Maternity HESI Case Study Test Latest
2027 Multiple Choices Questions and
ANSWERs GRADED A+
The nurse performs the first assessment upon the client's arrival to the
postpartum unit. Where would the nurse expect to palpate the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - ANSWER-b. 1 cm above
the umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
Fifteen minutes after the initial assessment, the nurse finds the client disoriented
and lying on her back in a pool of vaginal blood, with the sheets beneath her
saturated with blood.
Which action is most important for the nurse to implement immediately?
,a. Take vital signs
b. Massage the fundus
c. Check the bladder
d. Increase the IV rate - ANSWER-b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's hemorrhaging,
massing the fundus is the most important intervention. The nurse should also call
for assistance due to the amount of blood that has pooled under the client.
what is the most likely reason a postpartum patient would be hemorrhaging? -
ANSWER-uterine atony (a "boggy" fundus)
What should be assessed immediately after fundus is massaged and nurse has
called for help? - ANSWER-Assess for bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which
can contribute to diuresis. A distended bladder impedes uterine contraction and
contributes to excessive bleeding. After the fundus is massaged, the bladder
should be checked for distention.
When the nurse conducts a gestational age assessment, which findings may
indicate postmaturity? (Select all that apply. One, some, or all options may be
correct.)
,a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
e. Deep creases at the base of the toes extending to the heels. - ANSWER-c. d. and
e.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is lost prior to birth.
This results in the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending from the base
, The infant has a reddish papular rash across his face. How should the nurse
respond when the client asks about the rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
d. Good question. Let me take the infant's vital signs and examine him - ANSWER-
c. A newborn rash is very common, but it will disappear soon.
--> The infant rash, erythema toxicum, is very common and usually disappears by
the third day of life.
Which factor should alert the nurse to assess for the risk of jaundice? - ANSWER-
trauma at birth
what is a normal bilirubin range for a newborn? - ANSWER-5-6 mg/dL
Which instructions should the nurse include in the discharge planning regarding
the infant's jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
2027 Multiple Choices Questions and
ANSWERs GRADED A+
The nurse performs the first assessment upon the client's arrival to the
postpartum unit. Where would the nurse expect to palpate the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - ANSWER-b. 1 cm above
the umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
Fifteen minutes after the initial assessment, the nurse finds the client disoriented
and lying on her back in a pool of vaginal blood, with the sheets beneath her
saturated with blood.
Which action is most important for the nurse to implement immediately?
,a. Take vital signs
b. Massage the fundus
c. Check the bladder
d. Increase the IV rate - ANSWER-b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's hemorrhaging,
massing the fundus is the most important intervention. The nurse should also call
for assistance due to the amount of blood that has pooled under the client.
what is the most likely reason a postpartum patient would be hemorrhaging? -
ANSWER-uterine atony (a "boggy" fundus)
What should be assessed immediately after fundus is massaged and nurse has
called for help? - ANSWER-Assess for bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which
can contribute to diuresis. A distended bladder impedes uterine contraction and
contributes to excessive bleeding. After the fundus is massaged, the bladder
should be checked for distention.
When the nurse conducts a gestational age assessment, which findings may
indicate postmaturity? (Select all that apply. One, some, or all options may be
correct.)
,a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
e. Deep creases at the base of the toes extending to the heels. - ANSWER-c. d. and
e.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is lost prior to birth.
This results in the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending from the base
, The infant has a reddish papular rash across his face. How should the nurse
respond when the client asks about the rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
d. Good question. Let me take the infant's vital signs and examine him - ANSWER-
c. A newborn rash is very common, but it will disappear soon.
--> The infant rash, erythema toxicum, is very common and usually disappears by
the third day of life.
Which factor should alert the nurse to assess for the risk of jaundice? - ANSWER-
trauma at birth
what is a normal bilirubin range for a newborn? - ANSWER-5-6 mg/dL
Which instructions should the nurse include in the discharge planning regarding
the infant's jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
