MATERNITY HESI PREPARED BY ME
FROM EVOLVE EXAM QUESTIONS
WITH COMPLETE ANSWERS
During labor, the fetal heart rate slowly decelerates at the beginning of the
contraction and returns to baseline at the end of the contraction. What action should
the nurse take?
a. Turn the mother to her left side.
b. Administer oxygen to the mother via face mask.
c. Notify the health care provider regarding the findings.
d. Continue to monitor the progress of the client's labor.Correct Answer - ANSWER-
d. Continue to monitor the progress of the client's labor.
Rationale:
Early decelerations during labor are frequently caused by head compression within
the uterus, and no nursing intervention is required except to monitor the mother's
progress during labor.
The nurse is reinforcing instructions on newborn care for expectant parents. Which
instruction is correct for the nurse to include concerning the newborn infant born at
term?
a. Milia are red marks made by forceps and will disappear within 7 to 10 days.
b. Meconium is the first stool and is firm, and usually yellow gold in color.
c. Vernix is a white cheesy substance, predominately seen in skin folds.
d. Pseudostrabismus found in newborns is treated by minor surgery. - ANSWER-c.
Vernix is a white cheesy substance, predominately seen in skin folds.
Rationale:
Vernix, found in skin folds, is a common characteristic of term infants. Milia are white
pinpoint spots usually found over the nose and chin, caused by sebaceous glands
blockages. Meconium is the first stool, but it is tarry black, not golden yellow.
Pseudostrabismus (crossed eyes) is normal at birth and does not require surgery.
During a prenatal visit, the practical nurse (PN) discusses with a client the effects
that smoking has on the fetus. The nurse realizes the teaching is effective if the
client identifies which possible effect on the fetus?
a. Lower Apgar score recorded at delivery.
b. Lower initial weight documented at birth.Correct Answer
c. Higher oxygen used to stimulate breathing.
d. Higher prevalence of congenital anomalies - ANSWER-b. Lower initial weight
documented at birth.
Rationale:
Smoking is associated with low-birth-weight infants.
A client who is 40 weeks into pregnancy is having a vaginal examination at the clinic
when the nurse notes a sudden gush of yellowish, clear fluid from the vaginal area.
What should be the nurse's first action?
a. Measure the fetal heart rate.Correct Answer
b. Monitor for uterine contractions.
,c. Note the color and odor of the fluid.
d. Apply a dry pad under the client for her comfort. - ANSWER-a. Measure the fetal
heart rate.
Rationale:
When the amniotic sac ruptures, there is a risk that the umbilical cord could
prolapse, causing fetal bradycardia and decreased blood supply to the fetus. The
nurse should measure the fetal heart rate immediately when the amniotic sac
ruptures. If the cord has prolapsed, the fetus needs to be delivered immediately. It is
important to note the color and odor of the fluid for signs of infection and to assess
for uterine contractions; however, the priority is assessing for a prolapsed cord by
assessing the fetal heart rate. Placing a dry pad under the client is not a priority
action.
The practical nurse (PN) calls for help and gives two breaths to a newborn who is not
breathing. Which area on the image would the PN check for the newborn's pulse?
a. A
b. B
c. C
d. D - ANSWER-Correct Answer:
b. B
Rationale:
The brachial pulse is used to determine the presence of a pulse in the infant during
cardiopulmonary resuscitation.
The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse
notes that the client's temperature is 38° C (100.4° F). Which intervention should the
nurse implement?
a. Encourage fluids to increase hydration.Correct Answer
b. Recheck the temperature in 15 minutes.
c. Place an ice pack on the client's forehead.
d. Obtain a prescription for acetaminophen - ANSWER-a. Encourage fluids to
increase hydration.
Rationale:
It is normal for the postpartum client to have a temperature up to 38° C (100.4° F)
because of dehydration caused by labor. The most appropriate intervention is to
encourage fluids to rehydrate the patient.
A client at term presents to the labor and delivery in spontaneous labor; contractions
are occurring every 3 to 4 minutes and they are 60 seconds in durations. The client
states to the nurse, "I think I am having a breakout of my genital herpes." What
actions will the nurse take next? (Select all that apply.)
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
d. Open a vaginal delivery pack.
e. Assess her partner's penis for lesions - ANSWER-Correct Answer:
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
Rationale:
, The nurse needs to assess the client's perineum, and the health care provider will
determine the status of the lesions. If active lesions are present, the
recommendation is for a Cesarean section; therefore, opening a vaginal delivery
pack may be unnecessary. It would not be appropriate for the nurse to assess the
partner's penis.
