HESI PEDS & MATERNITY EXAM
QUESTIONS WITH 100% CORRECT
ANSWERS AND RATIONALES |
VERIFIED | LATEST UPDATE
1. A 32-week gestation client presents with painless, bright red vaginal bleeding.
What is the priority nursing action?
A. Perform a vaginal exam to assess cervical dilation
B. Prepare the client for an immediate cesarean section
C. Place the client in a left lateral position and begin continuous fetal monitoring
D. Administer oxytocin to augment labor
Correct Answer: C
Rationale: Painless third-trimester bleeding is a classic sign of placenta previa.
Vaginal exams are strictly contraindicated because they can cause catastrophic
hemorrhage. The priority is to place the client in a left lateral position to maximize
uterine perfusion and begin continuous fetal monitoring to assess fetal well-being.
Immediate cesarean section is not always indicated; management depends on the
severity of bleeding and fetal status.
---
2. A postpartum client who delivered 2 hours ago has a blood pressure of 82/50
mmHg and a heart rate of 128 bpm. What is the most likely cause and priority
intervention?
1
,A. Hypovolemic shock from uterine atony; perform fundal massage
B. Pulmonary embolism; administer oxygen and prepare for intubation
C. Amniotic fluid embolism; initiate CPR
D. Hemorrhage from vaginal lacerations; prepare for surgical repair
Correct Answer: A
Rationale: Postpartum hemorrhage is most commonly caused by uterine atony.
Uterine atony results in a boggy uterus that fails to contract, leading to excessive
bleeding. Fundal massage can help the uterus contract and reduce bleeding. The
client's hypotension and tachycardia indicate hypovolemic shock from hemorrhage.
---
3. A client at 36 weeks gestation presents with hypertension, proteinuria, and a
severe headache. What condition is most likely and what is the priority
intervention?
A. Gestational diabetes; administer insulin
B. Preeclampsia; initiate seizure precautions and monitor closely
C. Placental abruption; prepare for emergency delivery
D. Urinary tract infection; administer antibiotics
Correct Answer: B
Rationale: Hypertension, proteinuria, and headache indicate preeclampsia. The
headache may be a sign of severe preeclampsia with neurological symptoms that
requires close monitoring and potential hospitalization. The priority is to initiate
seizure precautions and monitor for signs of eclampsia. Severe preeclampsia with
neurological symptoms may require rapid blood pressure reduction with IV agents
like hydralazine or labetalol. Magnesium sulfate is the drug of choice for seizure
prophylaxis.
2
,---
4. A nurse is assessing a newborn and notes diffuse edema of the soft tissues of the
scalp that crosses the suture lines. How should the nurse document this finding?
A. Cephalohematoma
B. Caput succedaneum
C. Subgaleal hemorrhage
D. Molding
Correct Answer: B
Rationale: Caput succedaneum is diffuse edema of the soft tissues of the scalp that
crosses suture lines. It is caused by pressure during labor and delivery and typically
resolves within a few days. Cephalohematoma is a collection of blood between the
skull and periosteum that does not cross suture lines.
---
5. According to Erikson's stages of psychosocial development, an infant is in
which stage?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: A
3
, Rationale: Erikson's stages of development identify Trust vs. Mistrust as the stage
for infants. During this stage, infants develop a sense of trust when their basic
needs are met consistently by caregivers. Autonomy vs. Shame and Doubt is the
toddler stage, Initiative vs. Guilt is the preschool stage, and Industry vs. Inferiority
is the school-age stage.
---
6. An expectant father tells the nurse he fears his wife is "losing her mind" because
she talks to her unborn baby and prepares the nursery constantly. What is the best
response?
A. Reassure him that these are normal behaviors indicating maternal-fetal bonding
B. Suggest that his wife may need a psychiatric evaluation
C. Tell him to ignore these behaviors as they will pass
D. Advise him to discourage his wife from talking to the baby
Correct Answer: A
Rationale: These behaviors are positive signs of maternal-fetal bonding and are
considered normal. The nurse should reassure the father that this is a healthy part
of pregnancy. Reassuring him normal maternal-fetal bonding is occurring is the
most appropriate response.
---
7. A client at 12 weeks’ gestation reports nausea and vomiting. What is the most
appropriate nursing intervention?
