MATERNITY HESI TEST BANK
(COMBINED RED HESI AND OTHER
SOURCES) EXAM QUESTIONS AND
ANSWERS
A mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective in preventing nipple soreness?
A Wear a cotton bra with nonbinding support.
B. Increase nursing time gradually over several days.
C. Ensure that the baby is positioned correctly for latching on.
D. Manually express a small amount of milk before nursing. - Answer-C. Ensure that
the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the
infant on the breast for latching on. The baby's body is in alignment with the ears,
shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the
breast. Option A helps prevent chafing, and nonbinding support aids in prevention of
discomfort from the stretching of the Cooper ligament. Option B is important but is not
necessary for all women. Option D helps soften an engorged breast and encourages
correct infant latching on but is not the best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B ."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times
a day."
B. "Offer the baby extra bottled milk after her feeding and see if she still seems
hungry."
C. "If you're concerned, you might consider bottle feeding so that you can monitor
intake." - Answer-B."Your milk is sufficient if the baby is voiding pale, straw-colored
urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if
the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of
adequate nutrition, most home scales do not measure this accurately, and the
,suggestion will likely make the mother anxious. Option C causes nipple confusion and
diminishes the mother's milk production. Option D does not address the client's
question.
The client comes to the hospital assuming she is in labor. Which assessment findings
by the nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions - Answer-A.Pain in the lower back that
radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of false labor.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk."
C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - Answer-A."Breastfeeding my infant consistently
every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method. Option B is incorrect because alcohol
can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk.
Taking a warm shower will stimulate the production of milk, which will be more painful
after breastfeedings.
,A new mother who has just had her first baby says to the nurse, "I saw the baby in the
recovery room. She sure has a funny-looking head." Which response by the nurse is
best?
A."This is not an unusually shaped head, especially for a first baby."
B."It may look odd, but newborn babies are often born with heads like that."
C."That is normal. The head will return to a round shape within 7 to 10 days."
D."Your pelvis was too small, so the head had to adjust to the birth canal." - Answer-
C."That is normal. The head will return to a round shape within 7 to 10 days."
Rationale: Option C reassures the mother that this is normal in the newborn and
provides correct information regarding the return to a normal shape. Although option A
is correct, it implies that the client should not worry. Any implied or spoken "don't worry"
is usually the wrong answer. Option B is condescending and dismissing; the mother is
seeking reassurance and information. Option D is a negative statement and implies that
molding is the mother's fault.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the
nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - Answer-C.Place the client in a lateral position.
Rationale: The nurse should immediately turn the client to a lateral position or place a
pillow or wedge under one hip to deflect the uterus. Other immediate interventions
include increasing the rate of the main line IV infusion and administering oxygen by
facemask. If the blood pressure remains low after these interventions or decreases
further, the anesthesiologist or health care provider should be notified immediately. To
continue to monitor blood pressure without taking further action could constitute
malpractice. Option D may also be warranted, but such action is based on hospital
protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is
most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
, B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - Answer-A.Avoid alcohol because
it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and cognitive
impairment for the infant. Options B, C, and D should also be included in diet teaching
for a breastfeeding mother; however, because these do not involve safety of the infant,
they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just
experienced a small amount of vaginal bleeding, which she describes as bright red. The
bleeding has subsided. 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 department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection
(UTI). - Answer-A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright
red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by
intense uterine pain indicates abruptio placenta, which is life threatening to the mother
and fetus. If those symptoms were described, option B would be appropriate. Option C
does not address the cause of the symptoms. The client is not describing symptoms of
a UTI.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions
are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart
rate increases with each contraction and returns to baseline after the contraction. Which
action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
(COMBINED RED HESI AND OTHER
SOURCES) EXAM QUESTIONS AND
ANSWERS
A mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective in preventing nipple soreness?
A Wear a cotton bra with nonbinding support.
B. Increase nursing time gradually over several days.
C. Ensure that the baby is positioned correctly for latching on.
D. Manually express a small amount of milk before nursing. - Answer-C. Ensure that
the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the
infant on the breast for latching on. The baby's body is in alignment with the ears,
shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the
breast. Option A helps prevent chafing, and nonbinding support aids in prevention of
discomfort from the stretching of the Cooper ligament. Option B is important but is not
necessary for all women. Option D helps soften an engorged breast and encourages
correct infant latching on but is not the best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A. "Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B ."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times
a day."
B. "Offer the baby extra bottled milk after her feeding and see if she still seems
hungry."
C. "If you're concerned, you might consider bottle feeding so that you can monitor
intake." - Answer-B."Your milk is sufficient if the baby is voiding pale, straw-colored
urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if
the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of
adequate nutrition, most home scales do not measure this accurately, and the
,suggestion will likely make the mother anxious. Option C causes nipple confusion and
diminishes the mother's milk production. Option D does not address the client's
question.
The client comes to the hospital assuming she is in labor. Which assessment findings
by the nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions - Answer-A.Pain in the lower back that
radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of false labor.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk."
C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - Answer-A."Breastfeeding my infant consistently
every 3 to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method. Option B is incorrect because alcohol
can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk.
Taking a warm shower will stimulate the production of milk, which will be more painful
after breastfeedings.
,A new mother who has just had her first baby says to the nurse, "I saw the baby in the
recovery room. She sure has a funny-looking head." Which response by the nurse is
best?
A."This is not an unusually shaped head, especially for a first baby."
B."It may look odd, but newborn babies are often born with heads like that."
C."That is normal. The head will return to a round shape within 7 to 10 days."
D."Your pelvis was too small, so the head had to adjust to the birth canal." - Answer-
C."That is normal. The head will return to a round shape within 7 to 10 days."
Rationale: Option C reassures the mother that this is normal in the newborn and
provides correct information regarding the return to a normal shape. Although option A
is correct, it implies that the client should not worry. Any implied or spoken "don't worry"
is usually the wrong answer. Option B is condescending and dismissing; the mother is
seeking reassurance and information. Option D is a negative statement and implies that
molding is the mother's fault.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the
nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - Answer-C.Place the client in a lateral position.
Rationale: The nurse should immediately turn the client to a lateral position or place a
pillow or wedge under one hip to deflect the uterus. Other immediate interventions
include increasing the rate of the main line IV infusion and administering oxygen by
facemask. If the blood pressure remains low after these interventions or decreases
further, the anesthesiologist or health care provider should be notified immediately. To
continue to monitor blood pressure without taking further action could constitute
malpractice. Option D may also be warranted, but such action is based on hospital
protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is
most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
, B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - Answer-A.Avoid alcohol because
it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and cognitive
impairment for the infant. Options B, C, and D should also be included in diet teaching
for a breastfeeding mother; however, because these do not involve safety of the infant,
they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just
experienced a small amount of vaginal bleeding, which she describes as bright red. The
bleeding has subsided. 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 department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection
(UTI). - Answer-A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright
red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by
intense uterine pain indicates abruptio placenta, which is life threatening to the mother
and fetus. If those symptoms were described, option B would be appropriate. Option C
does not address the cause of the symptoms. The client is not describing symptoms of
a UTI.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions
are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart
rate increases with each contraction and returns to baseline after the contraction. Which
action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
