RN HESI MATERNITY ANSWERS AND QUESTIONS
SET A+
✔✔At 0600 while admitting a woman for a scheduled repeat c-section the client tells the
nurse that she had coffee at 0400 because she wanted avoid getting a headache. What
action should the nurse take first?
A. Ensure preoperative lab results are available
B. Start IV presecribed Lactated ringers
C. Inform the anesthesia care provider
D. Contact the client obstetrician - ✔✔C. Inform the anesthesia care provider
✔✔A mother spontaneously delivers her infant in a taxi cab on the way to the hospital.
The emergency room nurse reports that the mother has active herpes (HSVII) lesion on
the vulva. What intervention should the nurse implement first when admitting the
neonate in the nursery?
A. Obtain blood specimen for serum glucose level
B. Document the temperature on the flow sheet
C. Place newborn in the isolation area of the nursery
D. Administer Vitamin K injection - ✔✔C. Place newborn in the isolation area of the
nursery
✔✔Upon admission to the nursery, the nurse places a newborn supine under radiant
warmer , an external heat source. What should the nurse implement first to ensure safe
thermoregulation?
A. Dry the newborns scalp and place a stockinet cap on the head
B. Move the temperature probe over the ribs when turning to a lateral position
C. Place temperature probe on the abdomen in the line with the radiant heat source
D. Wrap the infant in two blankets and place the radiant warmer on low - ✔✔C. Place
temperature probe on the abdomen in the line with the radiant heat source
✔✔When planning care for a laboring client , the nurse identifies the need to withhold
solid foods while the client is in labor . What is the most important reason for this
nursing intervention?
A. Gastric emptying time decreases during labor
, B. Nausea occurs from analgesic used during labor
C. An increased risk for aspiration can occur if general analgesic is needed
D. Autonomic nervous system stimulation during labor decreases peristalsis - ✔✔C. An
increased risk for aspiration can occur if general analgesic is needed
✔✔A new mother who is breastfeeding her 4 week old infant has type 1 diabetes ,
reports that her insulin needs have decreased after the birth of her child. What action
should the nurse implement ?
A. Schedule an appointment with diabetic nurse educator
B. Advise the client to breastfeed more frequently
C. Counsel her to increase calorie intake
D. Inform her that a decreased need for insulin occurs while breastfeeding - ✔✔D.
Inform her that a decreased need for insulin occurs while breastfeeding
✔✔A multiparous women at 38 weeks gestation with a history of rapid progression of
labor is admitted for induction due to signs and symptoms of pregnancy induced
hypertension (PIH). One hour after the oxytocin infusion is initiated she complains of a
headache. Her contractions are occurring every 1-2 mins , lasting 60-75 seconds and a
vaginal exam reveals that her cervix is 90% and dilated 6 cm.What intervention is most
important for the nurse to implement?
A. Prepare for immediate delivery
B. Measure deep tendon reflexes
C. Discontinue the Pitocin infusion
D. Turn the client to her left side - ✔✔C. Discontinue the Pitocin infusion
✔✔An infant born to a heorin addict mother is admitted to the neonatal care unit. . What
behaviors can the baby exhibit?
A. Lethargy and a poor suck
B. Facial abnormalities and microcephaly
C. Irritability and high pitched cry
D. Low birth weight and intrauterine growth retardation - ✔✔C. Irritability and high
pitched cry
✔✔A multigravida full term , laboring client complains of back labor. Vaginal examine
reveals that the client is 3cm with 50% effacement , and the fetal head is at -1 station.
What action should the nurse implement first?
A. Apply counter - pressure to the sacral area
B. Turn the client lateral position
C. Notify the scrub nurse to prepare the OR
D. Ambulate the client between contractions - ✔✔A. Apply counter - pressure to the
sacral area
✔✔A postpartal client complains that she has the urge to urinate every hour but is only
able to void a small amount. What interventions provides the nurse with the most useful
information?
SET A+
✔✔At 0600 while admitting a woman for a scheduled repeat c-section the client tells the
nurse that she had coffee at 0400 because she wanted avoid getting a headache. What
action should the nurse take first?
A. Ensure preoperative lab results are available
B. Start IV presecribed Lactated ringers
C. Inform the anesthesia care provider
D. Contact the client obstetrician - ✔✔C. Inform the anesthesia care provider
✔✔A mother spontaneously delivers her infant in a taxi cab on the way to the hospital.
The emergency room nurse reports that the mother has active herpes (HSVII) lesion on
the vulva. What intervention should the nurse implement first when admitting the
neonate in the nursery?
A. Obtain blood specimen for serum glucose level
B. Document the temperature on the flow sheet
C. Place newborn in the isolation area of the nursery
D. Administer Vitamin K injection - ✔✔C. Place newborn in the isolation area of the
nursery
✔✔Upon admission to the nursery, the nurse places a newborn supine under radiant
warmer , an external heat source. What should the nurse implement first to ensure safe
thermoregulation?
A. Dry the newborns scalp and place a stockinet cap on the head
B. Move the temperature probe over the ribs when turning to a lateral position
C. Place temperature probe on the abdomen in the line with the radiant heat source
D. Wrap the infant in two blankets and place the radiant warmer on low - ✔✔C. Place
temperature probe on the abdomen in the line with the radiant heat source
✔✔When planning care for a laboring client , the nurse identifies the need to withhold
solid foods while the client is in labor . What is the most important reason for this
nursing intervention?
A. Gastric emptying time decreases during labor
, B. Nausea occurs from analgesic used during labor
C. An increased risk for aspiration can occur if general analgesic is needed
D. Autonomic nervous system stimulation during labor decreases peristalsis - ✔✔C. An
increased risk for aspiration can occur if general analgesic is needed
✔✔A new mother who is breastfeeding her 4 week old infant has type 1 diabetes ,
reports that her insulin needs have decreased after the birth of her child. What action
should the nurse implement ?
A. Schedule an appointment with diabetic nurse educator
B. Advise the client to breastfeed more frequently
C. Counsel her to increase calorie intake
D. Inform her that a decreased need for insulin occurs while breastfeeding - ✔✔D.
Inform her that a decreased need for insulin occurs while breastfeeding
✔✔A multiparous women at 38 weeks gestation with a history of rapid progression of
labor is admitted for induction due to signs and symptoms of pregnancy induced
hypertension (PIH). One hour after the oxytocin infusion is initiated she complains of a
headache. Her contractions are occurring every 1-2 mins , lasting 60-75 seconds and a
vaginal exam reveals that her cervix is 90% and dilated 6 cm.What intervention is most
important for the nurse to implement?
A. Prepare for immediate delivery
B. Measure deep tendon reflexes
C. Discontinue the Pitocin infusion
D. Turn the client to her left side - ✔✔C. Discontinue the Pitocin infusion
✔✔An infant born to a heorin addict mother is admitted to the neonatal care unit. . What
behaviors can the baby exhibit?
A. Lethargy and a poor suck
B. Facial abnormalities and microcephaly
C. Irritability and high pitched cry
D. Low birth weight and intrauterine growth retardation - ✔✔C. Irritability and high
pitched cry
✔✔A multigravida full term , laboring client complains of back labor. Vaginal examine
reveals that the client is 3cm with 50% effacement , and the fetal head is at -1 station.
What action should the nurse implement first?
A. Apply counter - pressure to the sacral area
B. Turn the client lateral position
C. Notify the scrub nurse to prepare the OR
D. Ambulate the client between contractions - ✔✔A. Apply counter - pressure to the
sacral area
✔✔A postpartal client complains that she has the urge to urinate every hour but is only
able to void a small amount. What interventions provides the nurse with the most useful
information?
