MATERNITY HESI ACTUAL FINALS ANSWERS AND
QUESTIONS SET A+
✔✔A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her
baby will become HIV-infected. Which explanation should the nurse provide?
A.Most infants of HIV-positive women will continue to test positive for HIV antibodies.
B.Infants who have HIV-positive mothers carry the virus and will eventually develop the
disease.
C.Medication taken during pregnancy to reduce the mother's viral load ensures that the
infant is HIV-negative.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are
no longer present. - ✔✔D.HIV infection is determined at 18 months of age, when
maternal HIV antibodies are no longer present.
Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from
the mother, so the evaluation of an infant for the HIV virus is determined at 18 months
of age, when all the maternal antibodies are no longer in the infant's blood. Passive HIV
antibodies disappear in the infant within 18 months of age. Option B is inaccurate.
Although administration of HIV medication during pregnancy can significantly reduce the
risk of vertical transmission, treatment does not ensure that the virus will not become
manifest in the infant.
✔✔A new mother is having trouble breastfeeding her newborn. The child is making
frantic rooting motions and will not grasp the nipple. Which intervention should the nurse
implement?
A.Encourage frequent use of a pacifier so that the infant becomes accustomed to
sucking.
B.Hold the infant's head firmly against the breast until he latches onto the nipple.
,C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
D.Provide formula for the infant until he becomes calm, and then offer the breast again.
- ✔✔C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
Rationale: The infant is becoming frustrated and so is the mother; both need a time out.
The mother should be encouraged to comfort the infant and to relax herself. After such
a time out, breastfeeding is often more successful. Options A and D would cause nipple
confusion. Option B would only cause the infant to be more resistant, resulting in the
mother and infant becoming more frustrated.
✔✔A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports
that her lochia is getting lighter in color. Which action should the nurse take?
A.Instruct the client to go to the emergency room.
B.Recommend vaginal douching.
C.Explain this is a normal finding.
D.Determine if ovulation has occurred. - ✔✔C.Explain this is a normal finding.
Rationale:The client is describing lochia serosa, a normal change in the lochial flow.
Options A, B, and D are not recommended for this normal finding.
✔✔A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in blood pressure. When the
client calls the clinic complaining of indigestion, which instruction should the nurse
provide?
A.Lie on your left side and call 911 for emergency assistance.
B.Take an antacid and call back if the pain has not subsided.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D.See your health care provider to obtain a prescription for a histamine blocking agent. -
✔✔C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
Rationale: Checking the blood pressure for an elevation is the best instruction to give at
this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia.
Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening
complication of gestational hypertension. Additional data are needed to confirm an
,emergency situation as described in option A. Options B and D ignore the threat to
client safety posed by a significant increase in blood pressure.
✔✔The nurse is counseling a couple who has sought information about conceiving. The
couple asks the nurse to explain when ovulation usually occurs. Which statement by the
nurse is correct?
A.Two weeks before menstruation
B.Immediately after menstruation
C.Immediately before menstruation
D.Three weeks before menstruation - ✔✔A.Two weeks before menstruation
Rationale:Ovulation occurs 14 days before the first day of the menstrual period.
Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation,
this is only true for a woman who has a perfect 28-day cycle. For many women, the
length of the menstrual cycle varies. Options B, C, and D are incorrect.
✔✔A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious.
Which of the following should be the focus of the nurse's response?
A.Telling the client and her partner that the labor process is often unpredictable
B.Informing the client that this means she will give birth sooner than expected
C.Asking the client and her partner if they would like the nurse to stay in the room
D.Affirming that the fetal heart rate is remaining within normal limits - ✔✔C.Asking the
client and her partner if they would like the nurse to stay in the room
Rationale: Offering to remain with the client and her partner offers support without
providing false reassurance. The length of labor is not always predictable, but options A
and B do not offer the client the support that is needed at this time. Option D may be
reassuring regarding the fetal heart rate but does not provide the client the emotional
support she needs at this time during the labor process.
✔✔When assessing a client at 12 weeks of gestation, the nurse recommends that she
and her husband consider attending childbirth preparation classes. When is the best
time for the couple to attend these classes?
A.At 16 weeks of gestation
B.At 20 weeks of gestation
, C.At 24 weeks of gestation
D.At 30 weeks of gestation - ✔✔D.At 30 weeks of gestation
Rationale: Learning is facilitated by an interested pupil. The couple is most interested in
childbirth toward the end of the pregnancy, when they are beginning to anticipate the
onset of labor and the birth of their child. Option D is closest to the time when parents
would be ready for such classes. Options A, B, and C are not the best times during a
pregnancy for the couple to attend childbirth education classes. At these times they will
have other teaching needs. Early pregnancy classes often include topics such as
nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal
development, maternal and fetal risk factors, and evolving roles of the mother and her
significant others.
✔✔The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The
nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with
intact membranes. The monitor indicates that the FHR decelerates at the onset of
several contractions and returns to baseline before each contraction ends. Which action
should the nurse take?
A.Reapply the external transducer.
B.Insert the intrauterine pressure catheter.
C.Discontinue the oxytocin infusion.
D.Continue to monitor labor progress - ✔✔D.Continue to monitor labor progress
Rationale: The fetal heart rate indicates early decelerations, which are not an ominous
sign, so the nurse should continue to monitor the labor progress and document the
findings in the client's record. There is no reason to reapply the external transducer if
the FHR tracings are being captured. Options B and C are not indicated at this time.
✔✔The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling fingers and dizziness. Which action should the nurse
take?
A.Administer oxygen by facemask.
B.Notify the health care provider of the client's symptoms.
C.Have the client breathe into her cupped hands.
D.Check the client's blood pressure and fetal heart rate. - ✔✔C.Have the client breathe
into her cupped hands.
QUESTIONS SET A+
✔✔A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her
baby will become HIV-infected. Which explanation should the nurse provide?
A.Most infants of HIV-positive women will continue to test positive for HIV antibodies.
B.Infants who have HIV-positive mothers carry the virus and will eventually develop the
disease.
C.Medication taken during pregnancy to reduce the mother's viral load ensures that the
infant is HIV-negative.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are
no longer present. - ✔✔D.HIV infection is determined at 18 months of age, when
maternal HIV antibodies are no longer present.
Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies from
the mother, so the evaluation of an infant for the HIV virus is determined at 18 months
of age, when all the maternal antibodies are no longer in the infant's blood. Passive HIV
antibodies disappear in the infant within 18 months of age. Option B is inaccurate.
Although administration of HIV medication during pregnancy can significantly reduce the
risk of vertical transmission, treatment does not ensure that the virus will not become
manifest in the infant.
✔✔A new mother is having trouble breastfeeding her newborn. The child is making
frantic rooting motions and will not grasp the nipple. Which intervention should the nurse
implement?
A.Encourage frequent use of a pacifier so that the infant becomes accustomed to
sucking.
B.Hold the infant's head firmly against the breast until he latches onto the nipple.
,C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
D.Provide formula for the infant until he becomes calm, and then offer the breast again.
- ✔✔C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
Rationale: The infant is becoming frustrated and so is the mother; both need a time out.
The mother should be encouraged to comfort the infant and to relax herself. After such
a time out, breastfeeding is often more successful. Options A and D would cause nipple
confusion. Option B would only cause the infant to be more resistant, resulting in the
mother and infant becoming more frustrated.
✔✔A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports
that her lochia is getting lighter in color. Which action should the nurse take?
A.Instruct the client to go to the emergency room.
B.Recommend vaginal douching.
C.Explain this is a normal finding.
D.Determine if ovulation has occurred. - ✔✔C.Explain this is a normal finding.
Rationale:The client is describing lochia serosa, a normal change in the lochial flow.
