HESI Maternity practice questions
Which action should the nurse implement when preparing to measure the fundal height of a
pregnant client? - ANS To accurately measure the fundal height, the bladder must be empty to
avoid elevation of the uterus.
The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform? - ANS The most common
neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may
be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the
affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal
swelling or tenderness, or cries when the arm is moved.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small
to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and
blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What
action should the nurse take immediately? - ANS Methergine is contraindicated for clients with
elevated blood pressure, so the nurse should contact the healthcare provider and question the
prescription
The nurse is preparing to give an enema to a laboring client. Which client requires the most
caution when carrying out this procedure? - ANS A 40-week primigravida who is at 6 cm cervical
dilatation and the presenting part is not engaged.
When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the
cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.
the Silverman-Anderson Index - ANS A Silverman-Anderson Index has five categories with
scores of 0, 1, or 2. The total score ranges from 0 to 10. A total score of 0 means the infant has
no dyspnea, a total score of 10 indicates maximum respiratory distress.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client? - ANS Do you have a history of rheumatic fever?
Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the
risk for cardiac decompensation due to the increased blood volume that occurs during
pregnancy, so obtaining information about this client's health history is a priority.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation.
The nurse determines that the client is not having contractions, the fetal heart rate (FHR)
baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse
take? - ANS The client should be asked if she has felt the fetus move.
,An NST is used to determine fetal well-being, and is often implemented when postmaturity is
suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response
to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to
fetal movement.
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care? - ANS A 4+ reflex in a client with pregnancy-induced
hypertension indicates hyperreflexia, which is an indication of an impending seizure.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following
data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110
beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what
intervention should the nurse implement? - ANS Monitoring bleeding from peripheral sites is the
priority intervention. This client is presenting with signs of placental abruption. Disseminated
intravascular coagulation (DIC) is a complication of placental abruptio, characterized by
abnormal bleeding.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion? - ANS Three plus deep tendon reflexes and
hyperclonus are indicative of an impending convulsion and requires immediate attention.
Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer.
The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80
beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next?
- ANS The nurse should immediately begin positive pressure ventilation because this infant's
vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression
in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60
breaths/minute.)
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing
history, the client indicates that she has delivered premature twins, one full-term baby, and has
had no abortions. Which GTPAL should the nurse document in this client's record? - ANS THIS
QUESTION WAS CONTRAINDICATED. EVOLVE SAYS THIS BUT CORRECTLY IT IS
SUPPOSE TO BE 3-1-2-0-3
The client has been pregnant 3 times including the current pregnancy (G-3). She had one
full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is
considered one birth when calculating parity). There were no abortions (A-0), so this client has a
total of 3 living children.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before
initiating this prescription, it is most important for the nurse to assess the client for which
condition? - ANS Gestational diabetes.
The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine)
increases blood glucose levels.
, A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three
weeks. Which assessment finding indicates to the nurse that the drug is effective? - ANS
Changes in apical heart rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an
increase in RBCs. Since the body has not had to compensate for anemia with an increased
heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse
explains to the client that her vaginal discharge will change from red to pink and then to white.
The client asks, "What if I start having red bleeding AFTER it changes?" What should the nurse
instruct the client to do? - ANS Lochia should progress in stages from rubra (red) to serosa
(pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates
subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare
provider and reduce her activity to conserve energy
A couple has been trying to conceive for nine months without success. Which information
obtained from the clients is most likely to have an impact on the couple's ability to conceive a
child? - ANS The use of lubricants has the potential to affect fertility because some lubricants
interfere with sperm motility.
A pregnant client tells the nurse that the first day of her last menstrual period was August 2,
2006. Based on Nägele's rule, what is the estimated date of delivery? - ANS Since this woman's
first day of her last normal menstrual period occurred on August 2, 2006, the estimated date of
delivery is May 9, 2007. Nägele's rule is used to calculate the expected date of delivery, and is
obtained by subtracting 3 months and adding 7 days beginning from the first day of the last
normal menstrual period.
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 centimeters dilated and 75%
effaced. What additional information is most important for the nurse to obtain? - ANS Date of
last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the fetal heart
pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and
administer corticosteroids to mature the lungs of the fetus.
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy.
What equipment should the nurse have available at the client's bedside? - ANS A single sterile
glove, an amniotic hook, and Doppler to check fetal heart tones are the necessary equipment
for performing an amniotomy.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose? - ANS Alpha-fetoprotein (AFP) is a screening test used in
Which action should the nurse implement when preparing to measure the fundal height of a
pregnant client? - ANS To accurately measure the fundal height, the bladder must be empty to
avoid elevation of the uterus.
The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform? - ANS The most common
neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may
be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the
affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal
swelling or tenderness, or cries when the arm is moved.
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small
to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and
blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What
action should the nurse take immediately? - ANS Methergine is contraindicated for clients with
elevated blood pressure, so the nurse should contact the healthcare provider and question the
prescription
The nurse is preparing to give an enema to a laboring client. Which client requires the most
caution when carrying out this procedure? - ANS A 40-week primigravida who is at 6 cm cervical
dilatation and the presenting part is not engaged.
