Maternity HESI Test bank (combined red
hesi and other sources) Exam Questions
With Well Explained Answers
A mother who is breastfeeding her baby receives instructions from the nurse.
Which instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing. - ANSWER -
C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of
the infant on the breast for latching on. The baby's body is in alignment with the
ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching
the breast. Option A helps prevent chafing, and nonbinding support aids in
prevention of discomfort from the stretching of the Cooper ligament. Option B is
important but is not necessary for all women. Option D helps soften an engorged
breast and encourages correct infant latching on but is not the best ANSWER.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A."Weigh the baby daily, and if she is gaining weight, she is getting enough to
eat."
B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to
ten times a day."
C."Offer the baby extra bottled milk after her feeding and see if she still seems
hungry."
, D."If you're concerned, you might consider bottle feeding so that you can monitor
intake." - ANSWER -B."Your milk is sufficient if the baby is voiding pale, straw-
colored urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10
times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day
is indicative of adequate nutrition, most home scales do not measure this
accurately, and the suggestion will likely make the mother anxious. Option C
causes nipple confusion and diminishes the mother's milk production. Option D
does not address the client's question.
The client comes to the hospital assuming she is in labor. Which assessment
findings by the nurse would indicate that the client is in true labor? (Select all that
apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions - ANSWER -A.Pain in the lower
back that radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of false
labor.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting
for the alcohol to clear my breast milk."
,C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - ANSWER -A."Breastfeeding my infant
consistently every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method. Option B is incorrect because
alcohol can immediately enter the breast milk. Nicotine is transferred to the infant
in breast milk. Taking a warm shower will stimulate the production of milk, which
will be more painful after breastfeedings.
A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. She sure has a funny-looking head." Which response by the
nurse is best?
A."This is not an unusually shaped head, especially for a first baby."
B."It may look odd, but newborn babies are often born with heads like that."
C."That is normal. The head will return to a round shape within 7 to 10 days."
D."Your pelvis was too small, so the head had to adjust to the birth canal." -
ANSWER -C."That is normal. The head will return to a round shape within 7 to
10 days."
Rationale: Option C reassures the mother that this is normal in the newborn and
provides correct information regarding the return to a normal shape. Although
option A is correct, it implies that the client should not worry. Any implied or
spoken "don't worry" is usually the wrong ANSWER. Option B is condescending
and dismissing; the mother is seeking reassurance and information. Option D is a
negative statement and implies that molding is the mother's fault.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should
the nurse take immediately?
A.Notify the health care provider or anesthesiologist.
, B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - ANSWER -C.Place the client in a lateral
position.
Rationale: The nurse should immediately turn the client to a lateral position or
place a pillow or wedge under one hip to deflect the uterus. Other immediate
interventions include increasing the rate of the main line IV infusion and
administering oxygen by facemask. If the blood pressure remains low after these
interventions or decreases further, the anesthesiologist or health care provider
should be notified immediately. To continue to monitor blood pressure without
taking further action could constitute malpractice. Option D may also be
warranted, but such action is based on hospital protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - ANSWER -A.Avoid alcohol
because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and
cognitive impairment for the infant. Options B, C, and D should also be included in
diet teaching for a breastfeeding mother; however, because these do not involve
safety of the infant, they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright
red. The bleeding has subsided. She further states that she is not experiencing any
uterine contractions or abdominal pain. What instruction should the nurse provide?
hesi and other sources) Exam Questions
With Well Explained Answers
A mother who is breastfeeding her baby receives instructions from the nurse.
Which instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing. - ANSWER -
C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of
the infant on the breast for latching on. The baby's body is in alignment with the
ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching
the breast. Option A helps prevent chafing, and nonbinding support aids in
prevention of discomfort from the stretching of the Cooper ligament. Option B is
important but is not necessary for all women. Option D helps soften an engorged
breast and encourages correct infant latching on but is not the best ANSWER.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A."Weigh the baby daily, and if she is gaining weight, she is getting enough to
eat."
B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to
ten times a day."
C."Offer the baby extra bottled milk after her feeding and see if she still seems
hungry."
, D."If you're concerned, you might consider bottle feeding so that you can monitor
intake." - ANSWER -B."Your milk is sufficient if the baby is voiding pale, straw-
colored urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10
times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day
is indicative of adequate nutrition, most home scales do not measure this
accurately, and the suggestion will likely make the mother anxious. Option C
causes nipple confusion and diminishes the mother's milk production. Option D
does not address the client's question.
The client comes to the hospital assuming she is in labor. Which assessment
findings by the nurse would indicate that the client is in true labor? (Select all that
apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions - ANSWER -A.Pain in the lower
back that radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of false
labor.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting
for the alcohol to clear my breast milk."
,C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - ANSWER -A."Breastfeeding my infant
consistently every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method. Option B is incorrect because
alcohol can immediately enter the breast milk. Nicotine is transferred to the infant
in breast milk. Taking a warm shower will stimulate the production of milk, which
will be more painful after breastfeedings.
A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. She sure has a funny-looking head." Which response by the
nurse is best?
A."This is not an unusually shaped head, especially for a first baby."
B."It may look odd, but newborn babies are often born with heads like that."
C."That is normal. The head will return to a round shape within 7 to 10 days."
D."Your pelvis was too small, so the head had to adjust to the birth canal." -
ANSWER -C."That is normal. The head will return to a round shape within 7 to
10 days."
Rationale: Option C reassures the mother that this is normal in the newborn and
provides correct information regarding the return to a normal shape. Although
option A is correct, it implies that the client should not worry. Any implied or
spoken "don't worry" is usually the wrong ANSWER. Option B is condescending
and dismissing; the mother is seeking reassurance and information. Option D is a
negative statement and implies that molding is the mother's fault.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should
the nurse take immediately?
A.Notify the health care provider or anesthesiologist.
, B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - ANSWER -C.Place the client in a lateral
position.
Rationale: The nurse should immediately turn the client to a lateral position or
place a pillow or wedge under one hip to deflect the uterus. Other immediate
interventions include increasing the rate of the main line IV infusion and
administering oxygen by facemask. If the blood pressure remains low after these
interventions or decreases further, the anesthesiologist or health care provider
should be notified immediately. To continue to monitor blood pressure without
taking further action could constitute malpractice. Option D may also be
warranted, but such action is based on hospital protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - ANSWER -A.Avoid alcohol
because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and
cognitive impairment for the infant. Options B, C, and D should also be included in
diet teaching for a breastfeeding mother; however, because these do not involve
safety of the infant, they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright
red. The bleeding has subsided. She further states that she is not experiencing any
uterine contractions or abdominal pain. What instruction should the nurse provide?
