HESI RN Maternity Assignment Exam
At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is
admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding
requires immediate intervention?
-uterine cramping
-abdominal tenderness
-systolic bp <100 mmHg
-intermittent nausea - answerA. Uterine cramping
A client states, "During the three months I've been pregnant, it seems like I have had to go to the
bathroom every five minutes." Which explanation should the nurse provide to this client?
-the client may have a bladder or kidney infection
-bladder capacity increases during pregnancy
-during pregnancy a woman is especially sensitive to body functions
-the growing uterus is putting pressure on the bladder - answerD. The growing uterus is putting pressure
on the bladder.
The nurse assesses a male newborn and determines that he has the following vital signs: axillary
temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on
these findings, which action should the nurse take first?
-check the infant's ABGs
-notify the pediatrician of the infants VS
-assess the infant's blood glucose level
-encourage the infant to take the breast or sugar water - answerC. Assess the infant's blood glucose
level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing
intervention?
-evaluate the blood pH
-begin humidified oxygen via hood
-stimulate infant crying
,-place the infant under a radiant warmer - answerB. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?
-quiet the infant before counting the HR
-listen at the apex of the heart
-count the HR for at least one full minute
-palpate the umbilical cord - answerC. Count the heart rate for at least one full minute
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the
nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to
make?
-inform the mother that the injection was prescribed by the HCP
-explore the mother's concerns about the infant receiving an injection of vitamin K
-explain that vitamin K is required by state law and compliance is mandatory
-remind the mother that all babies receive this shot and it is relatively painless - answerB. Explore the
mother's concerns about the infant receiving an injection of vitamin K
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important
to include in the teaching plan?
-avoid alcohol bc it is excreted in breast milk
-avoid spicy foods to prevent infant colic
-increase caloric intake by approx. 500 calories/day
-double prenatal milk intake to improve vitamin D transfer to the infant - answerA. Avoid alcohol
because it is excreted in breast milk
Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?
-brighten the lighting so the mother can view the infant
-complete the newborn assessment as quickly as possible
-provide positive reinforcement for maternal care of infant
-encourage early initiation of breast or formula feeding - answerD. Encourage early initiation of breast of
formula feeding
, A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her
baby. Which response best explains when a CHD may occur?
-it depends on what the causative factors are for a CHD
-we don't really know what or when CHDs occur
-they usually occur in the first trimester of pregnancy
-the heart develops in the third to fifth weeks after conception - answerD. The heart develops in the
third to fifth weeks after conception
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband
thinks she is imagining things. What information should the nurse provide?
-many women imagine what their baby is like by interpreting fetal movements
-the fetus in utero is capable of hearing and does respond to the mothers voice
-the HCP should address her concerns about her baby hearing function
-the interaction b/w the mothers voice and the fetus's response ensures bonding - answerB. The fetus in
utero is capable of hearing and does respond to the mother's voice
A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby
jumped in response to the noise. What information should the nurse provide?
-this is a demonstration of the fetus acoustical reflux
-the fetus can respond to sound by 24 weeks
-it is a coincidence the fetus responded at the same time
-report behavior to HCP - answerB. The fetus can respond to sound by 24-weeks gestation
A woman whose pregnancy is confirmed asks the nurse what the function of the placenta is in early
pregnancy. What information supports the explanation that the nurse should provide?
-excretes prolactin and insulin
-produces nutrients for fetal nutrition
-secretes both estrogen and progesterone
-forms a protective, impenetrable barrier - answerC. Secretes both estrogen and progesterone
At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is
admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding
requires immediate intervention?
-uterine cramping
-abdominal tenderness
-systolic bp <100 mmHg
-intermittent nausea - answerA. Uterine cramping
A client states, "During the three months I've been pregnant, it seems like I have had to go to the
bathroom every five minutes." Which explanation should the nurse provide to this client?
-the client may have a bladder or kidney infection
-bladder capacity increases during pregnancy
-during pregnancy a woman is especially sensitive to body functions
-the growing uterus is putting pressure on the bladder - answerD. The growing uterus is putting pressure
on the bladder.
The nurse assesses a male newborn and determines that he has the following vital signs: axillary
temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on
these findings, which action should the nurse take first?
-check the infant's ABGs
-notify the pediatrician of the infants VS
-assess the infant's blood glucose level
-encourage the infant to take the breast or sugar water - answerC. Assess the infant's blood glucose
level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing
intervention?
-evaluate the blood pH
-begin humidified oxygen via hood
-stimulate infant crying
,-place the infant under a radiant warmer - answerB. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?
-quiet the infant before counting the HR
-listen at the apex of the heart
-count the HR for at least one full minute
-palpate the umbilical cord - answerC. Count the heart rate for at least one full minute
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the
nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to
make?
-inform the mother that the injection was prescribed by the HCP
-explore the mother's concerns about the infant receiving an injection of vitamin K
-explain that vitamin K is required by state law and compliance is mandatory
-remind the mother that all babies receive this shot and it is relatively painless - answerB. Explore the
mother's concerns about the infant receiving an injection of vitamin K
The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important
to include in the teaching plan?
-avoid alcohol bc it is excreted in breast milk
-avoid spicy foods to prevent infant colic
-increase caloric intake by approx. 500 calories/day
-double prenatal milk intake to improve vitamin D transfer to the infant - answerA. Avoid alcohol
because it is excreted in breast milk
Which nursing intervention best enhances maternal-infant bonding during the fourth stage of labor?
-brighten the lighting so the mother can view the infant
-complete the newborn assessment as quickly as possible
-provide positive reinforcement for maternal care of infant
-encourage early initiation of breast or formula feeding - answerD. Encourage early initiation of breast of
formula feeding
, A client at 8-weeks gestation asks the nurse about the risk fora congenital heart defect (CHD) in her
baby. Which response best explains when a CHD may occur?
-it depends on what the causative factors are for a CHD
-we don't really know what or when CHDs occur
-they usually occur in the first trimester of pregnancy
-the heart develops in the third to fifth weeks after conception - answerD. The heart develops in the
third to fifth weeks after conception
A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband
thinks she is imagining things. What information should the nurse provide?
-many women imagine what their baby is like by interpreting fetal movements
-the fetus in utero is capable of hearing and does respond to the mothers voice
-the HCP should address her concerns about her baby hearing function
-the interaction b/w the mothers voice and the fetus's response ensures bonding - answerB. The fetus in
utero is capable of hearing and does respond to the mother's voice
A client at 25-weeks gestation tells the nurse that she dropped a cooking utensil last week and her baby
jumped in response to the noise. What information should the nurse provide?
-this is a demonstration of the fetus acoustical reflux
-the fetus can respond to sound by 24 weeks
-it is a coincidence the fetus responded at the same time
-report behavior to HCP - answerB. The fetus can respond to sound by 24-weeks gestation
A woman whose pregnancy is confirmed asks the nurse what the function of the placenta is in early
pregnancy. What information supports the explanation that the nurse should provide?
-excretes prolactin and insulin
-produces nutrients for fetal nutrition
-secretes both estrogen and progesterone
-forms a protective, impenetrable barrier - answerC. Secretes both estrogen and progesterone
