HESI REVIEW TEST-MATERNITY,
EVOLVE OBSTETRICS-MATERNITY
PRACTICE EXAM, HESI MATERNITY
QUESTIONS WITH CORRECT
ANSWERS
A new mother is afraid to touch her baby's head for fear of hurting the "large soft
spot." Which explanation should the nurse give to this anxious client? - ANSWER-
There's a strong, tough membrane there to protect the baby so you need not be
afraid to wash or comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing
actions? (Arrange in order.) - ANSWER-Reposition the client.
Provide oxygen via face mask.
Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority? - ANSWER-Put the newborn to breast. Putting the newborn to
breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this
intervention has the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in her lower back. Which intervention
should the nurse implement? - ANSWER-Apply firm pressure to sacral area. The
discomfort of back labor can be minimized by the application of firm pressure to the
sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her
bag of water has broken. The nurse identifies the presence of meconium fluid on the
perineum and determines the fetal heart rate is between 140 to 150 beats/minute.
What action should the nurse implement next? - ANSWER-Complete a sterile
vaginal exam. A vaginal exam (A) should be performed after the rupture of
membranes to determine the presence of a prolapsed cord.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks
gestation. The nurse determines that the client is not having contractions, the fetal
heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What
action should the nurse take? - ANSWER-Ask the client if she has felt any fetal
movement.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding
my first child, but I would like to try with this baby." Which intervention is best for the
,nurse to implement first? - ANSWER-Provide assistance to the mother to begin
breastfeeding as soon as possible after delivery.
A healthcare provider informs the charge nurse of a labor and delivery unit that a
client is coming to the unit with suspected abruptio placentae. What findings should
the charge nurse expect the client to demonstrate? (Select all that apply.) -
ANSWER-Dark, red vaginal bleeding.
Increased uterine irritability.
A rigid abdomen.
The nurse is teaching care of the newborn to a group of prospective parents and
describes the need for administering antibiotic ointment into the eyes of the newborn.
Which infectious organism will this treatment prevent from harming the infant? -
ANSWER-Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of
each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection
caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia
(C).
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-
Anderson Index, the nurse determines the infant has synchronized chest and
abdominal movement, just visible lower chest retractions, just visible xiphoid
retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on
auscultation. What Silverman-Anderson score should the nurse assign to this infant?
(Enter numeral value only.) - ANSWER-A Silverman-Anderson Index has five
categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the
these assessment findings should receive a score of 1, and the 5th finding
(synchronized chest and abdominal movement) receives a score of 0. Therefore, the
total score is 4. A total score of 0 means the infant has no dyspnea, a total score of
10 indicates maximum respiratory distress.
The nurse is teaching a woman how to use her basal body temperature (BBT)
pattern as a tool to assist her in conceiving a child. Which temperature pattern
indicates the occurrence of ovulation, and therefore, the best time for intercourse to
ensure conception? - ANSWER-Between the time the temperature falls and rises. In
most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to
72 hours after ovulation, when the corpus luteum of the ruptured ovary produces
progesterone. Therefore, intercourse between the time of the temperature fall and
rise (A) is the best time for conception.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation should the nurse provide? - ANSWER-Your milk is
sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. The
urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant
is adequately hydrated.
A 28-year-old client in active labor complains of cramps in her leg. What intervention
should the nurse implement? - ANSWER-Extend the leg and dorsiflex the foot.
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the
client is capable) (B), and putting the heel of the foot on the floor is the best means
of relieving leg cramps.
,A client at 30-weeks gestation, complaining of pressure over the pubic area, is
admitted for observation. She is contracting irregularly and demonstrates underlying
uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and
high. Based on these data, which intervention should the nurse implement first? -
ANSWER-Obtain a specimen for urine analysis. Obtaining a urine analysis (C)
should be done first because preterm clients with uterine irritability and contractions
are often suffering from a urinary tract infection, and this should be ruled out first.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the
postpartum unit. Which nursing plan is best in assisting this mother to bond with her
newborn infant? - ANSWER-Meet the mother's physical needs and demonstrate
warmth toward the infant. It is most important to meet the mother's requirement for
attention to her needs so that she can begin infant care-taking (D).
The nurse identifies crepitus when examining the chest of a newborn who was
delivered vaginally. Which further assessment should the nurse perform? -
ANSWER-Observe for an asymmetrical Moro (startle) reflex. The most common
neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an
infant may be asymptomatic, a fractured clavicle should be suspected if an infant has
limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex
(B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is
moved.
A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge? - ANSWER-It is difficult to consume 18 mg of additional iron by diet
alone. Consuming enough iron-containing foods to facilitate adequate fetal storage
of iron and to meet the demands of pregnancy is difficult (B) so iron supplements are
often recommended.