Which parental behavior is a warning to the practical nurse that there may be
negative bonding between parents and a newborn infant?
a. Parents frequently touch the infant and call the infant by name.
b. Parents hold the infant away from the body to show the infant's face.
c. Parents frequently leave the newborn infant wrapped in blankets.
d. Parents give immediate attention to infant's hunger and wet diapers. - ANSWER-c.
Parents frequently leave the newborn infant wrapped in blankets.
Rationale:
Attachment/bonding theory indicates that parents have an extreme interest in
visualizing every part of the newborn in a head to toe examination and exploration
process.
The practical nurse (PN) is assessing a client at 20 weeks' gestation. Which
measurement should be compared with the client's current weight to obtain data
about her weight gain during the entire pregnancy?
a. Usual pre-pregnancy weight
b. Weight at the first prenatal visit
c. Previous pregnancy weight gain
d. Daily weight gains or losses - ANSWER-a. Usual pre-pregnancy weight
Rationale:
Comparing the client's current weight with her pre-pregnancy weight allows for a
calculation of total weight gain.
The nurse is assisting with data collection on a client who is in her last trimester of
pregnancy. Which findings should the nurse report urgently to the health care
provider? (Select all that apply.)
a. Increased heartburn that is not relieved with doses of antacids
b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
c. Shoes and rings which are too tight because of peripheral edema in extremities
d. Decrease in ability for the client to sleep for more than 2 hours at a time
e. Headaches that have been lingering for a week behind the client's eyes -
ANSWER-a. Increased heartburn that is not relieved with doses of antacids
e. Headaches that have been lingering for a week behind the client's eyes
Rationale:
Intractable indigestion and lingering headaches are not unusual during pregnancy,
but can be symptoms of preeclampsia and should be reported to the health care
provider. The fetal heart rate normally ranges between 120 and 160. Peripheral
edema and difficulty sleeping are common during pregnancy and do not warrant
immediate notification of the health care provider.
Two hours following vaginal delivery in a birthing suite, the practical nurse (PN)
observes that a newborn has respirations that are 58 breaths/min and cyanotic
hands and feet. What action should the PN implement?
a. Continue to observe the infant.
FROM EVOLVE EXAM QUESTIONS
WITH COMPLETE ANSWERS
During labor, the fetal heart rate slowly decelerates at the beginning of the
contraction and returns to baseline at the end of the contraction. What action should
the nurse take?
a. Turn the mother to her left side.
b. Administer oxygen to the mother via face mask.
c. Notify the health care provider regarding the findings.
d. Continue to monitor the progress of the client's labor.Correct Answer - ANSWER-
d. Continue to monitor the progress of the client's labor.
Rationale:
Early decelerations during labor are frequently caused by head compression within
the uterus, and no nursing intervention is required except to monitor the mother's
progress during labor.
The nurse is reinforcing instructions on newborn care for expectant parents. Which
instruction is correct for the nurse to include concerning the newborn infant born at
term?
a. Milia are red marks made by forceps and will disappear within 7 to 10 days.
b. Meconium is the first stool and is firm, and usually yellow gold in color.
c. Vernix is a white cheesy substance, predominately seen in skin folds.
d. Pseudostrabismus found in newborns is treated by minor surgery. - ANSWER-c.
Vernix is a white cheesy substance, predominately seen in skin folds.
Rationale:
Vernix, found in skin folds, is a common characteristic of term infants. Milia are white
pinpoint spots usually found over the nose and chin, caused by sebaceous glands
blockages. Meconium is the first stool, but it is tarry black, not golden yellow.
Pseudostrabismus (crossed eyes) is normal at birth and does not require surgery.
During a prenatal visit, the practical nurse (PN) discusses with a client the effects
that smoking has on the fetus. The nurse realizes the teaching is effective if the
client identifies which possible effect on the fetus?
a. Lower Apgar score recorded at delivery.
b. Lower initial weight documented at birth.Correct Answer
c. Higher oxygen used to stimulate breathing.
d. Higher prevalence of congenital anomalies - ANSWER-b. Lower initial weight
documented at birth.
Rationale:
Smoking is associated with low-birth-weight infants.
A client who is 40 weeks into pregnancy is having a vaginal examination at the clinic
when the nurse notes a sudden gush of yellowish, clear fluid from the vaginal area.
What should be the nurse's first action?
a. Measure the fetal heart rate.Correct Answer
b. Monitor for uterine contractions.
