HESI A2 Exit Exam Maternity Practice
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the
right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV.
Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder
pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood
pressure of 86/48. Which action should the nurse implement next?
a. Check the hematocrit results.
b. Administer pain medication.
c. Increase the rate of IV fluids.
d. Monitor client for contractions. - ANSc. increase the rate of IV fluids
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask wen she could
use a home pregnancy test to diagnose pregnancy. Which response is best?
a. a home pregnancy test can be used right after your first missed period
b. these tests are most accurate after you have missed your second period
c. home pregnancy tests often give false positives and should not be trusted
d. the test can provide accurate information when used right after ovulation - ANSa. a home
pregnancy test can be used right after your first missed period
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse
knows that the most likely presenting symptom for a pediatric client with AIDS is:
a. shortness of breath
b. joint pain
c. a persistent cold
d. organmegaly - ANSc. a persistent cold
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood
pressure drops from 120/80 to 90/60. What action should the nurse take?
a. notify the healthcare provider or anesthesiologist
b. continue to assess the blood pressure q5min
c. place the woman in a lateral position
d. turn off continuous epidural - ANSc. place the woman in a lateral position
In developing a teaching plan for expectant parents, the nurse plans to include information
about when the parents can expect the infant's fontanels to close. The nurse bases the
explanation on knowledge that for the normal newborn, the
a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week
b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week
c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the second week
,d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month
- ANSd. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
month
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care?
a. patellar reflex 4+
b. blood pressure 158/80
c. four hour urine output 240 ml
d. respiration 12/minute - ANSa. patellar reflex 4+
A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which
assessment finding indicates to the nurse that the drug is effective?
a. slowly increasing urine output over the last week
b. respiratory rate changes from the 40s to the 60s
c. changes in apical heart rate from the 180 to the 140s
d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl - ANSc. changes in apical rate from the
180s to the 140s
A pregnant client tells the nurse that the first day of her last menstrual period was August 2,
2006. Based on Nagele's rule, what is the estimated date of delivery?
a. April 25, 2007
b. May 9, 2007
c. May 29, 2007
d. June 2, 2007 - ANSb. May 9, 2007
The nurse is performing a AGA on a full-term newborn during the first hour of transition using
the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a
maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate
is SGA? (Select all that apply.)
a. admission weight of 4 lbs 15 oz
b. head to heel length of 17 in
c. frontal occipital circumference of 12.5 in
d. skin smooth with visible veins and abundant vernix
e. anterior plantar crease and smooth heel surfaces
f. full flexion of all extremities in resting supine position - ANSa, b, c
The nurse assess a client admitted to the labor and delivery unit and obtains the following data:
BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment
findings, what intervention should the nurse implement?
a. insert a fetal monitor
b. assess for cervical changes q1H
c. monitor bleeding from IV sites
d. perform Leopold's maneuvers - ANSc. monitor for bleeding from IV sites
,Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer.
The infant has spontaneous respirations and the nurse assess an apical heart rate of 80 bpm
and respirations 20. What action should the nurse perform next?
a. initiate positive pressure ventilation
b. intervene after one minute APGAR is assessed
c. initiate CPR on the infant
d. assess the infant's blood glucose level - ANSa. initiate positive pressure ventilation
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The
nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced.
What additional information is most important for the nurse to obtain?
a. gravidity and parity
b. time and amount of last oral intake
c. date of last normal menstrual period
d. frequency and intensity of contractions - ANSc. date of last normal menstrual period
A mutigravida client at 41 weeks gestation present in the labor and delivery unit after a
non-stress test indicated that the fetus is experiencing some difficulties in utero. Which
diagnostic test should the nurse prepare the client for additional information about fetal status?
a. biophysical profile
b. ultrasound for fetal abnormalities
c. maternal serum alpha-fetoprotein screening
d. percutaneous umbilical blood sampling - ANSa. biophysical profile
A client receiving epidural anesthesia begins to experience nausea and becomes pale and
clammy. What intervention should the nurse implement first?
a. raise the foot of the bed
b. assess for vaginal bleeding
c. evaluate the fetal heart rate
d. take the client's blood pressure - ANSa. raise the foot of the bed
A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she
is not experiencing any uterine contractions or abdominal pain. What instruction should the
nurse provide?
