Maternity HESI Test bank (combined red hesi and other sources)
An expectant father tells the nurse he fears that his wife is "losing her
mind." He states that she is constantly rubbing her abdomen and
talking to the baby and that she actually reprimands the baby when it
moves too much. Which recommendation should the nurse make to
this expectant father?
A.Suggest that his wife seek professional counseling to deal with her
symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal
visit.
D.Reassure him that normal maternal-fetal bonding is occurring. -
correct answer✔ ✔ D) Reassure him that normal maternal-fetal
bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not
reflect ambivalence. No intervention is needed. Quickening, the first
,perception of fetal movement, occurs at 17 to 20 weeks of gestation
and begins a new phase of prenatal bonding during the second
trimester. Options A and C are not necessary because the behaviors
displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately
after the procedure is completed, it is most important for the nurse to
obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - correct answer✔ ✔ C. Fetal heart
rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect
changes that may indicate the presence of cord compression or
prolapse. An amniotomy (artificial rupture of membranes [AROM]) is
used to stimulate labor when the condition of the cervix is favorable.
,The fluid should be assessed for color, odor, and consistency. Option A
should be assessed every 15 to 20 minutes during labor but is not
specific for AROM. Option B is monitored hourly after the membranes
are ruptured to detect the development of amnionitis. Option D should
be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours
post-vaginal delivery. In developing a plan of care, the nurse should
give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - correct answer✔ ✔ B. Skin
color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated
levels of bilirubin, which should be further evaluated in a newborn <24
hours old. Acrocyanosis (blue color of the hands and feet) is a common
finding in newborns; it occurs because the capillary system is immature.
, Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and
antibiotic therapy is prescribed. Which instruction should the nurse
provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching
onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the
antibiotic effect on the infant. - correct answer✔ ✔ A.Breastfeed
the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast
engorgement, and breastfeeding during mastitis facilitates the
An expectant father tells the nurse he fears that his wife is "losing her
mind." He states that she is constantly rubbing her abdomen and
talking to the baby and that she actually reprimands the baby when it
moves too much. Which recommendation should the nurse make to
this expectant father?
A.Suggest that his wife seek professional counseling to deal with her
symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal
visit.
D.Reassure him that normal maternal-fetal bonding is occurring. -
correct answer✔ ✔ D) Reassure him that normal maternal-fetal
bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not
reflect ambivalence. No intervention is needed. Quickening, the first
,perception of fetal movement, occurs at 17 to 20 weeks of gestation
and begins a new phase of prenatal bonding during the second
trimester. Options A and C are not necessary because the behaviors
displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately
after the procedure is completed, it is most important for the nurse to
obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - correct answer✔ ✔ C. Fetal heart
rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect
changes that may indicate the presence of cord compression or
prolapse. An amniotomy (artificial rupture of membranes [AROM]) is
used to stimulate labor when the condition of the cervix is favorable.
,The fluid should be assessed for color, odor, and consistency. Option A
should be assessed every 15 to 20 minutes during labor but is not
specific for AROM. Option B is monitored hourly after the membranes
are ruptured to detect the development of amnionitis. Option D should
be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours
post-vaginal delivery. In developing a plan of care, the nurse should
give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - correct answer✔ ✔ B. Skin
color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated
levels of bilirubin, which should be further evaluated in a newborn <24
hours old. Acrocyanosis (blue color of the hands and feet) is a common
finding in newborns; it occurs because the capillary system is immature.
, Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and
antibiotic therapy is prescribed. Which instruction should the nurse
provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching
onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the
antibiotic effect on the infant. - correct answer✔ ✔ A.Breastfeed
the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast
engorgement, and breastfeeding during mastitis facilitates the