Options A, B, and D are not recommended for this normal finding.
✔✔A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in blood pressure. When the
client calls the clinic complaining of indigestion, which instruction should the nurse
provide?
A.Lie on your left side and call 911 for emergency assistance.
B.Take an antacid and call back if the pain has not subsided.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D.See your health care provider to obtain a prescription for a histamine blocking agent. -
✔✔C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
Rationale: Checking the blood pressure for an elevation is the best instruction to give at
this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia.
Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening
complication of gestational hypertension. Additional data are needed to confirm an
,emergency situation as described in option A. Options B and D ignore the threat to
client safety posed by a significant increase in blood pressure.
✔✔The nurse is counseling a couple who has sought information about conceiving. The
couple asks the nurse to explain when ovulation usually occurs. Which statement by the
nurse is correct?
A.Two weeks before menstruation
B.Immediately after menstruation
C.Immediately before menstruation
D.Three weeks before menstruation - ✔✔A.Two weeks before menstruation
Rationale:Ovulation occurs 14 days before the first day of the menstrual period.
Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation,
this is only true for a woman who has a perfect 28-day cycle. For many women, the
length of the menstrual cycle varies. Options B, C, and D are incorrect.
✔✔A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious.
Which of the following should be the focus of the nurse's response?
A.Telling the client and her partner that the labor process is often unpredictable
B.Informing the client that this means she will give birth sooner than expected
C.Asking the client and her partner if they would like the nurse to stay in the room
D.Affirming that the fetal heart rate is remaining within normal limits - ✔✔C.Asking the
client and her partner if they would like the nurse to stay in the room
Rationale: Offering to remain with the client and her partner offers support without
providing false reassurance. The length of labor is not always predictable, but options A
and B do not offer the client the support that is needed at this time. Option D may be
reassuring regarding the fetal heart rate but does not provide the client the emotional
support she needs at this time during the labor process.
✔✔When assessing a client at 12 weeks of gestation, the nurse recommends that she
and her husband consider attending childbirth preparation classes. When is the best
time for the couple to attend these classes?
A.At 16 weeks of gestation
B.At 20 weeks of gestation
, C.At 24 weeks of gestation
D.At 30 weeks of gestation - ✔✔D.At 30 weeks of gestation
Rationale: Learning is facilitated by an interested pupil. The couple is most interested in
childbirth toward the end of the pregnancy, when they are beginning to anticipate the
onset of labor and the birth of their child. Option D is closest to the time when parents
would be ready for such classes. Options A, B, and C are not the best times during a
pregnancy for the couple to attend childbirth education classes. At these times they will
have other teaching needs. Early pregnancy classes often include topics such as
nutrition, physiologic changes, coping with normal discomforts of pregnancy, fetal
development, maternal and fetal risk factors, and evolving roles of the mother and her
significant others.
✔✔The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The
nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with
intact membranes. The monitor indicates that the FHR decelerates at the onset of
several contractions and returns to baseline before each contraction ends. Which action
should the nurse take?
A.Reapply the external transducer.
B.Insert the intrauterine pressure catheter.
C.Discontinue the oxytocin infusion.
D.Continue to monitor labor progress - ✔✔D.Continue to monitor labor progress
Rationale: The fetal heart rate indicates early decelerations, which are not an ominous
sign, so the nurse should continue to monitor the labor progress and document the
findings in the client's record. There is no reason to reapply the external transducer if
the FHR tracings are being captured. Options B and C are not indicated at this time.
✔✔The nurse instructs a laboring client to use accelerated blow breathing. The client
begins to complain of tingling fingers and dizziness. Which action should the nurse
take?
A.Administer oxygen by facemask.
B.Notify the health care provider of the client's symptoms.
C.Have the client breathe into her cupped hands.
D.Check the client's blood pressure and fetal heart rate. - ✔✔C.Have the client breathe
into her cupped hands.
