HESI-FOCUS ON MATERNITY EXAM
QUESTIONS AND ANSWERS
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
last ate 2 hours ago. The client also states that "everything happened so fast" and
that she has had no preparation for the c-section. Which action should the nurse
take first - ANSWER-reporting the time of last food intake to the HCP
A nurse assists a pregnant client who is in the second trimester into lithotomy
position on the exam table in the OB office. The client suddenly becomes dizzy,
lightheaded, nauseated and pale. The nurse immediately - ANSWER-positions the
client on her side
A nurse is caring for a PP client who had a low-lying placenta. The nurse assesses
the client most closely for - ANSWER-hemorrhage
a nurse working in a prenatal clinic is reviewing the records of several clients
scheduled for prenatal visits today. Which client does the nurse identify as being at
risk for abruptio placentae SATA
a) a primipara
b) a 36 y/o
c) a hypertensive client
d) a pack a day smoker
e) a client who exercises regularly - ANSWER-c, d
a nurse caring for a client in labor performs an assessment. The client is having
consistent contractions less than 2 min apart. The FHR is 170bpm and fetal
monitoring indicates a pattern of decreased variability. In light of these findings, the
appropriate action is - ANSWER-contacting the HCP
A nurse provides instructions regarding PP exercises to a client who has delivered a
newborn vaginally. The nurse tells the client that - ANSWER-alternating contraction
and relaxation of the muscles of the perineal area should be practiced
QUESTIONS AND ANSWERS
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
last ate 2 hours ago. The client also states that "everything happened so fast" and
that she has had no preparation for the c-section. Which action should the nurse
take first - ANSWER-reporting the time of last food intake to the HCP
A nurse assists a pregnant client who is in the second trimester into lithotomy
position on the exam table in the OB office. The client suddenly becomes dizzy,
lightheaded, nauseated and pale. The nurse immediately - ANSWER-positions the
client on her side
A nurse is caring for a PP client who had a low-lying placenta. The nurse assesses
the client most closely for - ANSWER-hemorrhage
a nurse working in a prenatal clinic is reviewing the records of several clients
scheduled for prenatal visits today. Which client does the nurse identify as being at
risk for abruptio placentae SATA
a) a primipara
b) a 36 y/o
c) a hypertensive client
d) a pack a day smoker
e) a client who exercises regularly - ANSWER-c, d
a nurse caring for a client in labor performs an assessment. The client is having
consistent contractions less than 2 min apart. The FHR is 170bpm and fetal
monitoring indicates a pattern of decreased variability. In light of these findings, the
appropriate action is - ANSWER-contacting the HCP
A nurse provides instructions regarding PP exercises to a client who has delivered a
newborn vaginally. The nurse tells the client that - ANSWER-alternating contraction
and relaxation of the muscles of the perineal area should be practiced
