Maternity HESI Study
When assessing a newborn infant's heart rate, which technique is most important for the nurse
to use?
1. Quiet the infant before counting the heart rate.
2. Listen at the apex of the heart.
3. Count the heart rate for at least one full minute.
4. Palpate the umbilical cord - ANS 3. Count the heart rate for at least one full minute.
It is most important for the nurse to count the heart rate for at least one full minute (C) so that
irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be correctly
auscultated. The heart rate can be heard clearly over any point of an infant's chest, not just (B).
Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the most
accurate method of obtaining a newborn's heart rate.
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?
1. This is a demonstration of the fetus's acoustical reflex.
2. The fetus can respond to sound by 24-weeks gestation.
3. It is a coincidence the fetus responded at the same time.
4. Report the fetus's behavior to the healthcare provider. - ANS 2. The fetus can respond to
sound by 24-weeks gestation.
At 24-weeks gestation, the fetus's ability to hear loud environment sounds can illicit a startle
response (B). Acoustic stimulations can evoke a fetal heart rate response and fetal movement,
but (A and C) are inaccurate. (D) is not indicated.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should
the nurse assess first for signs of internal hemorrhage?
1. Vaginal bleeding.
2. Complaints of abdominal pain.
3. Changes in fetal heart rate patterns.
4. Alteration in maternal blood pressure - ANS 3. Changes in fetal heart rate patterns.
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. (A, B,
and D) are not the first findings of internal hemorrhage in the pregnant client.
,The nurse assesses a male newborn and determines that he has the following vital signs:
axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48
breaths/minute. Based on these findings, which action should the nurse take first?
1. Check the infant's arterial blood gases.
2. Notify the pediatrician of the infant's vital signs.
3. Assess the infant's blood glucose level.
4. Encourage the infant to take the breast or sugar water. - ANS 3. Assess the infant's blood
glucose level.
The nurse should first assess the infant's blood glucose level (C), because the infant is
displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and
hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy
demands. The infant's respiratory and heart rates are within normal limits, so (A) is not a priority.
(B and D) would be implemented after information regarding the blood sugar level has been
obtained.
A client at 29-weeks gestation with possible placental insufficiency is being prepared for
prenatal testing. Information about which diagnostic study should the nurse provide information
to the client?
1. Amniocentesis.
2. Ultrasonography.
3. Chorionic villus sampling.
4. Maternal serum alpha-fetoprotein. - ANS 2. Ultrasonography.
Gestational age, fetal growth, and the status and position of the placenta are monitored by
ultrasound.
A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine
pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active
labor. Which finding should require the nurse to implement further action?
1. Labor has progressed at 1 cm/hr dilation.
2. Intensity of contractions is 130 mm Hg.
3. Contractions are lasting 60 to 80 seconds.
4. Oxytocin is infusing at a rate ot 30 mU/min. - ANS 2. Intensity of contractions is 130 mm Hg.
The goal of induction of labor with oxytocin is to produce an effective labor, which can be
measured by an IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin, so (B)
requires further intervention. (A, C, and D) are goals for induction of labor using oxytocin.
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)?
,1. Pregnancy induced hypertension.
2. Placenta previa.
3. Gestational diabetes.
4. Postpartum hemorrhage. - ANS 1. Pregnancy induced hypertension.
Methergine is used for post-partum bleeding. A client's history of pregnancy-induced
hypertension (A) 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. (B, C, and D) are not contraindications for the use of Methergine.
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at
32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters
the right ventricle, what is the priority nursing assessment?
1. Assess fetal response to the procedure.
2. Note any complaint of sudden chest pain.
3. Monitor for premature ventricular contractions.
4. Observe for maternal blood pressure changes. - ANS 3. Monitor for premature ventricular
contractions.
During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be
monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is
important, the primary nursing assessment at this time is monitoring for immediate cardiac
changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes
in the client's heart rhythm before the client complains of chest pain (B). Manual blood
pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary
artery pressures is to detect early cardiac changes due to left ventricular failure.
A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which
food should the nurse recommend to increase the client's calcium intake?
1. Canned clams.
2. Fresh apricots.
3. Canned sardines.
4. Spaghetti with meat sauce. - ANS 3. Canned sardines.
A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of
milk (C). (A, B, and D) are not good sources for dietary calcium.
A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and
tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should
the nurse give?
, 1. Apply ice to the breasts.
2. Wear a loose-fitting bra.
3. Run warm water on the breasts during a shower.
4. Express small amounts of milk from the breasts. - ANS 1. Apply ice to the breasts.
Since the baby is receiving bottled formula, suppression of breast milk production is desired. Ice
applications to the breast cause vasoconstriction which reduces engorgement and provides
topical pain relief. A well-fitted support bra or breast binder , not (B), should be recommended to
reduce stimulation of the nipples and breast tissue, which often stimulates breast milk
production and engorgement. Applying heat to the breast causes vasodilation and increased
engorgement (C). Expressing milk from the breast will stimulate additional milk production (D)
and contribute to engorgement.
The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse
assess further? (Select all that apply.)
1. Shallow with an irregular rhythm.
2. Chest breathing with nasal flaring.
3. Diaphragmatic with chest retraction.
4. Abdominal with synchronous chest movements.
5. Heart rate of 158 beats per minute.
6. Grunting heard with a stethoscope. - ANS 2. Chest breathing with nasal flaring.
3. Diaphragmatic with chest retraction.
6. Grunting heard with a stethoscope.
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are
signs of respiratory distress in the infant.
The nurse is giving discharge instructions for a client following a suction curettage for
hydatidiform mole. The client asks why oral contraceptives are being recommended for the next
12 months. What information should the nurse provide?
1. Oral contraceptives prevent a reoccurrence of a molar pregnancy.
2. Pregnancy within 1 year decreases the chances of a future successful pregnancy.
3. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy.
4. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation. -
ANS 3. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by
pregnancy.
The major risk after a molar pregnancy is the development of choriocarcinoma, which is
detected by measuring the same hormone (hCG) that the body produces during pregnancy.
Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy
making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent
When assessing a newborn infant's heart rate, which technique is most important for the nurse
to use?
1. Quiet the infant before counting the heart rate.
2. Listen at the apex of the heart.
3. Count the heart rate for at least one full minute.
4. Palpate the umbilical cord - ANS 3. Count the heart rate for at least one full minute.
It is most important for the nurse to count the heart rate for at least one full minute (C) so that
irregularities or murmurs can be detected. (A) is not necessary for the heart rate to be correctly
auscultated. The heart rate can be heard clearly over any point of an infant's chest, not just (B).
Immediately after delivery, (D) will allow the nurse to assess the rate, but (B) is the most
accurate method of obtaining a newborn's heart rate.
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?
1. This is a demonstration of the fetus's acoustical reflex.
2. The fetus can respond to sound by 24-weeks gestation.
3. It is a coincidence the fetus responded at the same time.
4. Report the fetus's behavior to the healthcare provider. - ANS 2. The fetus can respond to
sound by 24-weeks gestation.
At 24-weeks gestation, the fetus's ability to hear loud environment sounds can illicit a startle
response (B). Acoustic stimulations can evoke a fetal heart rate response and fetal movement,
but (A and C) are inaccurate. (D) is not indicated.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which parameter should
the nurse assess first for signs of internal hemorrhage?
1. Vaginal bleeding.
2. Complaints of abdominal pain.
3. Changes in fetal heart rate patterns.
4. Alteration in maternal blood pressure - ANS 3. Changes in fetal heart rate patterns.
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. (A, B,
and D) are not the first findings of internal hemorrhage in the pregnant client.
,The nurse assesses a male newborn and determines that he has the following vital signs:
axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48
breaths/minute. Based on these findings, which action should the nurse take first?
1. Check the infant's arterial blood gases.
2. Notify the pediatrician of the infant's vital signs.
3. Assess the infant's blood glucose level.
4. Encourage the infant to take the breast or sugar water. - ANS 3. Assess the infant's blood
glucose level.
The nurse should first assess the infant's blood glucose level (C), because the infant is
displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and
hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy
demands. The infant's respiratory and heart rates are within normal limits, so (A) is not a priority.
(B and D) would be implemented after information regarding the blood sugar level has been
obtained.
A client at 29-weeks gestation with possible placental insufficiency is being prepared for
prenatal testing. Information about which diagnostic study should the nurse provide information
to the client?
1. Amniocentesis.
2. Ultrasonography.
3. Chorionic villus sampling.
4. Maternal serum alpha-fetoprotein. - ANS 2. Ultrasonography.
Gestational age, fetal growth, and the status and position of the placenta are monitored by
ultrasound.