A. Encourage the client to eat small, frequent meals
B. Advise the client to lie flat after eating
C. Instruct the client to avoid all fluids
4
QUESTIONS WITH 100% CORRECT
ANSWERS AND RATIONALES |
VERIFIED | LATEST UPDATE
1. A 32-week gestation client presents with painless, bright red vaginal bleeding.
What is the priority nursing action?
A. Perform a vaginal exam to assess cervical dilation
B. Prepare the client for an immediate cesarean section
C. Place the client in a left lateral position and begin continuous fetal monitoring
D. Administer oxytocin to augment labor
Correct Answer: C
Rationale: Painless third-trimester bleeding is a classic sign of placenta previa.
Vaginal exams are strictly contraindicated because they can cause catastrophic
hemorrhage. The priority is to place the client in a left lateral position to maximize
uterine perfusion and begin continuous fetal monitoring to assess fetal well-being.
Immediate cesarean section is not always indicated; management depends on the
severity of bleeding and fetal status.
---
2. A postpartum client who delivered 2 hours ago has a blood pressure of 82/50
mmHg and a heart rate of 128 bpm. What is the most likely cause and priority
intervention?
1
,A. Hypovolemic shock from uterine atony; perform fundal massage
B. Pulmonary embolism; administer oxygen and prepare for intubation
C. Amniotic fluid embolism; initiate CPR
D. Hemorrhage from vaginal lacerations; prepare for surgical repair
Correct Answer: A
Rationale: Postpartum hemorrhage is most commonly caused by uterine atony.
Uterine atony results in a boggy uterus that fails to contract, leading to excessive
bleeding. Fundal massage can help the uterus contract and reduce bleeding. The
client's hypotension and tachycardia indicate hypovolemic shock from hemorrhage.
---
3. A client at 36 weeks gestation presents with hypertension, proteinuria, and a
severe headache. What condition is most likely and what is the priority
intervention?
A. Gestational diabetes; administer insulin
B. Preeclampsia; initiate seizure precautions and monitor closely
C. Placental abruption; prepare for emergency delivery
D. Urinary tract infection; administer antibiotics
Correct Answer: B
Rationale: Hypertension, proteinuria, and headache indicate preeclampsia. The
headache may be a sign of severe preeclampsia with neurological symptoms that
requires close monitoring and potential hospitalization. The priority is to initiate
seizure precautions and monitor for signs of eclampsia. Severe preeclampsia with
neurological symptoms may require rapid blood pressure reduction with IV agents
like hydralazine or labetalol. Magnesium sulfate is the drug of choice for seizure
prophylaxis.
2
,---
4. A nurse is assessing a newborn and notes diffuse edema of the soft tissues of the
scalp that crosses the suture lines. How should the nurse document this finding?
A. Cephalohematoma
B. Caput succedaneum
C. Subgaleal hemorrhage
D. Molding
Correct Answer: B
Rationale: Caput succedaneum is diffuse edema of the soft tissues of the scalp that
crosses suture lines. It is caused by pressure during labor and delivery and typically
resolves within a few days. Cephalohematoma is a collection of blood between the
skull and periosteum that does not cross suture lines.
---
5. According to Erikson's stages of psychosocial development, an infant is in
which stage?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Correct Answer: A
3
, Rationale: Erikson's stages of development identify Trust vs. Mistrust as the stage
for infants. During this stage, infants develop a sense of trust when their basic
needs are met consistently by caregivers. Autonomy vs. Shame and Doubt is the
toddler stage, Initiative vs. Guilt is the preschool stage, and Industry vs. Inferiority
is the school-age stage.
---
6. An expectant father tells the nurse he fears his wife is "losing her mind" because
she talks to her unborn baby and prepares the nursery constantly. What is the best
response?
A. Reassure him that these are normal behaviors indicating maternal-fetal bonding
B. Suggest that his wife may need a psychiatric evaluation
C. Tell him to ignore these behaviors as they will pass
D. Advise him to discourage his wife from talking to the baby
Correct Answer: A
Rationale: These behaviors are positive signs of maternal-fetal bonding and are
considered normal. The nurse should reassure the father that this is a healthy part
of pregnancy. Reassuring him normal maternal-fetal bonding is occurring is the
most appropriate response.
---
7. A client at 12 weeks’ gestation reports nausea and vomiting. What is the most
appropriate nursing intervention?
A. Encourage the client to eat small, frequent meals
B. Advise the client to lie flat after eating
C. Instruct the client to avoid all fluids
4
