HESI Maternal-Newborn Exam Questions with
Correct Answers (VerifiedAnswers) Plus
Rationales 2026 Q&A Instant Download PDF
1. A nurse is assessing a client at 32 weeks of gestation who
has preeclampsia. Which finding requires the nurse's
immediate attention?
A. Mild ankle edema at the end of the day
B. Blood pressure of 142/90 mm Hg
C. Persistent severe headache and blurred vision
D. Urinary frequency
Correct answer: C. Persistent severe headache and blurred
vision
Rationale: A persistent severe headache accompanied by visual
disturbances suggests cerebral involvement from severe
preeclampsia and may precede seizures or other serious
complications. This finding requires immediate assessment and
intervention. Mild dependent edema is common during
pregnancy, while a blood pressure of 142/90 mm Hg indicates
hypertension but is not by itself the most immediately
threatening finding listed. Urinary frequency is common during
pregnancy.
,2. A client in labor has an external fetal monitor showing
recurrent late decelerations. What should the nurse do first?
A. Increase the oxytocin infusion
B. Place the client in a lateral position
C. Encourage the client to begin pushing
D. Prepare the client for discharge
Correct answer: B. Place the client in a lateral position
Rationale: Recurrent late decelerations indicate uteroplacental
insufficiency and decreased fetal oxygenation. Repositioning the
client to a lateral position, commonly the left lateral position,
can improve uteroplacental blood flow. The nurse should also
discontinue or reduce oxytocin if it is contributing to excessive
uterine activity, administer oxygen according to institutional
protocol, and notify the appropriate provider. Increasing
oxytocin would worsen uterine stimulation and potentially
compromise fetal oxygenation further.
3. A postpartum client reports passing a large clot
approximately the size of a golf ball. What is the nurse's
priority action?
A. Document the finding as expected
B. Assess the client's fundus and vaginal bleeding
,C. Encourage increased oral fluid intake
D. Assist the client to ambulate
Correct answer: B. Assess the client's fundus and vaginal
bleeding
Rationale: Passage of a large clot after delivery can indicate
excessive postpartum bleeding and requires immediate
assessment. The nurse should evaluate uterine tone, fundal
position, and the amount and character of vaginal bleeding. A
boggy uterus may indicate uterine atony, a major cause of
postpartum hemorrhage. Although lochia and small clots can be
expected, a large clot requires further evaluation rather than
routine documentation.
4. Which finding is most characteristic of true labor?
A. Contractions decrease with walking
B. Contractions remain irregular
C. Cervical dilation and effacement occur
D. Discomfort is relieved by hydration
Correct answer: C. Cervical dilation and effacement occur
Rationale: True labor produces progressive cervical dilation and
effacement as uterine contractions become stronger, longer,
and more regular. False labor contractions generally do not
result in progressive cervical changes and may diminish with
, rest, hydration, or changes in activity. Cervical change is
therefore one of the most reliable distinctions between true and
false labor.
5. A pregnant client with Rh-negative blood has delivered an
Rh-positive newborn. Which medication should the nurse
anticipate administering?
A. Oxytocin
B. Rho(D) immune globulin
C. Magnesium sulfate
D. Methylergonovine
Correct answer: B. Rho(D) immune globulin
Rationale: Rho(D) immune globulin is administered to an Rh-
negative, unsensitized client after exposure to Rh-positive fetal
blood, including after delivery of an Rh-positive newborn. It
prevents maternal formation of Rh antibodies that could affect
a future Rh-positive pregnancy. The medication is not given to
an Rh-positive client or to a client who has already developed
significant Rh sensitization.
6. A nurse is caring for a client receiving magnesium sulfate for
severe preeclampsia. Which assessment finding requires
immediate intervention?
Correct Answers (VerifiedAnswers) Plus
Rationales 2026 Q&A Instant Download PDF
1. A nurse is assessing a client at 32 weeks of gestation who
has preeclampsia. Which finding requires the nurse's
immediate attention?
A. Mild ankle edema at the end of the day
B. Blood pressure of 142/90 mm Hg
C. Persistent severe headache and blurred vision
D. Urinary frequency
Correct answer: C. Persistent severe headache and blurred
vision
Rationale: A persistent severe headache accompanied by visual
disturbances suggests cerebral involvement from severe
preeclampsia and may precede seizures or other serious
complications. This finding requires immediate assessment and
intervention. Mild dependent edema is common during
pregnancy, while a blood pressure of 142/90 mm Hg indicates
hypertension but is not by itself the most immediately
threatening finding listed. Urinary frequency is common during
pregnancy.
,2. A client in labor has an external fetal monitor showing
recurrent late decelerations. What should the nurse do first?
A. Increase the oxytocin infusion
B. Place the client in a lateral position
C. Encourage the client to begin pushing
D. Prepare the client for discharge
Correct answer: B. Place the client in a lateral position
Rationale: Recurrent late decelerations indicate uteroplacental
insufficiency and decreased fetal oxygenation. Repositioning the
client to a lateral position, commonly the left lateral position,
can improve uteroplacental blood flow. The nurse should also
discontinue or reduce oxytocin if it is contributing to excessive
uterine activity, administer oxygen according to institutional
protocol, and notify the appropriate provider. Increasing
oxytocin would worsen uterine stimulation and potentially
compromise fetal oxygenation further.
3. A postpartum client reports passing a large clot
approximately the size of a golf ball. What is the nurse's
priority action?
A. Document the finding as expected
B. Assess the client's fundus and vaginal bleeding
,C. Encourage increased oral fluid intake
D. Assist the client to ambulate
Correct answer: B. Assess the client's fundus and vaginal
bleeding
Rationale: Passage of a large clot after delivery can indicate
excessive postpartum bleeding and requires immediate
assessment. The nurse should evaluate uterine tone, fundal
position, and the amount and character of vaginal bleeding. A
boggy uterus may indicate uterine atony, a major cause of
postpartum hemorrhage. Although lochia and small clots can be
expected, a large clot requires further evaluation rather than
routine documentation.
4. Which finding is most characteristic of true labor?
A. Contractions decrease with walking
B. Contractions remain irregular
C. Cervical dilation and effacement occur
D. Discomfort is relieved by hydration
Correct answer: C. Cervical dilation and effacement occur
Rationale: True labor produces progressive cervical dilation and
effacement as uterine contractions become stronger, longer,
and more regular. False labor contractions generally do not
result in progressive cervical changes and may diminish with
, rest, hydration, or changes in activity. Cervical change is
therefore one of the most reliable distinctions between true and
false labor.
5. A pregnant client with Rh-negative blood has delivered an
Rh-positive newborn. Which medication should the nurse
anticipate administering?
A. Oxytocin
B. Rho(D) immune globulin
C. Magnesium sulfate
D. Methylergonovine
Correct answer: B. Rho(D) immune globulin
Rationale: Rho(D) immune globulin is administered to an Rh-
negative, unsensitized client after exposure to Rh-positive fetal
blood, including after delivery of an Rh-positive newborn. It
prevents maternal formation of Rh antibodies that could affect
a future Rh-positive pregnancy. The medication is not given to
an Rh-positive client or to a client who has already developed
significant Rh sensitization.
6. A nurse is caring for a client receiving magnesium sulfate for
severe preeclampsia. Which assessment finding requires
immediate intervention?