,c. Note the color and odor of the fluid.
d. Apply a dry pad under the client for her comfort. - ANSWER-a. Measure the fetal
heart rate.
Rationale:
When the amniotic sac ruptures, there is a risk that the umbilical cord could
prolapse, causing fetal bradycardia and decreased blood supply to the fetus. The
nurse should measure the fetal heart rate immediately when the amniotic sac
ruptures. If the cord has prolapsed, the fetus needs to be delivered immediately. It is
important to note the color and odor of the fluid for signs of infection and to assess
for uterine contractions; however, the priority is assessing for a prolapsed cord by
assessing the fetal heart rate. Placing a dry pad under the client is not a priority
action.
The practical nurse (PN) calls for help and gives two breaths to a newborn who is not
breathing. Which area on the image would the PN check for the newborn's pulse?
a. A
b. B
c. C
d. D - ANSWER-Correct Answer:
b. B
Rationale:
The brachial pulse is used to determine the presence of a pulse in the infant during
cardiopulmonary resuscitation.
The nurse is taking the temperature of a client who is 6 hours postpartum. The nurse
notes that the client's temperature is 38° C (100.4° F). Which intervention should the
nurse implement?
a. Encourage fluids to increase hydration.Correct Answer
b. Recheck the temperature in 15 minutes.
c. Place an ice pack on the client's forehead.
d. Obtain a prescription for acetaminophen - ANSWER-a. Encourage fluids to
increase hydration.
Rationale:
It is normal for the postpartum client to have a temperature up to 38° C (100.4° F)
because of dehydration caused by labor. The most appropriate intervention is to
encourage fluids to rehydrate the patient.
A client at term presents to the labor and delivery in spontaneous labor; contractions
are occurring every 3 to 4 minutes and they are 60 seconds in durations. The client
states to the nurse, "I think I am having a breakout of my genital herpes." What
actions will the nurse take next? (Select all that apply.)
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
d. Open a vaginal delivery pack.
e. Assess her partner's penis for lesions - ANSWER-Correct Answer:
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
Rationale:
, The nurse needs to assess the client's perineum, and the health care provider will
determine the status of the lesions. If active lesions are present, the
recommendation is for a Cesarean section; therefore, opening a vaginal delivery
pack may be unnecessary. It would not be appropriate for the nurse to assess the
partner's penis.
Which parental behavior is a warning to the practical nurse that there may be
negative bonding between parents and a newborn infant?
a. Parents frequently touch the infant and call the infant by name.
b. Parents hold the infant away from the body to show the infant's face.
c. Parents frequently leave the newborn infant wrapped in blankets.
d. Parents give immediate attention to infant's hunger and wet diapers. - ANSWER-c.
Parents frequently leave the newborn infant wrapped in blankets.
Rationale:
Attachment/bonding theory indicates that parents have an extreme interest in
visualizing every part of the newborn in a head to toe examination and exploration
process.
The practical nurse (PN) is assessing a client at 20 weeks' gestation. Which
measurement should be compared with the client's current weight to obtain data
about her weight gain during the entire pregnancy?
a. Usual pre-pregnancy weight
b. Weight at the first prenatal visit
c. Previous pregnancy weight gain
d. Daily weight gains or losses - ANSWER-a. Usual pre-pregnancy weight
Rationale:
Comparing the client's current weight with her pre-pregnancy weight allows for a
calculation of total weight gain.
The nurse is assisting with data collection on a client who is in her last trimester of
pregnancy. Which findings should the nurse report urgently to the health care
provider? (Select all that apply.)
a. Increased heartburn that is not relieved with doses of antacids
b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
c. Shoes and rings which are too tight because of peripheral edema in extremities
d. Decrease in ability for the client to sleep for more than 2 hours at a time
e. Headaches that have been lingering for a week behind the client's eyes -
ANSWER-a. Increased heartburn that is not relieved with doses of antacids
e. Headaches that have been lingering for a week behind the client's eyes
Rationale:
Intractable indigestion and lingering headaches are not unusual during pregnancy,
but can be symptoms of preeclampsia and should be reported to the health care
provider. The fetal heart rate normally ranges between 120 and 160. Peripheral
edema and difficulty sleeping are common during pregnancy and do not warrant
immediate notification of the health care provider.
Two hours following vaginal delivery in a birthing suite, the practical nurse (PN)
observes that a newborn has respirations that are 58 breaths/min and cyanotic
hands and feet. What action should the PN implement?
a. Continue to observe the infant.