a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops
d. bring a urine specimen to the lab tomorrow to determine if you have a UTI - ANSa. come to
the clinic today for an ultrasound
Which nursing intervention is helpful in relieving "afterpains"?
a. using relaxation breathing techniques
, b. using a breast pump
c. massaging the abdomen
d. giving oxytocic medications - ANSa. using relaxation breathing techniques
The nurse is counseling a couple who has sought information about conceiving. For teaching
purposes, the nurses should know that ovulation usually occurs
a. two weeks before menstruation
b. immediately after menstruation
c. immediately before menstruation
d. three weeks before menstruation - ANSa. two weeks before menstruation
A client who has an autosomal dominant inherited disorder is exploring family planning options
and the risk of transmission of the disorder to an infant. The nurses's response should be based
on what information?
a. males inherit the disorder with a greater frequency than females
b. each pregnancy carries a 50% chance of inheriting the disorder
c. the disorder occurs in 25% of pregnancies
d. all children will be carriers of the disorder - ANSb. each pregnancy carries 50% chance of
inheriting the disorder
The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider?
a. yellowish tinge to the skin
b. Babinski reflex present bilaterally
c. pink papular rash on the face
d. Moro reflex noted after a loud noise - ANSa. yellowish tinge to the skin
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most
important for the nurse to provide this client?
a. elevate lower legs while resting
b. increase caloric intake by 200 to 300 calories per day
c. increase water intake to 8 full glasses per day
d. take prescribed multivitamin and mineral supplements - ANSd. take prescribed multivitamin
and mineral supplements
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
a. blood glucose level of 45
b. blood pressure of 82/45
c. non-bulging anterior fontanel
d. central cyanosis when crying - ANSd. central cyanosis when crying
A 28 year old client in active labor complains of cramps in her leg. What intervention should the
nurse implement?
a. massage the calf and foot
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the
right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV.
Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder
pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood
pressure of 86/48. Which action should the nurse implement next?
a. Check the hematocrit results.
b. Administer pain medication.
c. Increase the rate of IV fluids.
d. Monitor client for contractions. - ANSc. increase the rate of IV fluids
A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask wen she could
use a home pregnancy test to diagnose pregnancy. Which response is best?
a. a home pregnancy test can be used right after your first missed period
b. these tests are most accurate after you have missed your second period
c. home pregnancy tests often give false positives and should not be trusted
d. the test can provide accurate information when used right after ovulation - ANSa. a home
pregnancy test can be used right after your first missed period
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse
knows that the most likely presenting symptom for a pediatric client with AIDS is:
a. shortness of breath
b. joint pain
c. a persistent cold
d. organmegaly - ANSc. a persistent cold
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood
pressure drops from 120/80 to 90/60. What action should the nurse take?
a. notify the healthcare provider or anesthesiologist
b. continue to assess the blood pressure q5min
c. place the woman in a lateral position
d. turn off continuous epidural - ANSc. place the woman in a lateral position
In developing a teaching plan for expectant parents, the nurse plans to include information
about when the parents can expect the infant's fontanels to close. The nurse bases the
explanation on knowledge that for the normal newborn, the
a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week
b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the week
c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the second week
,d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month
- ANSd. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
month
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care?
a. patellar reflex 4+
b. blood pressure 158/80
c. four hour urine output 240 ml
d. respiration 12/minute - ANSa. patellar reflex 4+
A 4 week old premature infant has been receiving epoetin alfa for the last three weeks. Which
assessment finding indicates to the nurse that the drug is effective?
a. slowly increasing urine output over the last week
b. respiratory rate changes from the 40s to the 60s
c. changes in apical heart rate from the 180 to the 140s
d. change in indirect bilirubin from 12 mg/dl to 8 mg/dl - ANSc. changes in apical rate from the
180s to the 140s
A pregnant client tells the nurse that the first day of her last menstrual period was August 2,
2006. Based on Nagele's rule, what is the estimated date of delivery?
a. April 25, 2007
b. May 9, 2007
c. May 29, 2007
d. June 2, 2007 - ANSb. May 9, 2007
The nurse is performing a AGA on a full-term newborn during the first hour of transition using
the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a
maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate
is SGA? (Select all that apply.)
