RN HESI Maternity NEWEST 2025 ACTUAL
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
The parents of a newborn tell the nurse that their baby is already trying to walk. How should
the nurse respond?
A. Encourage the parents to report this to the healthcare provider
B. Acknowledge the parents' observation.
C. Schedule the newborn for further neurological testing.
D. Explain the newborn's normal stepping reflex. ****answer****D. Explain the newborn's
normal stepping reflex.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of
thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the best
explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth
D. The TSH is high because of the low production of T4 by the thyroid. ****answer****D. The
TSH is high because of the low production of T4 by the thyroid.
,The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation.
Which assessment finding should receive the highest priority when planning this infants care?
A. Blood pressure 76/42 mm/Hg
B. Faint heart murmur
C. Respiratory rate 76 breaths/min
D. Blood glucose 45 mg/dl ****answer****C. Respiratory rate 76 breaths/min
At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse
that she is feeling fetal movement. Fundal height measurement is 20 cm, and the clients only
complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further
evaluation?
A. Presence of fetal movements.
B. Gestational weight gain
C. Fundal height measurement
D. Leakage from breasts ****answer****B. Gestational weight gain
The nurse is planning discharge teaching for a client who had an evacuation of gestational
trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to
include in this client's teaching plan? ****answer****Oral contraceptive use for at least one
year.
A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a
hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet?
A. Carrots
B. Chicken
C. Yogurt
D. Cheese ****answer****B. Chicken
,The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1,
AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How
many ml should the nurse administer? ****answer****0.3
The nurse places one hand above the symphysis while massaging the fundus of a multiparous
client
whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which
information
should the nurse provide the client about this finding? ****answer****Both the lower uterine
segment and the fundus must be massaged.
The nurse is preparing to administer methylergonovine maleate (Methergine)
to a postpartum client. Based on what assessment finding should the nurse
withhold the drug?
A. Respiratory rate of 22 breaths/min
B. A large amount of lochia rubra
C. Blood pressure 149/90
D. Positive Homan's sign ****answer****C. Blood pressure 149/90
At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best
time
to administer a rubella vaccine to this client? ****answer****Early postpartum, within 72
hours of delivery.
A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
, B. Blood pressure
C. Infusion site
D. Contraction pattern ****answer****D. Contraction pattern.
A client delivers a viable infant , but begins to have excessive uncontrolled vaginal .. notifying
the healthcare provider of the clients condition ,What information is most important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused ****answer****A. Maternal blood pressure.
A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia.
What is the primary nursing consideration when
supporting the parents of a child with this anomaly?
A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
B. Support the parents in their decision to assign sex of their child according to their preference
C. Offer information about ultrasonography and genotyping to determine sex assignment
D. Explain that corrective surgical procedures consistent with sex
assignment can be delayed ****answer****C. Offer information about ultrasonography and
genotyping to determine sex assignment
During a 26-week gestation prenatal exam, a client reports occasional dizziness and
lightheadness
when she is lying down. What intervention is best for the nurse to recommend to this client.
****answer****Elevate the head with two pillows while sleeping.
The current vital signs for a primipara who delivered vaginally during the previous shift are:
temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood
QUESTIONS AND CORRECT DETAILED ANSWERS
(VERIFIED ANSWERS) |ALREADY GRADED A+
The parents of a newborn tell the nurse that their baby is already trying to walk. How should
the nurse respond?
A. Encourage the parents to report this to the healthcare provider
B. Acknowledge the parents' observation.
C. Schedule the newborn for further neurological testing.
D. Explain the newborn's normal stepping reflex. ****answer****D. Explain the newborn's
normal stepping reflex.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of
thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the best
explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth
D. The TSH is high because of the low production of T4 by the thyroid. ****answer****D. The
TSH is high because of the low production of T4 by the thyroid.
,The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation.
Which assessment finding should receive the highest priority when planning this infants care?
A. Blood pressure 76/42 mm/Hg
B. Faint heart murmur
C. Respiratory rate 76 breaths/min
D. Blood glucose 45 mg/dl ****answer****C. Respiratory rate 76 breaths/min
At 20-weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse
that she is feeling fetal movement. Fundal height measurement is 20 cm, and the clients only
complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further
evaluation?
A. Presence of fetal movements.
B. Gestational weight gain
C. Fundal height measurement
D. Leakage from breasts ****answer****B. Gestational weight gain
The nurse is planning discharge teaching for a client who had an evacuation of gestational
trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to
include in this client's teaching plan? ****answer****Oral contraceptive use for at least one
year.
A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a
hematocrit of 25.1%. What food should the nurse encourage this client to include in her diet?
A. Carrots
B. Chicken
C. Yogurt
D. Cheese ****answer****B. Chicken
,The newborn nursery admission protocol includes a prescption for phytonadione (Vitamin K1,
AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule provides 2 mg/ml. How
many ml should the nurse administer? ****answer****0.3
The nurse places one hand above the symphysis while massaging the fundus of a multiparous
client
whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant. Which
information
should the nurse provide the client about this finding? ****answer****Both the lower uterine
segment and the fundus must be massaged.
The nurse is preparing to administer methylergonovine maleate (Methergine)
to a postpartum client. Based on what assessment finding should the nurse
withhold the drug?
A. Respiratory rate of 22 breaths/min
B. A large amount of lochia rubra
C. Blood pressure 149/90
D. Positive Homan's sign ****answer****C. Blood pressure 149/90
At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best
time
to administer a rubella vaccine to this client? ****answer****Early postpartum, within 72
hours of delivery.
A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
, B. Blood pressure
C. Infusion site
D. Contraction pattern ****answer****D. Contraction pattern.
A client delivers a viable infant , but begins to have excessive uncontrolled vaginal .. notifying
the healthcare provider of the clients condition ,What information is most important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused ****answer****A. Maternal blood pressure.
A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia.
What is the primary nursing consideration when
supporting the parents of a child with this anomaly?
A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
B. Support the parents in their decision to assign sex of their child according to their preference
C. Offer information about ultrasonography and genotyping to determine sex assignment
D. Explain that corrective surgical procedures consistent with sex
assignment can be delayed ****answer****C. Offer information about ultrasonography and
genotyping to determine sex assignment
During a 26-week gestation prenatal exam, a client reports occasional dizziness and
lightheadness
when she is lying down. What intervention is best for the nurse to recommend to this client.
****answer****Elevate the head with two pillows while sleeping.
The current vital signs for a primipara who delivered vaginally during the previous shift are:
temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood
