Western Governors University D 443
Maternity HESI Test bank (combined red hesi
and other sources) Questions Verified and
Provided with A+ Graded Answers Latest
Updated 2026
C
An expectant father tells the nurse he fears that hisD) Reassure him that normal maternal-fetal bonding is occurring. wife is "losing her
mind." He states that she is
Rationale:
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which
recommendation These behaviors are positive signs of maternal-fetal bonding and do not reflect
should the nurse make to this expectant father? ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester.
A.Suggest that his wife seek professional Options A and C are not necessary because the behaviors displayed are
counseling to deal with her symptoms. normal.
B.Explain that his wife is exhibiting ambivalence
about the pregnancy.
C. Ask him to report similar abnormal behaviors at
the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding
is occurring.
,The nurse is preparing a laboring client for C. Fetal heart rate (FHR)
an amniotomy. Immediately after the
procedure is completed, it is most important Rationale:
for the nurse to obtain which information? The FHR should be assessed before and after the procedure to
detect changes that may indicate the presence of cord
A.Maternal blood pressure compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of
B.Maternal temperature the cervix is favorable. The fluid should be assessed for color, odor,
and consistency. Option A should be assessed every 15 to 20 minutes
C.Fetal heart rate (FHR) during labor but is not specific for AROM. Option B is monitored
hourly after the membranes are ruptured to detect the development
D.White blood cell count (WBC) of amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a
B. Skin color that is slightly jaundiced
newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give
Rationale: Jaundice, a yellow skin coloration, is caused by elevated
the highest priority to which finding?
levels of bilirubin, which should be further evaluated in a newborn <24
hours old. Acrocyanosis (blue color of the hands and feet) is a common
A.Cyanosis of the hands and feet
finding in newborns; it occurs because the capillary system is immature.
Milia are small white papules present on the nose and chin that are
B.Skin color that is slightly jaundiced
caused by sebaceous gland blockage and disappear in a few
weeks.
C.Tiny white papules on the nose or chin
Small red patches on the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
D.Red patches on the cheeks and trunk
A breastfeeding postpartum client is
A.Breastfeed the infant, ensuring that both breasts are completely
diagnosed with mastitis, and antibiotic therapy
emptied.
is prescribed. Which instruction should the nurse
provide to this client?
Rationale:Mastitis, caused by plugged milk ducts, is related to breast
engorgement, and breastfeeding during mastitis facilitates the
A.Breastfeed the infant, ensuring that both breasts
complete emptying of engorged breasts, eliminating the pressure on
are completely emptied.
the inflamed breast tissue. Option B is less painful but does not facilitate
complete emptying of the breast tissue. Option C will not relieve the
B.Feed expressed breast milk to avoid the pain of
engorgement on the affected side. Option D will not decrease antibiotic
the infant latching onto the infected breast. effects on the infant.
C.Breastfeed on the unaffected breast only until
the mastitis subsides.
D.Dilute expressed breast milk with sterile water to
reduce the antibiotic effect on the infant.
A 38-week primigravida who works as a secretary
C.Move about every hour.
and sits at a computer 8 hours each day tells the
nurse that her feet have begun to swell.
Rationale:
Which instruction will aid in the prevention of
Pooling of blood in the lower extremities results from the enlarged
pooling of blood in the lower extremities?
uterus exerting pressure on the pelvic veins. Moving about every hour
will relieve pressure on the pelvic veins and increase venous
A.Wear support stockings.
return.
Option A would increase venous return from varicose veins in the lower
B.Reduce salt in the diet.
extremities but would be of little help with swelling. Option B might be
helpful with generalized edema but is not specific for edematous lower
C.Move about every hour.
extremities. Option D does not address venous return, and there is no
indication in the question that constrictive clothing is a problem.
D.Avoid constrictive clothing.
, Twenty-four hours after admission to the A.Cephalhematoma, which is caused by forceps trauma
newborn nursery, a full-term male infant
develops localized swelling on the right side of Rationale: Cephalhematoma, a slight abnormal variation of the
his head. In a newborn, what is the most likely newborn, usually arises within the first 24 hours after delivery. Trauma
cause of this accumulation of blood between from delivery causes capillary bleeding between the periosteum and
the periosteum and skull that does not cross skull. Option C is a cranial distortion lasting 5 to 7 days, caused by
the suture line? pressure on the cranium during vaginal delivery, and is a common
variation of the newborn. Options B and D both involve intracranial
A.Cephalhematoma, which is caused by forceps bleeding and could not be detected by physical assessment alone.
trauma
B.Subarachnoid hematoma, which requires
immediate drainage
C.Molding, which is caused by pressure during
labor
D.Subdural hematoma, which can result in lifelong
damage
Prior to discharge, what instructions should the
C.Allow the cord to air-dry as much as possible.
nurse give to parents regarding the newborn's
umbilical cord care at home?