a. admission weight of 4 lbs 15 oz
b. head to heel length of 17 in
c. frontal occipital circumference of 12.5 in
d. skin smooth with visible veins and abundant vernix
e. anterior plantar crease and smooth heel surfaces
f. full flexion of all extremities in resting supine position - ANSa, b, c
The nurse assess a client admitted to the labor and delivery unit and obtains the following data:
BP 110/68, FHR 110 bpm, cervix 1 cm dilated and uneffaced. Based on these assessment
findings, what intervention should the nurse implement?
a. insert a fetal monitor
b. assess for cervical changes q1H
c. monitor bleeding from IV sites
d. perform Leopold's maneuvers - ANSc. monitor for bleeding from IV sites
,Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer.
The infant has spontaneous respirations and the nurse assess an apical heart rate of 80 bpm
and respirations 20. What action should the nurse perform next?
a. initiate positive pressure ventilation
b. intervene after one minute APGAR is assessed
c. initiate CPR on the infant
d. assess the infant's blood glucose level - ANSa. initiate positive pressure ventilation
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The
nurse performs a vaginal examination that reveals the cervix is 3 cm dilated and 75% effaced.
What additional information is most important for the nurse to obtain?
a. gravidity and parity
b. time and amount of last oral intake
c. date of last normal menstrual period
d. frequency and intensity of contractions - ANSc. date of last normal menstrual period
A mutigravida client at 41 weeks gestation present in the labor and delivery unit after a
non-stress test indicated that the fetus is experiencing some difficulties in utero. Which
diagnostic test should the nurse prepare the client for additional information about fetal status?
a. biophysical profile
b. ultrasound for fetal abnormalities
c. maternal serum alpha-fetoprotein screening
d. percutaneous umbilical blood sampling - ANSa. biophysical profile
A client receiving epidural anesthesia begins to experience nausea and becomes pale and
clammy. What intervention should the nurse implement first?
a. raise the foot of the bed
b. assess for vaginal bleeding
c. evaluate the fetal heart rate
d. take the client's blood pressure - ANSa. raise the foot of the bed
A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she
is not experiencing any uterine contractions or abdominal pain. What instruction should the
nurse provide?
a. come to the clinic today for an ultrasound
b. go immediately to the emergency room
c. lie on your left side for about one hour and see if the bleeding stops
d. bring a urine specimen to the lab tomorrow to determine if you have a UTI - ANSa. come to
the clinic today for an ultrasound
Which nursing intervention is helpful in relieving "afterpains"?
a. using relaxation breathing techniques
, b. using a breast pump
c. massaging the abdomen
d. giving oxytocic medications - ANSa. using relaxation breathing techniques
The nurse is counseling a couple who has sought information about conceiving. For teaching
purposes, the nurses should know that ovulation usually occurs
a. two weeks before menstruation
b. immediately after menstruation
c. immediately before menstruation
d. three weeks before menstruation - ANSa. two weeks before menstruation
A client who has an autosomal dominant inherited disorder is exploring family planning options
and the risk of transmission of the disorder to an infant. The nurses's response should be based
on what information?
a. males inherit the disorder with a greater frequency than females
b. each pregnancy carries a 50% chance of inheriting the disorder
c. the disorder occurs in 25% of pregnancies
d. all children will be carriers of the disorder - ANSb. each pregnancy carries 50% chance of
inheriting the disorder
The nurse is assessing a 3 day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider?
a. yellowish tinge to the skin
b. Babinski reflex present bilaterally
c. pink papular rash on the face
d. Moro reflex noted after a loud noise - ANSa. yellowish tinge to the skin
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most
important for the nurse to provide this client?
a. elevate lower legs while resting
b. increase caloric intake by 200 to 300 calories per day
c. increase water intake to 8 full glasses per day
d. take prescribed multivitamin and mineral supplements - ANSd. take prescribed multivitamin
and mineral supplements
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
a. blood glucose level of 45
b. blood pressure of 82/45
c. non-bulging anterior fontanel
d. central cyanosis when crying - ANSd. central cyanosis when crying
A 28 year old client in active labor complains of cramps in her leg. What intervention should the
nurse implement?
a. massage the calf and foot
