HESI OB MATERNITY CORE REVIEWS ANSWERS AND
QUESTIONS SET A+
✔✔A client in active labor is admitted with preeclampsia. Which assessment finding is
most significant in planning this client's care?
A. Patellar reflex 4+
B. Blood pressure 158/80
C. Four-hour urine output 240 ml
D. Respiration 12/minute - ✔✔A. Patellar reflex 4+
A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia,
which is an indication of an impending seizure.
✔✔A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding indicates to the nurse that the drug is effective?
A. Slowly increasing urinary output over the last week
B. Respiratory rate changes from the 40s to the 60s
C. Changes in apical heart rate from the 180s to the 140s
D. Change in indirect bilirubin from 12mg/dl to 8 mg/dl - ✔✔C. Changes in apical heart
rate from the 180s to the 140s
Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting
in an increase in RBCs. Since the body has not had to compensate for anemia with an
increased heart rate, changes in heart rate from high to normal is one indicator that
Epogen is effective
✔✔The healthcare provider prescribes terbutaline (Brethine) for a client in preterm
labor. Before initiating this prescription, it is most important for the nurse to assess the
client for which condition?
A. Gestational diabetes
B. Elevated blood pressure
C. Urinary tract infection
D. Swelling in lower extremities - ✔✔A. Gestational diabetes
, .
The nurse should evaluate the client for gestational diabetes because terbutaline
(Brethine) increases blood glucose levels.
✔✔A client with NO prenatal care arrives at the labor unit screaming, "The baby is
coming!" The nurse performs a vaginal examination that reveals the cervix is 3
centimeters dilated and 75% effaced. What additional information is most important for
the nurse to obtain?
A. Gravidity and parity
B. Time and amount of last oral intake
C. Date of last normal menstrual period
D. Frequency and intensity of contractions - ✔✔C. Date of last normal menstrual period
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the
fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the
pregnancy and administer corticosteroids to mature the lungs of the fetus.
✔✔The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP
110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse implement?
A. Insert an internal fetal monitor
B. Assess for cervical changes q1h
C. Monitor bleeding from IV sites
D. Perform Leopold's maneuvers - ✔✔C. Monitor bleeding from IV sites
Monitoring bleeding from peripheral sites is the priority intervention. This client is
presenting with signs of placental abruption. Disseminated intravascular coagulation
(DIC) is a complication of placental abruptio, characterized by abnormal bleeding.
✔✔Immediately after birth a newborn infant is suctioned, dried, and placed under a
radiant warmer. The infant has spontaneous respirations and the nurse assesses an
apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action
should the nurse perform next?
A. Initiate positive pressure ventilation
B. Intervene after the one minute Apgar is assessed
C. Initiate CPR on the infant
D. Assess the infant's blood glucose level - ✔✔A. Initiate positive pressure ventilation
The nurse should immediately begin positive pressure ventilation because this infant's
vital signs are not within the normal range, and oxygen deprivation leads to cardiac
depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and
respirations are 40 to 60 breaths/minute.)
QUESTIONS SET A+
✔✔A client in active labor is admitted with preeclampsia. Which assessment finding is
most significant in planning this client's care?
A. Patellar reflex 4+
B. Blood pressure 158/80
C. Four-hour urine output 240 ml
D. Respiration 12/minute - ✔✔A. Patellar reflex 4+
A 4+ reflex in a client with pregnancy-induced hypertension indicates hyperreflexia,
which is an indication of an impending seizure.
✔✔A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last
three weeks. Which assessment finding indicates to the nurse that the drug is effective?
A. Slowly increasing urinary output over the last week
B. Respiratory rate changes from the 40s to the 60s
C. Changes in apical heart rate from the 180s to the 140s
D. Change in indirect bilirubin from 12mg/dl to 8 mg/dl - ✔✔C. Changes in apical heart
rate from the 180s to the 140s
Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting
in an increase in RBCs. Since the body has not had to compensate for anemia with an
increased heart rate, changes in heart rate from high to normal is one indicator that
Epogen is effective
✔✔The healthcare provider prescribes terbutaline (Brethine) for a client in preterm
labor. Before initiating this prescription, it is most important for the nurse to assess the
client for which condition?
A. Gestational diabetes
B. Elevated blood pressure
C. Urinary tract infection
D. Swelling in lower extremities - ✔✔A. Gestational diabetes
, .
The nurse should evaluate the client for gestational diabetes because terbutaline
(Brethine) increases blood glucose levels.
✔✔A client with NO prenatal care arrives at the labor unit screaming, "The baby is
coming!" The nurse performs a vaginal examination that reveals the cervix is 3
centimeters dilated and 75% effaced. What additional information is most important for
the nurse to obtain?
A. Gravidity and parity
B. Time and amount of last oral intake
C. Date of last normal menstrual period
D. Frequency and intensity of contractions - ✔✔C. Date of last normal menstrual period
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the
fetal heart pattern is reassuring, the healthcare provider may attempt to prolong the
pregnancy and administer corticosteroids to mature the lungs of the fetus.
✔✔The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP
110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse implement?
A. Insert an internal fetal monitor
B. Assess for cervical changes q1h
C. Monitor bleeding from IV sites
D. Perform Leopold's maneuvers - ✔✔C. Monitor bleeding from IV sites
Monitoring bleeding from peripheral sites is the priority intervention. This client is
presenting with signs of placental abruption. Disseminated intravascular coagulation
(DIC) is a complication of placental abruptio, characterized by abnormal bleeding.
✔✔Immediately after birth a newborn infant is suctioned, dried, and placed under a
radiant warmer. The infant has spontaneous respirations and the nurse assesses an
apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action
should the nurse perform next?
A. Initiate positive pressure ventilation
B. Intervene after the one minute Apgar is assessed
C. Initiate CPR on the infant
D. Assess the infant's blood glucose level - ✔✔A. Initiate positive pressure ventilation
The nurse should immediately begin positive pressure ventilation because this infant's
vital signs are not within the normal range, and oxygen deprivation leads to cardiac
depression in infants. (The normal newborn pulse is 100 to 160 beats/minute and
respirations are 40 to 60 breaths/minute.)