Rationale:Recent studies have indicated that air drying or plain water
application may be equal to or more effective than alcohol in the cord
A.Wash the cord frequently with mild soap and
healing process. Options A, B, and D are incorrect because they
water.
promote moisture and increase the potential for infection.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath
A mother expresses fear about changing the
C.Place petroleum ointment around the glans with each diaper change
infant's diaper after circumcision. What information
and cleansing.
should the nurse include in the teaching plan?
Rationale:
A.Cleanse the penis with prepackaged diaper
With each diaper change, the glans penis should be washed with
wipes every 3 to 4 hours.
warm water to remove any urine or feces, and petroleum ointment
should be applied to prevent the diaper from sticking to the healing
B.Wash off the yellow exudate on the glans once
surface.
every day to prevent infection.
Prepackaged wipes often contain other products that may irritate
the site. The yellow exudate, which covers the glans penis as the area
C.Place petroleum ointment around the glans with
heals and epithelializes, is not an infective process and should not
each diaper change and cleansing.
be removed. If bleeding occurs at home, the client should be
instructed to apply gentle pressure to the site of the bleeding with
D.Apply pressure by squeezing the penis with the
sterile gauze squares and call the health care provider.
fingers for 5 minutes if bleeding occurs.
A 26-year-old gravida 2, para 1, client is admitted
C.Tachycardia and a feeling of nervousness
to the hospital at 28 weeks of gestation in
preterm labor. She is given three doses of
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,
terbutaline sulfate (Brethine), 0.25 mg
stimulates beta-adrenergic receptors in the uterine muscle to stop
subcutaneously, to stop her labor contractions.
contractions. The beta-adrenergic agonist properties of the drug may
What are the primary side effects of terbutaline
cause tachycardia, increased cardiac output, restlessness, headache,
sulfate?
and a feeling of nervousness. Option A is not a side effect. Options
B and D are side effects of magnesium sulfate.
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth
Maternity HESI Test bank (combined red hesi
and other sources) Questions Verified and
Provided with A+ Graded Answers Latest
Updated 2026
C
An expectant father tells the nurse he fears that hisD) Reassure him that normal maternal-fetal bonding is occurring. wife is "losing her
mind." He states that she is
Rationale:
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby when it moves too much. Which
recommendation These behaviors are positive signs of maternal-fetal bonding and do not reflect
should the nurse make to this expectant father? ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester.
A.Suggest that his wife seek professional Options A and C are not necessary because the behaviors displayed are
counseling to deal with her symptoms. normal.
B.Explain that his wife is exhibiting ambivalence
about the pregnancy.
C. Ask him to report similar abnormal behaviors at
the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding
is occurring.
,The nurse is preparing a laboring client for C. Fetal heart rate (FHR)
an amniotomy. Immediately after the
procedure is completed, it is most important Rationale:
for the nurse to obtain which information? The FHR should be assessed before and after the procedure to
detect changes that may indicate the presence of cord
A.Maternal blood pressure compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of
B.Maternal temperature the cervix is favorable. The fluid should be assessed for color, odor,
and consistency. Option A should be assessed every 15 to 20 minutes
C.Fetal heart rate (FHR) during labor but is not specific for AROM. Option B is monitored
hourly after the membranes are ruptured to detect the development
D.White blood cell count (WBC) of amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a
B. Skin color that is slightly jaundiced
newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give
Rationale: Jaundice, a yellow skin coloration, is caused by elevated
the highest priority to which finding?
levels of bilirubin, which should be further evaluated in a newborn <24
hours old. Acrocyanosis (blue color of the hands and feet) is a common
A.Cyanosis of the hands and feet
finding in newborns; it occurs because the capillary system is immature.
Milia are small white papules present on the nose and chin that are
B.Skin color that is slightly jaundiced
caused by sebaceous gland blockage and disappear in a few
weeks.
C.Tiny white papules on the nose or chin
Small red patches on the cheeks and trunk are called erythema toxicum
neonatorum, a common finding in newborns.
D.Red patches on the cheeks and trunk
A breastfeeding postpartum client is
A.Breastfeed the infant, ensuring that both breasts are completely
diagnosed with mastitis, and antibiotic therapy
emptied.
is prescribed. Which instruction should the nurse
provide to this client?
