RN HESI MATERNITY UPDATED ACTUAL QUESTIONS AND CORRECT
ANSWERS VERIFIED 2027 EDITION
1. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The
nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment
finding confirms to the nurse that the client is not labor at this time?
Contractions decrease with walking.
2. A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the
grieving process which intervention is most for the nurse to implement ? A. explain the possible cause
of the fetal demise B. Provide a time for the parents to hold their infant in privacy C. Encourage the
parents to seek counseling within the next few weeks D. Assist the couple to request autopsy
B. provide a time for the parents to hold their infant in privacy
3. What is the priority nursing assessment immediately following the birth of an infant with
esophageal atresia and a tracheoesophageal (the) fistula ? A. body temperature B. level of pain C. time
of first void D. number of vessels in the cord
A. body temperature
4. What is the most important assessment for the nurse to conduct following the administration of
epidural anesthesia to a client who is at 40-weeks gestation? A. Level of pain sensation B. Station of
presenting part C. Variability of fetal heart rate D. Maternal blood pressure
D. Maternal blood pressure
5. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate
500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the
nurse program the infusion pump? (Enter numeric value only) A. 120 B. 70 C. 65 D. 75
D. 75
6. A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse,
"Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that
apply) A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother
that it does not hurt his mother C. Remind him that his mother breastfed him too D. Suggest that the
baby can also drink from a bottle E. Clarify that breastfeeding is his mother's choice
A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does
not hurt his mother C. Remind him that his mother breastfed him too
7. The nurse is examining an infant for possible cryptorchidism. Which exam technique should be
used? A. Place the infant in side-lying to facilitate the exam B. Hold the penis and retract the foreskin
gently C. Cleanse the penis with an antiseptic-soaked pad D. Place the infant in warm room and use a
calm approach
D. Place the infant in warm room and use a calm approach
8. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor.
What maternal prescription is most important in preventing this fetus from developing respiratory
distress syndrome? A. Betamethasone (Celestone) 12 mg deep IM B. Butorphanol 1 mg IV push q2h
PRN pain C. Ampicillin 1 Gram IV push q8h D. Terbutaline (Brethine) 0.25 mg subcutaneously q15
minutes x3
A. Betamethasone (Celestone) 12 mg deep IM
1
,9. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent
urinary retention. The home health nurse notes that the child has developed episodes of sneezing,
urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to
take? A. Auscultate the lungs for respiratory pneumonia. B. Draw blood to analyze for streptococcal
infection C. Change to latex-free gloves when handling infant D. Apply zinc oxide to perineum with
each diaper change
C. Change to latex-free gloves when handling infant
10. The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2
proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe
frontal headache. Which medication should the nurse anticipate for this client? A. Clonidine
hydrochloride B. Carbamazepine C. Furosemide D. Magnesium sulfate
D. Magnesium sulfate
11. 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
12. 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
13. 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
14. 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
15. 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
2
, 16. 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
17. 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
18. 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
19. 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
20. 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
21. 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
22. 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
23. 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
24. 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.
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ANSWERS VERIFIED 2027 EDITION
1. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The
nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What assessment
finding confirms to the nurse that the client is not labor at this time?
Contractions decrease with walking.
2. A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the
grieving process which intervention is most for the nurse to implement ? A. explain the possible cause
of the fetal demise B. Provide a time for the parents to hold their infant in privacy C. Encourage the
parents to seek counseling within the next few weeks D. Assist the couple to request autopsy
B. provide a time for the parents to hold their infant in privacy
3. What is the priority nursing assessment immediately following the birth of an infant with
esophageal atresia and a tracheoesophageal (the) fistula ? A. body temperature B. level of pain C. time
of first void D. number of vessels in the cord
A. body temperature
4. What is the most important assessment for the nurse to conduct following the administration of
epidural anesthesia to a client who is at 40-weeks gestation? A. Level of pain sensation B. Station of
presenting part C. Variability of fetal heart rate D. Maternal blood pressure
D. Maternal blood pressure
5. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate
500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the
nurse program the infusion pump? (Enter numeric value only) A. 120 B. 70 C. 65 D. 75
D. 75
6. A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse,
"Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that
apply) A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother
that it does not hurt his mother C. Remind him that his mother breastfed him too D. Suggest that the
baby can also drink from a bottle E. Clarify that breastfeeding is his mother's choice
A. Explain that newborns get milk from their mothers in this way B. Reassure the older brother that it does
not hurt his mother C. Remind him that his mother breastfed him too
7. The nurse is examining an infant for possible cryptorchidism. Which exam technique should be
used? A. Place the infant in side-lying to facilitate the exam B. Hold the penis and retract the foreskin
gently C. Cleanse the penis with an antiseptic-soaked pad D. Place the infant in warm room and use a
calm approach
D. Place the infant in warm room and use a calm approach
8. The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor.
What maternal prescription is most important in preventing this fetus from developing respiratory
distress syndrome? A. Betamethasone (Celestone) 12 mg deep IM B. Butorphanol 1 mg IV push q2h
PRN pain C. Ampicillin 1 Gram IV push q8h D. Terbutaline (Brethine) 0.25 mg subcutaneously q15
minutes x3
A. Betamethasone (Celestone) 12 mg deep IM
1
,9. A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent
urinary retention. The home health nurse notes that the child has developed episodes of sneezing,
urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to
take? A. Auscultate the lungs for respiratory pneumonia. B. Draw blood to analyze for streptococcal
infection C. Change to latex-free gloves when handling infant D. Apply zinc oxide to perineum with
each diaper change
C. Change to latex-free gloves when handling infant
10. The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2
proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe
frontal headache. Which medication should the nurse anticipate for this client? A. Clonidine
hydrochloride B. Carbamazepine C. Furosemide D. Magnesium sulfate
D. Magnesium sulfate
11. 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
12. 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
13. 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
14. 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
15. 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
2
, 16. 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
17. 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
18. 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
19. 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
20. 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
21. 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
22. 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
23. 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
24. 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.
3