A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine
pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active
labor. Which finding should require the nurse to implement further action?
1. Labor has progressed at 1 cm/hr dilation.
2. Intensity of contractions is 130 mm Hg.
3. Contractions are lasting 60 to 80 seconds.
4. Oxytocin is infusing at a rate ot 30 mU/min. - ANS 2. Intensity of contractions is 130 mm Hg.
The goal of induction of labor with oxytocin is to produce an effective labor, which can be
measured by an IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin, so (B)
requires further intervention. (A, C, and D) are goals for induction of labor using oxytocin.
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)?
,1. Pregnancy induced hypertension.
2. Placenta previa.
3. Gestational diabetes.
4. Postpartum hemorrhage. - ANS 1. Pregnancy induced hypertension.
Methergine is used for post-partum bleeding. A client's history of pregnancy-induced
hypertension (A) 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. (B, C, and D) are not contraindications for the use of Methergine.
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at
32-weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters
the right ventricle, what is the priority nursing assessment?
1. Assess fetal response to the procedure.
2. Note any complaint of sudden chest pain.
3. Monitor for premature ventricular contractions.
4. Observe for maternal blood pressure changes. - ANS 3. Monitor for premature ventricular
contractions.
During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be
monitored for the occurrence of any ventricular ectopy (C). Although fetal well-being (A) is
important, the primary nursing assessment at this time is monitoring for immediate cardiac
changes in the mother. Adverse cardiac responses to PAC insertion should first identify changes
in the client's heart rhythm before the client complains of chest pain (B). Manual blood
pressures (D) evaluate systemic perfusion, but the primary purpose in monitoring pulmonary
artery pressures is to detect early cardiac changes due to left ventricular failure.
A primigravida at 12-weeks gestation tells the nurse that she does not like diary products. Which
food should the nurse recommend to increase the client's calcium intake?
1. Canned clams.
2. Fresh apricots.
3. Canned sardines.
4. Spaghetti with meat sauce. - ANS 3. Canned sardines.
A 3 ounce can of sardines (with bones) provides about the same amount of calcium as 1 cup of
milk (C). (A, B, and D) are not good sources for dietary calcium.
A woman who is bottle-feeding her newborn infant calls the clinic 72 hours after delivery and
tells the nurse that both of her breasts are swollen, warm, and tender. What instructions should
the nurse give?
, 1. Apply ice to the breasts.
2. Wear a loose-fitting bra.
3. Run warm water on the breasts during a shower.
4. Express small amounts of milk from the breasts. - ANS 1. Apply ice to the breasts.
Since the baby is receiving bottled formula, suppression of breast milk production is desired. Ice
applications to the breast cause vasoconstriction which reduces engorgement and provides
topical pain relief. A well-fitted support bra or breast binder , not (B), should be recommended to
reduce stimulation of the nipples and breast tissue, which often stimulates breast milk
production and engorgement. Applying heat to the breast causes vasodilation and increased
engorgement (C). Expressing milk from the breast will stimulate additional milk production (D)
and contribute to engorgement.
The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse
assess further? (Select all that apply.)
1. Shallow with an irregular rhythm.
2. Chest breathing with nasal flaring.
3. Diaphragmatic with chest retraction.
4. Abdominal with synchronous chest movements.
5. Heart rate of 158 beats per minute.
6. Grunting heard with a stethoscope. - ANS 2. Chest breathing with nasal flaring.
3. Diaphragmatic with chest retraction.
6. Grunting heard with a stethoscope.
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are
signs of respiratory distress in the infant.
The nurse is giving discharge instructions for a client following a suction curettage for
hydatidiform mole. The client asks why oral contraceptives are being recommended for the next
12 months. What information should the nurse provide?
1. Oral contraceptives prevent a reoccurrence of a molar pregnancy.
2. Pregnancy within 1 year decreases the chances of a future successful pregnancy.
3. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy.
4. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation. -
ANS 3. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by
pregnancy.
The major risk after a molar pregnancy is the development of choriocarcinoma, which is
detected by measuring the same hormone (hCG) that the body produces during pregnancy.
Continued elevated hCG levels may be either from choriocarcinoma or a subsequent pregnancy
making diagnosis and treatment difficult, so oral contraceptives are prescribed to prevent
