1
HESI MILESTONE 3 EXAM Questions
and Answers LATEST UPDATE 2025
TOP RATED A+
The nurse is caring for an infant scheduled for reduction of intussusceptions. The day
before the scheduled procedure the infant passes a soft-formed brown stool. Which
intervention should the nurse implement?
Correct Answer: Notify the healthcare provider of the passage of brown stool.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client
is coming to the unit suspected abruptio placentae. What findings should the charge
nurse expect the client to demonstrate?
Correct Answer: A. dark,red vaginal bleeding
D. increased uterine irritability
F. Rigid abdomen
placenta abruption s/s
Correct Answer: severe abdominal and back pain
uterine rigidity
bright red or dark vaginal bleeding
maternal hypovolemia
22
-A client who is at 32 wks calls the HCP b/c she is experiencing dark red vag bleeding.
, 2
She is admitted to the ED, where the nurse determines the FHR to be 100bpm. The
client's abd is rigid & boardlike, & she is complaining of severe pain. What action does
the nurse take first?
Correct Answer: -Use their knowledge base to differentiate b/w abruption & previa
-IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG MANIPULATION OR EXAMS
-ADMIN O2 BY FACEMASK
-MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK FOR DIC
-EMERGENCY C-SECTION REQUIRED b/c uteroplacental perfusion to the fetus is
being compromised by early sep. of the placenta from the uterus
While in labor at 39 weeks' gestation, a primigravida develops a temperature of 38.2°C
(100.7°F), and fetal tachycardia is noted at 170 beats per minute. The student nurse
asks the experienced nurse what this could indicate. How should the experienced nurse
respond?
Correct Answer: A temperature of 38.2°C (100.7°F) may indicate an infection such as
chorioamnionitis, and the practitioner should be notified.
Prolapsed Cord: Care
Correct Answer: Care Includes: Knee to Chest position OR Trendelenburg
PATIENT IS IN DELIVERY, NURSE NOTICES PRESENCE OF UMBILICAL CORD
PROTRUDING THROUGH VAGINA. WHAT WOULD YOU DO?
23
Correct Answer: Knee-to-chest position or Trendelenburg's, oxygen, call physician
A primipara with a breech presentation is in the transition phase of labor. The nurse
visualizes the perineum and sees the umbilical cord extruding from the introitus. In
which position should the nurse place the client?
, 3
Correct Answer: supine with the foot of the bed elevated.
need to aleviate pressure on the prolapsed cord.
Shoulder dystocia actions
Correct Answer: McRoberts' maneuver and suprapubic pressure (need step stool)
Variable deceleration actions
Correct Answer: Change maternal position.
2. Stimulate fetus if indicated.
3. Discontinue oxytocin (Pitocin) if infusing.
4. Administer oxygen (O2) at 10 L by tight facemask.
5. Perform a vaginal examination to check for cord prolapse.
6. Report findings to physician and document.
Pt has variable deceleration. What is nursing action?
Correct Answer: Turn her on her side
Nurse discovers the postpartum client has a boggy uterus and is on the left side
24
Correct Answer: fundal massage and administer uterotonic to increase uterine
contraction.
- give oxytocin
A hospitalized child stiffens and starts to seize as the nurse enters the room. What
actions should the nurse take? (Select all apply)
Correct Answer: • Turn client to the side if possible
• Pad side rails with available pillows and blankets• Monitor duration and progress of the
seizure
, 4
Mother brings infant complaining of vomiting and diarrhea to ER that's been
breastfeeding and introducing formula -
Correct Answer: Ask what kind of water are you mixing with formula
How is symmetric IUGR diagnosed
Correct Answer: By serial ultrasound, which is the reason for 1st trimester ultrasound
Engorgement Teaching
Correct Answer: Avoid nipple stimulation
Do not express milk
Place ice packs for 15 minute
25
Tight fitting bra or binder
A new mother reports breast engorgement and nipple pain on day 2 after the delivery of
a healthy newborn. The mother tells the nurse, "I'm not sure that breastfeeding the baby
is for me." What should the nurse advise the mother to do to help relieve discomfort and
encourage persevering with breastfeeding?
Correct Answer: Inform the mother that breastfeeding the newborn more frequently
will help treat these symptoms.
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce
breast engorgement. Which instruction should the nurse provide?