The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions,
BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on
these assessment findings, what intervention should the nurse implement? -
ANSWER-Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites
(C) is the priority intervention. This client is presenting with signs of placental
abruption. Disseminated intravascular coagulation (DIC) is a complication of
placental abruptio, characterized by abnormal bleeding.
In developing a teaching plan for expectant parents, the nurse plans to include
information about when the parents can expect the infant's fontanels to close. The
nurse bases the explanation on knowledge that for the normal newborn, the -
ANSWER-anterior fontanel closes at 12 to 18 months and the posterior by the end of
the second month. In the normal infant the anterior fontanel closes at 12 to 18
months of age and the posterior fontanel by the end of the second month (D).
The nurse is performing a gestational age assessment on a full-term newborn during
the first hour of transition using the Ballard (Dubowitz) scale. Based on this
assessment, the nurse determines that the neonate has a maturity rating of 40-
, weeks. What findings should the nurse identify to determine if the neonate is small
for gestational age (SGA)? (Select all that apply.) - ANSWER-Admission weight of 4
pounds, 15 ounces (2244 grams).
Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved? -
ANSWER-A decrease in respiratory rate from 24 to 16.
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12
indicates toxic effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.) - ANSWER-A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?" - ANSWER-Lying prone with a pillow on the abdomen.
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin)
to augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions? - ANSWER-Transition labor with contractions every 2
minutes, lasting 90 seconds each.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a
dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood
sample and initiates an IV. Thirty minutes after admission, the client reports feeling a
sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis,
a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should
the nurse implement next? - ANSWER-Increase IV rate. The client is demonstrating
symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at
approximately 14-weeks gestation when embryonic growth expands the fallopian
tube causing its rupture, and can result in hemorrage and hypovolemic shock.
Increasing the IV infusion rate (C) provides intravascular fluid to maintain blood
pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and tender
upon palpation. What action should the nurse take? - ANSWER-Apply cold
compresses to both breasts for comfort. The client is experiencing engorgement
even though she is bottle-feeding her infant, and cold compresses (A) may help
reduce discomfort. Lactation begins about the third day after delivery, so the mother
should avoid any breast stimulation,
EVOLVE OBSTETRICS-MATERNITY
PRACTICE EXAM, HESI MATERNITY
QUESTIONS WITH CORRECT
ANSWERS
A new mother is afraid to touch her baby's head for fear of hurting the "large soft
spot." Which explanation should the nurse give to this anxious client? - ANSWER-
There's a strong, tough membrane there to protect the baby so you need not be
afraid to wash or comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing
actions? (Arrange in order.) - ANSWER-Reposition the client.
Provide oxygen via face mask.
Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority? - ANSWER-Put the newborn to breast. Putting the newborn to
breast (D) will help contract the uterus and prevent a postpartum hemorrhage--this
intervention has the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in her lower back. Which intervention
should the nurse implement? - ANSWER-Apply firm pressure to sacral area. The
discomfort of back labor can be minimized by the application of firm pressure to the
sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her
bag of water has broken. The nurse identifies the presence of meconium fluid on the
perineum and determines the fetal heart rate is between 140 to 150 beats/minute.
What action should the nurse implement next? - ANSWER-Complete a sterile
vaginal exam. A vaginal exam (A) should be performed after the rupture of
membranes to determine the presence of a prolapsed cord.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks
gestation. The nurse determines that the client is not having contractions, the fetal
heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What
action should the nurse take? - ANSWER-Ask the client if she has felt any fetal
movement.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding
my first child, but I would like to try with this baby." Which intervention is best for the
,nurse to implement first? - ANSWER-Provide assistance to the mother to begin
breastfeeding as soon as possible after delivery.
A healthcare provider informs the charge nurse of a labor and delivery unit that a
client is coming to the unit with suspected abruptio placentae. What findings should
the charge nurse expect the client to demonstrate? (Select all that apply.) -
ANSWER-Dark, red vaginal bleeding.
Increased uterine irritability.
A rigid abdomen.
The nurse is teaching care of the newborn to a group of prospective parents and
describes the need for administering antibiotic ointment into the eyes of the newborn.
Which infectious organism will this treatment prevent from harming the infant? -
ANSWER-Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of
each eye within 2 hours after birth to prevent ophthalmica neonatorum, an infection
caused by gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia
(C).
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-
Anderson Index, the nurse determines the infant has synchronized chest and
abdominal movement, just visible lower chest retractions, just visible xiphoid
retractions, minimal and transient nasal flaring, and an expiratory grunt heard only on
auscultation. What Silverman-Anderson score should the nurse assign to this infant?
(Enter numeral value only.) - ANSWER-A Silverman-Anderson Index has five
categories with scores of 0, 1, or 2. The total score ranges from 0 to 10. Four of the
these assessment findings should receive a score of 1, and the 5th finding
(synchronized chest and abdominal movement) receives a score of 0. Therefore, the
total score is 4. A total score of 0 means the infant has no dyspnea, a total score of
10 indicates maximum respiratory distress.
