RN HESI Maternity
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a
diagnosis of eclampsia. She is not presently convulsing. Which intervention should the
nurse plan to include in this client's nursing care plan? - Monitor Blood pressure, pulse,
and respirations q4h.
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
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - B. Notify the healthcare
provider from the client's bedside
A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a
non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin (
Pitocin ) infusion. Which finding is most important for the nurse to report to the health
care provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - D. A pattern of late fetal decelerations
A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test
(NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin)
infusion. Which finding is most important for the nurse to report to the healthcare
provider?
A. Spontaneous rupture of membranes.
B. Fetal heart rate accelerations with fetal movement.
C. Absences of uterine contraction of 20 minutes.
D. A pattern of fetal late decelerations. - D. A pattern of fetal late decelerations.
,A breastfeeding infant, screened for congenital hypothyroidism, is found to have low
levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the
best explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
D. The TSH is high because of the low production of T4 by the thyroid. - D. The TSH is
high because of the low production of T4 by the thyroid.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
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. Breastfeed the infant, ensuring that both breasts are completely emptied.
A client at 28 weeks gestation is admitted to the obstetrical unit following her
involvement in a motor vehicle collision. While stabilizing the patient , the nurse obtains
fetal monitor reading. Which action should the nurse take if the fetus is tachycardic is on
the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - D. Contact the
healthcare provider after initiating oxygen per face mask
A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in blood pressure. When the
client calls the clinic complaining of indigestion, which instruction should the nurse
provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent.
- C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
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
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
A client delivers a viable infant , but begins to have excessive uncontrolled vaginal ..
notifying the healthcare provider of the clients condition ,What information is most
important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused - A. Maternal blood pressure.
A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious.
Which of the following should be the focus of the nurse's response?
A. Telling the client and her partner that the labor process is often unpredictable
B. Informing the client that this means she will give birth sooner than expected
C. Asking the client and her partner if they would like the nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within normal limits - C. Asking the
client and her partner if they would like the nurse to stay in the room
A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern - D. Contraction pattern.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that
her lochia is getting lighter in color and asks when the flow will stop. How should the
nurse respond?
A. 2 weeks
B. 10 days
C. When the placental site has healed
D.After the first time ovulation occurs - C. When the placental site has healed
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a
diagnosis of eclampsia. She is not presently convulsing. Which intervention should the
nurse plan to include in this client's nursing care plan? - Monitor Blood pressure, pulse,
and respirations q4h.
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
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - B. Notify the healthcare
provider from the client's bedside
A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a
non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin (
Pitocin ) infusion. Which finding is most important for the nurse to report to the health
care provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - D. A pattern of late fetal decelerations
A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test
(NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin)
infusion. Which finding is most important for the nurse to report to the healthcare
provider?
A. Spontaneous rupture of membranes.
B. Fetal heart rate accelerations with fetal movement.
C. Absences of uterine contraction of 20 minutes.
D. A pattern of fetal late decelerations. - D. A pattern of fetal late decelerations.
,A breastfeeding infant, screened for congenital hypothyroidism, is found to have low
levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the
best explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
D. The TSH is high because of the low production of T4 by the thyroid. - D. The TSH is
high because of the low production of T4 by the thyroid.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
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. Breastfeed the infant, ensuring that both breasts are completely emptied.
A client at 28 weeks gestation is admitted to the obstetrical unit following her
involvement in a motor vehicle collision. While stabilizing the patient , the nurse obtains
fetal monitor reading. Which action should the nurse take if the fetus is tachycardic is on
the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - D. Contact the
healthcare provider after initiating oxygen per face mask
A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in blood pressure. When the
client calls the clinic complaining of indigestion, which instruction should the nurse
provide?
A. Lie on your left side and call 911 for emergency assistance.
B. Take an antacid and call back if the pain has not subsided.
C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
D. See your health care provider to obtain a prescription for a histamine blocking agent.
- C. Take your blood pressure now and if it is seriously elevated, go to the hospital.
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
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
A client delivers a viable infant , but begins to have excessive uncontrolled vaginal ..
notifying the healthcare provider of the clients condition ,What information is most
important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused - A. Maternal blood pressure.
A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she had expected. Her partner is also becoming anxious.
Which of the following should be the focus of the nurse's response?
A. Telling the client and her partner that the labor process is often unpredictable
B. Informing the client that this means she will give birth sooner than expected
C. Asking the client and her partner if they would like the nurse to stay in the room
D. Affirming that the fetal heart rate is remaining within normal limits - C. Asking the
client and her partner if they would like the nurse to stay in the room
A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern - D. Contraction pattern.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that
her lochia is getting lighter in color and asks when the flow will stop. How should the
nurse respond?
A. 2 weeks
B. 10 days
C. When the placental site has healed
D.After the first time ovulation occurs - C. When the placental site has healed