When the presenting part is ballottable, it is floating out of the pelvis. In such a situation, the
cord can descend before the fetus causing a prolapsed cord, which is an emergency situation.
the Silverman-Anderson Index - ANS A Silverman-Anderson Index has five categories with
scores of 0, 1, or 2. The total score ranges from 0 to 10. A total score of 0 means the infant has
no dyspnea, a total score of 10 indicates maximum respiratory distress.
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client? - ANS Do you have a history of rheumatic fever?
Clients with a history of rheumatic fever may develop mitral valve prolapse, which increases the
risk for cardiac decompensation due to the increased blood volume that occurs during
pregnancy, so obtaining information about this client's health history is a priority.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation.
The nurse determines that the client is not having contractions, the fetal heart rate (FHR)
baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse
take? - ANS The client should be asked if she has felt the fetus move.
,An NST is used to determine fetal well-being, and is often implemented when postmaturity is
suspected. A "reactive" NST occurs if the FHR accelerates 15 bpm for 15 seconds in response
to the fetus' own movement, and is "nonreactive" if no FHR acceleration occurs in response to
fetal movement.
A client in active labor is admitted with preeclampsia. Which assessment finding is most
significant in planning this client's care? - ANS A 4+ reflex in a client with pregnancy-induced
hypertension indicates hyperreflexia, which is an indication of an impending seizure.
The nurse assesses a client admitted to the labor and delivery unit and obtains the following
data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110
beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what
intervention should the nurse implement? - ANS Monitoring bleeding from peripheral sites is the
priority intervention. This client is presenting with signs of placental abruption. Disseminated
intravascular coagulation (DIC) is a complication of placental abruptio, characterized by
abnormal bleeding.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion? - ANS Three plus deep tendon reflexes and
hyperclonus are indicative of an impending convulsion and requires immediate attention.
Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer.
The infant has spontaneous respirations and the nurse assesses an apical heart rate of 80
beats/minute and respirations of 20 breaths/minute. What action should the nurse perform next?
- ANS The nurse should immediately begin positive pressure ventilation because this infant's
vital signs are not within the normal range, and oxygen deprivation leads to cardiac depression
in infants. (The normal newborn pulse is 100 to 160 beats/minute and respirations are 40 to 60
breaths/minute.)
A pregnant woman comes to the prenatal clinic for an initial visit. In reviewing her childbearing
history, the client indicates that she has delivered premature twins, one full-term baby, and has
had no abortions. Which GTPAL should the nurse document in this client's record? - ANS THIS
QUESTION WAS CONTRAINDICATED. EVOLVE SAYS THIS BUT CORRECTLY IT IS
SUPPOSE TO BE 3-1-2-0-3
The client has been pregnant 3 times including the current pregnancy (G-3). She had one
full-term infant (T-1). She also had a preterm (P-1) twin pregnancy (a multifetal gestation is
considered one birth when calculating parity). There were no abortions (A-0), so this client has a
total of 3 living children.
The healthcare provider prescribes terbutaline (Brethine) for a client in preterm labor. Before
initiating this prescription, it is most important for the nurse to assess the client for which
condition? - ANS Gestational diabetes.
The nurse should evaluate the client for gestational diabetes because terbutaline (Brethine)
increases blood glucose levels.
, A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three
weeks. Which assessment finding indicates to the nurse that the drug is effective? - ANS
Changes in apical heart rate from the 180s to the 140s.
Epogen, given to prevent or treat anemia, stimulates erythropoietin production, resulting in an
increase in RBCs. Since the body has not had to compensate for anemia with an increased
heart rate, changes in heart rate from high to normal is one indicator that Epogen is effective
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The nurse
explains to the client that her vaginal discharge will change from red to pink and then to white.
The client asks, "What if I start having red bleeding AFTER it changes?" What should the nurse
instruct the client to do? - ANS Lochia should progress in stages from rubra (red) to serosa
(pinkish) to alba (whitish), and not return to red. The return to rubra usually indicates
subinvolution or infection. If such a sign occurs, the mother should notify the clinic/healthcare
provider and reduce her activity to conserve energy
A couple has been trying to conceive for nine months without success. Which information
obtained from the clients is most likely to have an impact on the couple's ability to conceive a
child? - ANS The use of lubricants has the potential to affect fertility because some lubricants
interfere with sperm motility.
A pregnant client tells the nurse that the first day of her last menstrual period was August 2,
2006. Based on Nägele's rule, what is the estimated date of delivery? - ANS Since this woman's
first day of her last normal menstrual period occurred on August 2, 2006, the estimated date of
delivery is May 9, 2007. Nägele's rule is used to calculate the expected date of delivery, and is
obtained by subtracting 3 months and adding 7 days beginning from the first day of the last
normal menstrual period.
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 centimeters dilated and 75%
effaced. What additional information is most important for the nurse to obtain? - ANS Date of
last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and the fetal heart
pattern is reassuring, the healthcare provider may attempt to prolong the pregnancy and
administer corticosteroids to mature the lungs of the fetus.
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy.
What equipment should the nurse have available at the client's bedside? - ANS A single sterile
glove, an amniotic hook, and Doppler to check fetal heart tones are the necessary equipment
for performing an amniotomy.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose? - ANS Alpha-fetoprotein (AFP) is a screening test used in