Rationale:Mastitis, caused by plugged milk ducts, is related to breast
engorgement, and breastfeeding during mastitis facilitates the
A.Breastfeed the infant, ensuring that both breasts
complete emptying of engorged breasts, eliminating the pressure on
are completely emptied.
the inflamed breast tissue. Option B is less painful but does not facilitate
complete emptying of the breast tissue. Option C will not relieve the
B.Feed expressed breast milk to avoid the pain of
engorgement on the affected side. Option D will not decrease antibiotic
the infant latching onto the infected breast. effects on the infant.
C.Breastfeed on the unaffected breast only until
the mastitis subsides.
D.Dilute expressed breast milk with sterile water to
reduce the antibiotic effect on the infant.
A 38-week primigravida who works as a secretary
C.Move about every hour.
and sits at a computer 8 hours each day tells the
nurse that her feet have begun to swell.
Rationale:
Which instruction will aid in the prevention of
Pooling of blood in the lower extremities results from the enlarged
pooling of blood in the lower extremities?
uterus exerting pressure on the pelvic veins. Moving about every hour
will relieve pressure on the pelvic veins and increase venous
A.Wear support stockings.
return.
Option A would increase venous return from varicose veins in the lower
B.Reduce salt in the diet.
extremities but would be of little help with swelling. Option B might be
helpful with generalized edema but is not specific for edematous lower
C.Move about every hour.
extremities. Option D does not address venous return, and there is no
indication in the question that constrictive clothing is a problem.
D.Avoid constrictive clothing.
, Twenty-four hours after admission to the A.Cephalhematoma, which is caused by forceps trauma
newborn nursery, a full-term male infant
develops localized swelling on the right side of Rationale: Cephalhematoma, a slight abnormal variation of the
his head. In a newborn, what is the most likely newborn, usually arises within the first 24 hours after delivery. Trauma
cause of this accumulation of blood between from delivery causes capillary bleeding between the periosteum and
the periosteum and skull that does not cross skull. Option C is a cranial distortion lasting 5 to 7 days, caused by
the suture line? pressure on the cranium during vaginal delivery, and is a common
variation of the newborn. Options B and D both involve intracranial
A.Cephalhematoma, which is caused by forceps bleeding and could not be detected by physical assessment alone.
trauma
B.Subarachnoid hematoma, which requires
immediate drainage
C.Molding, which is caused by pressure during
labor
D.Subdural hematoma, which can result in lifelong
damage
Prior to discharge, what instructions should the
C.Allow the cord to air-dry as much as possible.
nurse give to parents regarding the newborn's
umbilical cord care at home?
Rationale:Recent studies have indicated that air drying or plain water
application may be equal to or more effective than alcohol in the cord
A.Wash the cord frequently with mild soap and
healing process. Options A, B, and D are incorrect because they
water.
promote moisture and increase the potential for infection.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath
A mother expresses fear about changing the
C.Place petroleum ointment around the glans with each diaper change
infant's diaper after circumcision. What information
and cleansing.
should the nurse include in the teaching plan?
Rationale:
A.Cleanse the penis with prepackaged diaper
With each diaper change, the glans penis should be washed with
wipes every 3 to 4 hours.
warm water to remove any urine or feces, and petroleum ointment
should be applied to prevent the diaper from sticking to the healing
B.Wash off the yellow exudate on the glans once
surface.
every day to prevent infection.
Prepackaged wipes often contain other products that may irritate
the site. The yellow exudate, which covers the glans penis as the area
C.Place petroleum ointment around the glans with
heals and epithelializes, is not an infective process and should not
each diaper change and cleansing.
be removed. If bleeding occurs at home, the client should be
instructed to apply gentle pressure to the site of the bleeding with
D.Apply pressure by squeezing the penis with the
sterile gauze squares and call the health care provider.
fingers for 5 minutes if bleeding occurs.
A 26-year-old gravida 2, para 1, client is admitted
C.Tachycardia and a feeling of nervousness
to the hospital at 28 weeks of gestation in
preterm labor. She is given three doses of
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,
terbutaline sulfate (Brethine), 0.25 mg
stimulates beta-adrenergic receptors in the uterine muscle to stop
subcutaneously, to stop her labor contractions.
contractions. The beta-adrenergic agonist properties of the drug may
What are the primary side effects of terbutaline
cause tachycardia, increased cardiac output, restlessness, headache,
sulfate?
and a feeling of nervousness. Option A is not a side effect. Options
B and D are side effects of magnesium sulfate.
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth
