HESI-FOCUS ON MATERNITY EXAM SET
QUESTIONS AND ANSWERS
A nurse is assisting a HCP in performing a physical exam of a client who has just been
told that she is pregnant. The HCP tells the nurse that the Goodell sign is present. The
nurse understands that this sign is indicative of - Answer-an increase in vascularity and
hypertrophy of the cervix
a nurse performing an assessment of a pregnant client prepares to auscultate the fetal
heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are
fetal heart sounds audible with the use of this device - Answer-12 weeks
a nurse is assisting a midwife who is assessing a client for ballottement. Which action
does the nurse anticipate that the midwife will employ to test for ballottement - Answer-
performing a sudden tap on the cervix
after the delivery of a newborn, a nurse performs an initial assessment and determines
that the Apgar score is 8. The nurse interprets this score as indicating that the infant -
Answer-is adjusting well to extrauterine life
A nurse teaching a pregnant client about measures to strengthen the pelvic floor
instructs the client to - Answer-perform kegel exercises in 10 repetitions, three times per
day
a nurse is caring for a client in labor who has sickle cell anemia. Which intervention
does the nurse implement to help prevent a sickling crisis - Answer-administering
oxygen as prescribed
a nurse teaches a new mother how to perform umbilical cord care and how to recognize
the signs of a cord infection. Which finding does the nurse tell the mother is an indicator
of infection - Answer-edema at the base of the cord
a nurse is performing assessments every 30 min on a client who is receiving mag
sulfate for preE. Which finding would prompt the nurse to contact the HCP - Answer-
resp of 10 breaths/min
a nurse is monitoring a client in the third trimester of pregnancy who has a dx of severe
preE. Which finding would prompt the nurse to contact the HCP - Answer-diaphoresis
and tachycardia
a pregnant client is seen in the clinic for the first time. This is the client's first pregnancy
and the client tells the nurse that she has DM. The nurse provides instruction to the
client regarding health care during pregnancy. Which statements by the client indicate
the need for further instruction SATA
, a) I need to follow the prescribed diabetic diet
b) I need to limit exercise while I'm pregnant
c) I need to report signs of infection to my HCP
d) My insulin requirements may change while I'm pregnant
e) I'll come back for a prenatal visit every month during my first trimester - Answer-b, e
during a prenatal visit, the nurse notes that an adolescent pregnant client with DM has
lost 10lbs during the first 15 weeks of gestation. The nurse discusses the weight loss
with the client, and the client states, "I don't eat regular meals". The appropriate
response is - Answer-Let's make a list of what you're eating
A nurse provides information about the tx for hypoglycemia to a client with gestational
diabetes who will be taking insulin. The nurse tells the client that if s/s of hypoglycemia
occur, she must immediately - Answer-check her BGL
A nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted
in the infant, would indicate that the criteria for early d/c have been met SATA
a) The infant has urinated
b) the infant has passed 1 stool
c) VS are documented as normal
d) the infant has completed one successful feeding
e) the infant has shown no evidence of jaundice in the first 6 hours of life - Answer-a, b,
c
a client admitted to the maternity unit 12 hours ago has been experiencing strong
contractions every 3 min but has remained at station 0. the FHR on admission was
140bpm and regular. The FHR is slowing and a persistent FHR pattern is present. The
appropriate nursing action in this situation is - Answer-preparing the client for a c-
section
Immediately after the delivery of a newborn infant, the nurse prepares to deliver the
placenta. The nurse initially - Answer-instructs the mother to push when signs of
separation have occurred
A multigravida woman with a hx of multiple c-sections is admitted to the maternity unit in
labor. The client is experiencing excessively strong contractions and the nurse monitors
the client closely for uterine rupture. Which assessment findings are indicative of
complete uterine rupture SATA
a) fetal bradycardia
b) maternal tachypnea
c) excessive vaginal bleeding
d) increased uterine contractions
e) maternal complaint of sudden sharp abdominal pain - Answer-a, b, e
a client is admitted to the hospital for an emergency c-section. Contractions are
occurring every 15 min, the client has a temp of 100 F and the client reports that she
QUESTIONS AND ANSWERS
