RN HESI MATERNITY EVALUATION ANSWERS AND
QUESTIONS SET A+
✔✔A client at 35-weeks gestation complains of a "pain whenever the baby moves." On
assessment, the nurse notes the client's temperature to be 101.2F, with severe
abdominal or uterine tenderness on palpation. The nurse knows that these findings are
indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection. - ✔✔B. Chorioamnionitis
✔✔A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his
mother who tells the nurse that the child refuses to drink anything. The nurse
determines that the child has a weak cry with no tears. Which prescription is most
important to implement?
A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket - ✔✔B. Infuse normal saline intravenously
✔✔A 6-month old child who had a cleft-lip repair has elbow restraints in place. What
nursing intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all
times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises - ✔✔D. remove restraints
one at a time to provide ROM exercises
,✔✔A new mother calls the nurse stating that she wants to start feeding her 6-month-old
child something besides breast milk, but is concerned that the infant is too young to
start eating solid foods. How should the nurse respond?
A. encourage the mother to schedule a developmental assessment of the infant
B. advise the mother to wait at least another month before starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
D. reassure the mother that the infant is old enough to eat iron-fortified cereal - ✔✔D.
reassure the mother that the infant is old enough to eat iron-fortified cereal
✔✔While caring for a laboring client on continuous fetal monitoring, the nurse notes a
fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What
action should the nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position - ✔✔D. Change the maternal position
✔✔A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin
(RhoGam) after delivery of an infant who is Rh-positive. Which information should the
nure provide this client?
A. RhoGam is not necessary unless all her pregnancies are Rh-positive
B. The R-positive factor from the fetus threatens her blood cells
C. The mother should receive RhoGam when the baby is Rh-negative
D. RhoGam prevents maternal antibody formation for future Rh-positive babies - ✔✔D.
RhoGam prevents maternal antibody formation for future Rh-positive babies
✔✔A 6-week-old infant diagnosed with pyloric stenosis has recently developed
projectile vomiting. Which assessment finding indicates to the nurse that the infant is
becoming dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant - ✔✔A. Weak cry without any tears
✔✔A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns
cyanotic. What should the nurse do first?
A. Suction the oral and nasal passages
B. Give oxygen by positive pressure
C. Stimulate the infant to cry
D. Turn the infant onto the right side - ✔✔C. Stimulate the infant to cry
✔✔A client at 40-weeks' gestation presents to the obstetrical floor and indicates that the
amniotic membranes ruptured spontaneously at home. She is in active labor and feels
, the need to bear down and push. What information is most important for the nurse to
obtain first?
A. the estimated amount of fluid
B. time the membranes ruptured
C. color and consistency of the fluid
D. any odor noted when membranes ruptured. - ✔✔C. color and consistency of the fluid
✔✔An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which
action should the nurse implement first?A. Administer morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask. - ✔✔C. Place the infant in a knee-chest position
✔✔A one-day-old neonate develops a cephalohematoma. The nurse should closely
assess this neonate for which common complication?
A. jaundice
B. poor appetite
C. brain damage
D. hypoglycemia - ✔✔A. jaundice
✔✔The nurse is reviewing the serum laboratory finding for a 5-day-old infant with
congenital adrenal hyperplasia. Which laboratory results should be reported to the
healthcare provider immediatly?
A. Bilirubin of 1.5 mg/dl
B. Glucose of 80 mg/dl
C. Potassium of 4.5 mEq/L
D. Sodium of 119 mEq/L - ✔✔D. Sodium of 119 mEq/L
✔✔At 39-weeks gestation, a multigravida is having a non-stress test (NST). The fetal
heart rate (FHR) has remained nonreactive during the 30 minutes of evaluation. Based
on this finding, which action should the nurse implement?
A. Initiate an intravenous infusion
B. Observe the FHR pattern for 30 more minutes
C. Schedule a biophysical profile
D. Place an acoustic stimulator on the abdomen - ✔✔D. Place an acoustic stimulator on
the abdomen
✔✔A community health nurse visits a family in which a 16-year-old unmarried daughter
is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse
that she has been having intermittent back pain since the night before. What is the
priority nursing intervention?
A. Ask the clients mother to call an ambulance for transport to the hospital immediately.
B. Determine what physical activities the client has performed for the past 24 hours
C. Teach the client if she has experienced any recent changes in vaginal discharge. -
✔✔C. Teach the client if she has experienced any recent changes in vaginal discharge.
