MATERNITY HESI ASSIGNMENT EXAM UPDATED ACTUAL QUESTIONS
AND CORRECT ANSWERS VERIFIED 2027 EDITION
1. Which finding in the medical history of a post-partum client should the nurse withhold the
administration of a routine standing order for methylergonovine maleate (Methergine)?
Pregnancy induced hypertension. Rationale: Methergine is used for post-partum bleeding. A client's
history of pregnancy-induced hypertension is a contraindication for Methergine which causes
vasoconstriction and increases blood pressure, so the routine standing order should be withheld and
reported to the healthcare provider.
2. A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her
husband thinks she is imagining things. What information should the nurse provide?
The fetus in utero is capable of hearing and does respond to the mother's voice. Rationale: Fetal hearing
and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound of
the mother's voice.
3. A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife
in providing obstetric care. What information should the nurse provide?
The pregnancy should progress normally and be considered low risk. Rationale: A nurse midwife is an
advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client.
4. What nursing action should be included in the plan of care for a newborn experiencing symptoms
of drug withdrawal ?
Swaddle the infant snugly and hold tightly. Rationale: An infant experiencing drug withdrawal should be
swaddled, wrapped snugly, or placed in a "kangaroo pouch" to reduce self-stimulation behaviors and
protect skin from abrasions that may occur due to muscular irritability.
5. The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most
important to include in the teaching plan?
Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while
breastfeeding because, when consumed by the mother, it is excreted in breast milk.
6. A primigravida at 12-weeks gestation who just moved to the United States indicates she has not
received any immunizations. Which immunization(s) should the nurse administer at this time? (Select
all that apply.) Tetanus. Rubella. Diphtheria. Chickenpox. Hepatitis B.
Correct selections are (A, C, and E). Rationale: Vaccines composed of killed viruses may be administered
during pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live viruses which would be
contraindicated during pregnancy due to potential teratogenicity.
7. A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her
baby jumped in response to the noise. What information should the nurse provide?
The fetus can respond to sound by 24-weeks gestation. Rationale: At 24-weeks gestation, the fetus's ability
to hear loud environment sounds can illicit a startle response.
8. A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the
nurse assess first for signs of internal hemorrhage?
Changes in fetal heart rate patterns. Rationale: Hypoperfusion of the fetus may be present before the
onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal
monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in
the mother.
1
, 9. The nurse is discussing the stages of labor with a group of women in the last month of pregnancy
and provides examples of different positional techniques used during the second stage of labor.
Which position should the nurse address that provides the best advantage of gravity during delivery?
Squatting. Rationale: Squatting helps to align the fetus with the pelvic outlet and allows gravity to assist in
fetal descent and gives the client an adventitious position for birth.
10. A multiparous client is bearing down with contractions and crying out, "The baby is coming!"
Which immediate action should the nurse implement?
Visualize the perineum for bulging. Rationale: The perineum should be visualized for bulging or the
presentation of the baby so assistance with the impending birth can be immediately rendered.
11. The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse
assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal
flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Rate of
58 breaths per minute. Grunting heard with a stethoscope.
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of
respiratory distress in the infant.
12. A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in
early pregnancy. What information supports the explanation that the nurse should provide?
Secretes both estrogen and progesterone. Rationale: One of the early functions of the placenta as an
endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to
maintain the pregnancy and support the embryo and fetus.
13. What nursing action should be implemented when intermittently gavage-feeding a preterm
infant?
Allow formula to flow by gravity. Rationale: Gavage feeding is commonly used to feed preterm infants who
are born at less than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who are
unable to tolerate oral feedings. The feeding should flow by gravity to avoid over-distention and a sudden
sensation of fullness that may cause vomiting.
14. The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse
assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal
flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Heart
rate of 158 beats per minute. Grunting heard with a stethoscope.
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of
respiratory distress in the infant.
15. The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart
rate occurring with the peak of each contraction. What action should the nurse implement?
Place the client in a side-lying position. Rationale: Variable decelerations are caused by compression of the
umbilical cord and are evidenced by V shape appearance,characterized by a rapid descent and ascent to
and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should
reposition the client into a side-lying position.
16. Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks
gestation?
Pica. Rationale: Pica, the consumption of low- or non-nutrient substances, may cause more nutritious
foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere
with the absorption of nutrients and minerals.