A nurse is assisting a HCP in performing a physical exam of a client who has just been
told that she is pregnant. The HCP tells the nurse that the Goodell sign is present. The
nurse understands that this sign is indicative of - Answer-an increase in vascularity and
hypertrophy of the cervix
a nurse performing an assessment of a pregnant client prepares to auscultate the fetal
heart sounds, using a Doppler ultrasound stethoscope. By which week of gestation are
fetal heart sounds audible with the use of this device - Answer-12 weeks
a nurse is assisting a midwife who is assessing a client for ballottement. Which action
does the nurse anticipate that the midwife will employ to test for ballottement - Answer-
performing a sudden tap on the cervix
after the delivery of a newborn, a nurse performs an initial assessment and determines
that the Apgar score is 8. The nurse interprets this score as indicating that the infant -
Answer-is adjusting well to extrauterine life
A nurse teaching a pregnant client about measures to strengthen the pelvic floor
instructs the client to - Answer-perform kegel exercises in 10 repetitions, three times per
day
a nurse is caring for a client in labor who has sickle cell anemia. Which intervention
does the nurse implement to help prevent a sickling crisis - Answer-administering
oxygen as prescribed
a nurse teaches a new mother how to perform umbilical cord care and how to recognize
the signs of a cord infection. Which finding does the nurse tell the mother is an indicator
of infection - Answer-edema at the base of the cord
a nurse is performing assessments every 30 min on a client who is receiving mag
sulfate for preE. Which finding would prompt the nurse to contact the HCP - Answer-
resp of 10 breaths/min
a nurse is monitoring a client in the third trimester of pregnancy who has a dx of severe
preE. Which finding would prompt the nurse to contact the HCP - Answer-diaphoresis
and tachycardia
a pregnant client is seen in the clinic for the first time. This is the client's first pregnancy
and the client tells the nurse that she has DM. The nurse provides instruction to the
client regarding health care during pregnancy. Which statements by the client indicate
the need for further instruction SATA
, a) I need to follow the prescribed diabetic diet
b) I need to limit exercise while I'm pregnant
c) I need to report signs of infection to my HCP
d) My insulin requirements may change while I'm pregnant
e) I'll come back for a prenatal visit every month during my first trimester - Answer-b, e
during a prenatal visit, the nurse notes that an adolescent pregnant client with DM has
lost 10lbs during the first 15 weeks of gestation. The nurse discusses the weight loss
with the client, and the client states, "I don't eat regular meals". The appropriate
response is - Answer-Let's make a list of what you're eating
A nurse provides information about the tx for hypoglycemia to a client with gestational
diabetes who will be taking insulin. The nurse tells the client that if s/s of hypoglycemia
occur, she must immediately - Answer-check her BGL
A nurse is reviewing the criteria for early discharge of a newborn infant. Which, if noted
in the infant, would indicate that the criteria for early d/c have been met SATA
a) The infant has urinated
b) the infant has passed 1 stool
c) VS are documented as normal
d) the infant has completed one successful feeding
e) the infant has shown no evidence of jaundice in the first 6 hours of life - Answer-a, b,
c
a client admitted to the maternity unit 12 hours ago has been experiencing strong
contractions every 3 min but has remained at station 0. the FHR on admission was
140bpm and regular. The FHR is slowing and a persistent FHR pattern is present. The
appropriate nursing action in this situation is - Answer-preparing the client for a c-
section
Immediately after the delivery of a newborn infant, the nurse prepares to deliver the
placenta. The nurse initially - Answer-instructs the mother to push when signs of
separation have occurred
A multigravida woman with a hx of multiple c-sections is admitted to the maternity unit in
labor. The client is experiencing excessively strong contractions and the nurse monitors
the client closely for uterine rupture. Which assessment findings are indicative of
complete uterine rupture SATA
a) fetal bradycardia
b) maternal tachypnea
c) excessive vaginal bleeding
d) increased uterine contractions
e) maternal complaint of sudden sharp abdominal pain - Answer-a, b, e
a client is admitted to the hospital for an emergency c-section. Contractions are
occurring every 15 min, the client has a temp of 100 F and the client reports that she