The nurse is teaching a woman how to use her basal body temperature (BBT)
pattern as a tool to assist her in conceiving a child. Which temperature pattern
indicates the occurrence of ovulation, and therefore, the best time for intercourse to
ensure conception? - ANSWER-Between the time the temperature falls and rises. In
most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to
72 hours after ovulation, when the corpus luteum of the ruptured ovary produces
progesterone. Therefore, intercourse between the time of the temperature fall and
rise (A) is the best time for conception.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation should the nurse provide? - ANSWER-Your milk is
sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. The
urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant
is adequately hydrated.
A 28-year-old client in active labor complains of cramps in her leg. What intervention
should the nurse implement? - ANSWER-Extend the leg and dorsiflex the foot.
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the
client is capable) (B), and putting the heel of the foot on the floor is the best means
of relieving leg cramps.
,A client at 30-weeks gestation, complaining of pressure over the pubic area, is
admitted for observation. She is contracting irregularly and demonstrates underlying
uterine irritability. Vaginal examination reveals that her cervix is closed, thick, and
high. Based on these data, which intervention should the nurse implement first? -
ANSWER-Obtain a specimen for urine analysis. Obtaining a urine analysis (C)
should be done first because preterm clients with uterine irritability and contractions
are often suffering from a urinary tract infection, and this should be ruled out first.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the
postpartum unit. Which nursing plan is best in assisting this mother to bond with her
newborn infant? - ANSWER-Meet the mother's physical needs and demonstrate
warmth toward the infant. It is most important to meet the mother's requirement for
attention to her needs so that she can begin infant care-taking (D).
The nurse identifies crepitus when examining the chest of a newborn who was
delivered vaginally. Which further assessment should the nurse perform? -
ANSWER-Observe for an asymmetrical Moro (startle) reflex. The most common
neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an
infant may be asymptomatic, a fractured clavicle should be suspected if an infant has
limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex
(B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is
moved.
A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge? - ANSWER-It is difficult to consume 18 mg of additional iron by diet
alone. Consuming enough iron-containing foods to facilitate adequate fetal storage
of iron and to meet the demands of pregnancy is difficult (B) so iron supplements are
often recommended.
The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions,
BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on
these assessment findings, what intervention should the nurse implement? -
ANSWER-Monitor bleeding from IV sites. Monitoring bleeding from peripheral sites
(C) is the priority intervention. This client is presenting with signs of placental
abruption. Disseminated intravascular coagulation (DIC) is a complication of
placental abruptio, characterized by abnormal bleeding.
In developing a teaching plan for expectant parents, the nurse plans to include
information about when the parents can expect the infant's fontanels to close. The
nurse bases the explanation on knowledge that for the normal newborn, the -
ANSWER-anterior fontanel closes at 12 to 18 months and the posterior by the end of
the second month. In the normal infant the anterior fontanel closes at 12 to 18
months of age and the posterior fontanel by the end of the second month (D).
The nurse is performing a gestational age assessment on a full-term newborn during
the first hour of transition using the Ballard (Dubowitz) scale. Based on this
assessment, the nurse determines that the neonate has a maturity rating of 40-
, weeks. What findings should the nurse identify to determine if the neonate is small
for gestational age (SGA)? (Select all that apply.) - ANSWER-Admission weight of 4
pounds, 15 ounces (2244 grams).
Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved? -
ANSWER-A decrease in respiratory rate from 24 to 16.
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased
respiratory rate (C) indicates that the drug is effective. (Respiratory rate below 12
indicates toxic effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.) - ANSWER-A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine
contractions or "afterpains?" - ANSWER-Lying prone with a pillow on the abdomen.
Lying prone (A) keeps the fundus contracted and is especially useful with multiparas,
who commonly experience afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin)
to augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions? - ANSWER-Transition labor with contractions every 2
minutes, lasting 90 seconds each.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a
dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood
sample and initiates an IV. Thirty minutes after admission, the client reports feeling a
sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis,
a heart rate of 120 beats/minute, and a blood pressure of 86/48. Which action should
the nurse implement next? - ANSWER-Increase IV rate. The client is demonstrating
symptoms of blood loss, probably the result of an ectopic pregnancy, which occurs at
approximately 14-weeks gestation when embryonic growth expands the fallopian
tube causing its rupture, and can result in hemorrage and hypovolemic shock.
Increasing the IV infusion rate (C) provides intravascular fluid to maintain blood
pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During
assessment, the nurse determines that both breasts are swollen, warm, and tender
upon palpation. What action should the nurse take? - ANSWER-Apply cold
compresses to both breasts for comfort. The client is experiencing engorgement
even though she is bottle-feeding her infant, and cold compresses (A) may help
reduce discomfort. Lactation begins about the third day after delivery, so the mother
should avoid any breast stimulation,