QUESTIONS SET A+
✔✔A client at 35-weeks gestation complains of a "pain whenever the baby moves." On
assessment, the nurse notes the client's temperature to be 101.2F, with severe
abdominal or uterine tenderness on palpation. The nurse knows that these findings are
indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection. - ✔✔B. Chorioamnionitis
✔✔A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his
mother who tells the nurse that the child refuses to drink anything. The nurse
determines that the child has a weak cry with no tears. Which prescription is most
important to implement?
A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket - ✔✔B. Infuse normal saline intravenously
✔✔A 6-month old child who had a cleft-lip repair has elbow restraints in place. What
nursing intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all
times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises - ✔✔D. remove restraints
one at a time to provide ROM exercises
,✔✔A new mother calls the nurse stating that she wants to start feeding her 6-month-old
child something besides breast milk, but is concerned that the infant is too young to
start eating solid foods. How should the nurse respond?
A. encourage the mother to schedule a developmental assessment of the infant
B. advise the mother to wait at least another month before starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
D. reassure the mother that the infant is old enough to eat iron-fortified cereal - ✔✔D.
reassure the mother that the infant is old enough to eat iron-fortified cereal
✔✔While caring for a laboring client on continuous fetal monitoring, the nurse notes a
fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What
action should the nurse take first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position - ✔✔D. Change the maternal position
✔✔A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin
(RhoGam) after delivery of an infant who is Rh-positive. Which information should the
nure provide this client?
A. RhoGam is not necessary unless all her pregnancies are Rh-positive
B. The R-positive factor from the fetus threatens her blood cells
C. The mother should receive RhoGam when the baby is Rh-negative
D. RhoGam prevents maternal antibody formation for future Rh-positive babies - ✔✔D.
RhoGam prevents maternal antibody formation for future Rh-positive babies
✔✔A 6-week-old infant diagnosed with pyloric stenosis has recently developed
projectile vomiting. Which assessment finding indicates to the nurse that the infant is
becoming dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant - ✔✔A. Weak cry without any tears
✔✔A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns
cyanotic. What should the nurse do first?
A. Suction the oral and nasal passages
B. Give oxygen by positive pressure
C. Stimulate the infant to cry
D. Turn the infant onto the right side - ✔✔C. Stimulate the infant to cry
✔✔A client at 40-weeks' gestation presents to the obstetrical floor and indicates that the
amniotic membranes ruptured spontaneously at home. She is in active labor and feels
, the need to bear down and push. What information is most important for the nurse to
obtain first?
A. the estimated amount of fluid
B. time the membranes ruptured
C. color and consistency of the fluid
D. any odor noted when membranes ruptured. - ✔✔C. color and consistency of the fluid
✔✔An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which
action should the nurse implement first?A. Administer morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask. - ✔✔C. Place the infant in a knee-chest position
✔✔A one-day-old neonate develops a cephalohematoma. The nurse should closely
assess this neonate for which common complication?
A. jaundice
B. poor appetite
C. brain damage
D. hypoglycemia - ✔✔A. jaundice
✔✔The nurse is reviewing the serum laboratory finding for a 5-day-old infant with
congenital adrenal hyperplasia. Which laboratory results should be reported to the
healthcare provider immediatly?
A. Bilirubin of 1.5 mg/dl
B. Glucose of 80 mg/dl
C. Potassium of 4.5 mEq/L
D. Sodium of 119 mEq/L - ✔✔D. Sodium of 119 mEq/L
✔✔At 39-weeks gestation, a multigravida is having a non-stress test (NST). The fetal
heart rate (FHR) has remained nonreactive during the 30 minutes of evaluation. Based
on this finding, which action should the nurse implement?
A. Initiate an intravenous infusion
B. Observe the FHR pattern for 30 more minutes
C. Schedule a biophysical profile
D. Place an acoustic stimulator on the abdomen - ✔✔D. Place an acoustic stimulator on
the abdomen
✔✔A community health nurse visits a family in which a 16-year-old unmarried daughter
is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse
that she has been having intermittent back pain since the night before. What is the
priority nursing intervention?
A. Ask the clients mother to call an ambulance for transport to the hospital immediately.
B. Determine what physical activities the client has performed for the past 24 hours
C. Teach the client if she has experienced any recent changes in vaginal discharge. -
✔✔C. Teach the client if she has experienced any recent changes in vaginal discharge.