Correct Answer: Breastfeed the infant every 2 hours
The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about
HESI MILESTONE 3 EXAM Questions
and Answers LATEST UPDATE 2025
TOP RATED A+
The nurse is caring for an infant scheduled for reduction of intussusceptions. The day
before the scheduled procedure the infant passes a soft-formed brown stool. Which
intervention should the nurse implement?
Correct Answer: Notify the healthcare provider of the passage of brown stool.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client
is coming to the unit suspected abruptio placentae. What findings should the charge
nurse expect the client to demonstrate?
Correct Answer: A. dark,red vaginal bleeding
D. increased uterine irritability
F. Rigid abdomen
placenta abruption s/s
Correct Answer: severe abdominal and back pain
uterine rigidity
bright red or dark vaginal bleeding
maternal hypovolemia
22
-A client who is at 32 wks calls the HCP b/c she is experiencing dark red vag bleeding.
, 2
She is admitted to the ED, where the nurse determines the FHR to be 100bpm. The
client's abd is rigid & boardlike, & she is complaining of severe pain. What action does
the nurse take first?
Correct Answer: -Use their knowledge base to differentiate b/w abruption & previa
-IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG MANIPULATION OR EXAMS
-ADMIN O2 BY FACEMASK
-MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK FOR DIC
-EMERGENCY C-SECTION REQUIRED b/c uteroplacental perfusion to the fetus is
being compromised by early sep. of the placenta from the uterus
While in labor at 39 weeks' gestation, a primigravida develops a temperature of 38.2°C
(100.7°F), and fetal tachycardia is noted at 170 beats per minute. The student nurse
asks the experienced nurse what this could indicate. How should the experienced nurse
respond?
Correct Answer: A temperature of 38.2°C (100.7°F) may indicate an infection such as
chorioamnionitis, and the practitioner should be notified.
Prolapsed Cord: Care
Correct Answer: Care Includes: Knee to Chest position OR Trendelenburg
PATIENT IS IN DELIVERY, NURSE NOTICES PRESENCE OF UMBILICAL CORD
PROTRUDING THROUGH VAGINA. WHAT WOULD YOU DO?
23
Correct Answer: Knee-to-chest position or Trendelenburg's, oxygen, call physician
A primipara with a breech presentation is in the transition phase of labor. The nurse
visualizes the perineum and sees the umbilical cord extruding from the introitus. In
which position should the nurse place the client?
, 3
Correct Answer: supine with the foot of the bed elevated.
need to aleviate pressure on the prolapsed cord.
Shoulder dystocia actions
Correct Answer: McRoberts' maneuver and suprapubic pressure (need step stool)
Variable deceleration actions
Correct Answer: Change maternal position.
2. Stimulate fetus if indicated.
3. Discontinue oxytocin (Pitocin) if infusing.
4. Administer oxygen (O2) at 10 L by tight facemask.
5. Perform a vaginal examination to check for cord prolapse.
6. Report findings to physician and document.
Pt has variable deceleration. What is nursing action?
Correct Answer: Turn her on her side
Nurse discovers the postpartum client has a boggy uterus and is on the left side
24
Correct Answer: fundal massage and administer uterotonic to increase uterine
contraction.
- give oxytocin
A hospitalized child stiffens and starts to seize as the nurse enters the room. What
actions should the nurse take? (Select all apply)
Correct Answer: • Turn client to the side if possible
• Pad side rails with available pillows and blankets• Monitor duration and progress of the
seizure
, 4
Mother brings infant complaining of vomiting and diarrhea to ER that's been
breastfeeding and introducing formula -
Correct Answer: Ask what kind of water are you mixing with formula
How is symmetric IUGR diagnosed
Correct Answer: By serial ultrasound, which is the reason for 1st trimester ultrasound
Engorgement Teaching
Correct Answer: Avoid nipple stimulation
Do not express milk
Place ice packs for 15 minute
25
Tight fitting bra or binder
A new mother reports breast engorgement and nipple pain on day 2 after the delivery of
a healthy newborn. The mother tells the nurse, "I'm not sure that breastfeeding the baby
is for me." What should the nurse advise the mother to do to help relieve discomfort and
encourage persevering with breastfeeding?
Correct Answer: Inform the mother that breastfeeding the newborn more frequently
will help treat these symptoms.
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce
breast engorgement. Which instruction should the nurse provide?
Correct Answer: Breastfeed the infant every 2 hours
The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about