2
AND CORRECT ANSWERS VERIFIED 2027 EDITION
1. Which finding in the medical history of a post-partum client should the nurse withhold the
administration of a routine standing order for methylergonovine maleate (Methergine)?
Pregnancy induced hypertension. Rationale: Methergine is used for post-partum bleeding. A client's
history of pregnancy-induced hypertension is a contraindication for Methergine which causes
vasoconstriction and increases blood pressure, so the routine standing order should be withheld and
reported to the healthcare provider.
2. A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her
husband thinks she is imagining things. What information should the nurse provide?
The fetus in utero is capable of hearing and does respond to the mother's voice. Rationale: Fetal hearing
and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound of
the mother's voice.
3. A female client who wants to delivery at home asks the nurse to explain the role of a nurse-midwife
in providing obstetric care. What information should the nurse provide?
The pregnancy should progress normally and be considered low risk. Rationale: A nurse midwife is an
advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client.
4. What nursing action should be included in the plan of care for a newborn experiencing symptoms
of drug withdrawal ?
Swaddle the infant snugly and hold tightly. Rationale: An infant experiencing drug withdrawal should be
swaddled, wrapped snugly, or placed in a "kangaroo pouch" to reduce self-stimulation behaviors and
protect skin from abrasions that may occur due to muscular irritability.
5. The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most
important to include in the teaching plan?
Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while
breastfeeding because, when consumed by the mother, it is excreted in breast milk.
6. A primigravida at 12-weeks gestation who just moved to the United States indicates she has not
received any immunizations. Which immunization(s) should the nurse administer at this time? (Select
all that apply.) Tetanus. Rubella. Diphtheria. Chickenpox. Hepatitis B.
Correct selections are (A, C, and E). Rationale: Vaccines composed of killed viruses may be administered
during pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live viruses which would be
contraindicated during pregnancy due to potential teratogenicity.
7. A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her
baby jumped in response to the noise. What information should the nurse provide?
The fetus can respond to sound by 24-weeks gestation. Rationale: At 24-weeks gestation, the fetus's ability
to hear loud environment sounds can illicit a startle response.
8. A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should the
nurse assess first for signs of internal hemorrhage?
Changes in fetal heart rate patterns. Rationale: Hypoperfusion of the fetus may be present before the
onset of clinical signs of maternal compromise or shock in a pregnant woman, so the external fetal
monitor tracings should be assessed first to determine signs of fetal hypoxia due to internal bleeding in
the mother.
1
, 9. The nurse is discussing the stages of labor with a group of women in the last month of pregnancy
and provides examples of different positional techniques used during the second stage of labor.
Which position should the nurse address that provides the best advantage of gravity during delivery?
Squatting. Rationale: Squatting helps to align the fetus with the pelvic outlet and allows gravity to assist in
fetal descent and gives the client an adventitious position for birth.
10. A multiparous client is bearing down with contractions and crying out, "The baby is coming!"
Which immediate action should the nurse implement?
Visualize the perineum for bulging. Rationale: The perineum should be visualized for bulging or the
presentation of the baby so assistance with the impending birth can be immediately rendered.
11. The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse
assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal
flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Rate of
58 breaths per minute. Grunting heard with a stethoscope.
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of
respiratory distress in the infant.
12. A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in
early pregnancy. What information supports the explanation that the nurse should provide?
Secretes both estrogen and progesterone. Rationale: One of the early functions of the placenta as an
endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to
maintain the pregnancy and support the embryo and fetus.
13. What nursing action should be implemented when intermittently gavage-feeding a preterm
infant?
Allow formula to flow by gravity. Rationale: Gavage feeding is commonly used to feed preterm infants who
are born at less than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who are
unable to tolerate oral feedings. The feeding should flow by gravity to avoid over-distention and a sudden
sensation of fullness that may cause vomiting.
14. The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse
assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal
flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Heart
rate of 158 beats per minute. Grunting heard with a stethoscope.
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of
respiratory distress in the infant.
15. The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart
rate occurring with the peak of each contraction. What action should the nurse implement?
Place the client in a side-lying position. Rationale: Variable decelerations are caused by compression of the
umbilical cord and are evidenced by V shape appearance,characterized by a rapid descent and ascent to
and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should
reposition the client into a side-lying position.
16. Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks
gestation?
Pica. Rationale: Pica, the consumption of low- or non-nutrient substances, may cause more nutritious
foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere
with the absorption of nutrients and minerals.
2
