta can precipitate
sudden, massive, life-threatening hemorrhage.
9. A nurse is providing discharge instructions to a postpartum client who is formula
feeding her infant. Which instruction regarding postpartum lactation suppression is most
appropriate?
A. Express breast milk manually every two hours to relieve pressure
B. Apply warm compresses to both breasts continuously throughout the day
C. Wear a supportive, snug-fitting bra and avoid breast stimulation
D. Restrict all fluid intake to less than 500 mL per 24 hours
ANSWER: C. Wear a supportive, snug-fitting bra and avoid breast stimulation
Lactation suppression is achieved by avoiding any mechanical stimulation or expression of
milk, which signals the pituitary gland to decrease prolactin production. Wearing a firm,
supportive bra and applying ice packs help reduce engorgement and discomfort.
10. A nurse is evaluating a client at 36 weeks of gestation who is suspected of having
abruptio placentae. Which clinical manifestation differentiates abruptio placentae from
placenta previa?
A. Painless, bright red vaginal bleeding
