MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
1) A 38-week primigravida who works as a secretary and sits at a computer for 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction would be most effective
in preventing pooling of blood in the lower extremities?
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins
and increase venous return.
2) A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestationin
preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to
stop her labor contractions. The nurse plans to monitor for which primary side effect of
terbutaline sulfate?
Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergicreceptors
in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug
may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of
"nervousness".
3) When do the anterior and posterior fontanels close?
anterior fontanel closes at 12 to 18 months and the posterior by the end of thesecond
month.
4) The nurse should encourage the laboring client to begin pushing when...the
cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely dilatedat 10
cm (C). If pushing begins before the cervix is completely dilated the cervix
1
, MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
can become edematous and may never completely dilate, necessitating an operative
delivery. Many primigravida’s begin active labor 100%and theneffacedproceed to
dilate.
5) The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to
complain of tingling fingers and dizziness. What action should the nurse take?
Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbon dioxide. This can befacilitated by
breathing into a paper bag or cupped hands.
6) Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized edema on the right side of his head. The nurse knows that, in thenewborn, an
accumulation of blood between the periosteum and skull which does not cross the suture
line is a newborn variation known as...
a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24
hours after delivery. Trauma from delivery causes capillary bleeding between theperiosteum and
the skull.
7) When does the head return to its normal
shape? 7-10 days
8) What did Nurse theorist Reva Rubin describe?
The initial postpartum period as the "taking-in phase," which is characterized by maternal
reliance on others to satisfy the needs for comfort, rest, nourishment, andcloseness to families
and the newborn.
9) A couple, concerned because the woman has not been able to conceive, is referred toa
healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which
post procedure complaint indicates that the fallopian tubes are patent?
Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
collection of peritoneal dye/gas.
10) Which nursing intervention is most helpful in relieving postpartum uterine contractionsor
"afterpains?"
Lying prone with a pillow on the abdomen
2
, MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
Lying prone keeps the fundus contracted and is especially useful with multiparas,who
commonly experience afterpains due to lack of uterine tone.
11) Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
Her arms and hands receive the infant and she then traces the infant's profile withher
fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
described in during the first visit with the newborn, which may be at delivery or later.
12) 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?
A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate
indicates that the drug is effective. (Respiratory rate below 12 indicatestoxic effects.)
13) Urinary output must be monitored when administering magnesium sulfate and should be at
least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH clientis 4.8 to 9.6
mg/dl.) What is the therapeutic level of magnesium sulfate?
The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6mg/dl. What
does it help prevent? helps prevent seizures
What indicates toxic levels? 3
Respiratory rate below 12 indicates toxic effects.
Urine output of less than 100 ml/4 hours
Absent DTRs
14) Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's
blood pressure drops from 120/80 to 90/60. What action should the nurse take?
Place woman in a lateral position
The nurse should immediately turn the woman to a lateral position, place a pillow orwedge
under the right hip to deflect the uterus, increase the rate of the main line IVinfusion, and
administer oxygen by face mask at 10-12 L/min. If the blood pressureremains low,
especially if it further decreases, the anesthesiologist/healthcare provider should be notified
immediately.
15) A client at 28-weeks gestation calls the antepartum clinic and states that she is experiencing
a small amount of vaginal bleeding which she describes as bright red. She further states that
she is not experiencing any uterine contractions or abdominalpain. What instruction should
the nurse provide?
3
, MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
Come to the clinic today for an ultrasound
Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-
threatening, nor cause for hypovolemic shock. Diagnosis is confirmedby transabdominal
ultrasound.
16) 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 hasthe highest
priority?
Put the newborn to breast
Putting the newborn to breast will help contract the uterus and prevent apostpartum
hemorrhage--this intervention has the highest priority.
17) A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The clientasks the
nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide
this client?
Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
To help preserve cardiac reserves, the woman may need to restrict her activitiesand
complete bedrest is often prescribed.
18) 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?
Gonorrhea
Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hoursafter
birth to prevent ophthalmic neonatorum, an infection caused by gonorrhea, and inclusion
conjunctivitis, an infection caused by chlamydia. The infant may be exposedto these bacteria
when passing through the birth canal.
19) 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 toensure conception?
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 is the best time for
conception. The human ovum can be fertilized 16 to 24 hoursafter ovulation.
4
1) A 38-week primigravida who works as a secretary and sits at a computer for 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction would be most effective
in preventing pooling of blood in the lower extremities?
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic veins
and increase venous return.
2) A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestationin
preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to
stop her labor contractions. The nurse plans to monitor for which primary side effect of
terbutaline sulfate?
Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergicreceptors
in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug
may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of
"nervousness".
3) When do the anterior and posterior fontanels close?
anterior fontanel closes at 12 to 18 months and the posterior by the end of thesecond
month.
4) The nurse should encourage the laboring client to begin pushing when...the
cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely dilatedat 10
cm (C). If pushing begins before the cervix is completely dilated the cervix
1
, MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
can become edematous and may never completely dilate, necessitating an operative
delivery. Many primigravida’s begin active labor 100%and theneffacedproceed to
dilate.
5) The nurse instructs a laboring client to use accelerated-blow breathing. The client begins to
complain of tingling fingers and dizziness. What action should the nurse take?
Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbon dioxide. This can befacilitated by
breathing into a paper bag or cupped hands.
6) Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized edema on the right side of his head. The nurse knows that, in thenewborn, an
accumulation of blood between the periosteum and skull which does not cross the suture
line is a newborn variation known as...
a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the first 24
hours after delivery. Trauma from delivery causes capillary bleeding between theperiosteum and
the skull.
7) When does the head return to its normal
shape? 7-10 days
8) What did Nurse theorist Reva Rubin describe?
The initial postpartum period as the "taking-in phase," which is characterized by maternal
reliance on others to satisfy the needs for comfort, rest, nourishment, andcloseness to families
and the newborn.
9) A couple, concerned because the woman has not been able to conceive, is referred toa
healthcare provider for a fertility workup and a hysterosalpingography is scheduled. Which
post procedure complaint indicates that the fallopian tubes are patent?
Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
collection of peritoneal dye/gas.
10) Which nursing intervention is most helpful in relieving postpartum uterine contractionsor
"afterpains?"
Lying prone with a pillow on the abdomen
2
, MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
Lying prone keeps the fundus contracted and is especially useful with multiparas,who
commonly experience afterpains due to lack of uterine tone.
11) Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
Her arms and hands receive the infant and she then traces the infant's profile withher
fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
described in during the first visit with the newborn, which may be at delivery or later.
12) 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?
A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory rate
indicates that the drug is effective. (Respiratory rate below 12 indicatestoxic effects.)
13) Urinary output must be monitored when administering magnesium sulfate and should be at
least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH clientis 4.8 to 9.6
mg/dl.) What is the therapeutic level of magnesium sulfate?
The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6mg/dl. What
does it help prevent? helps prevent seizures
What indicates toxic levels? 3
Respiratory rate below 12 indicates toxic effects.
Urine output of less than 100 ml/4 hours
Absent DTRs
14) Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's
blood pressure drops from 120/80 to 90/60. What action should the nurse take?
Place woman in a lateral position
The nurse should immediately turn the woman to a lateral position, place a pillow orwedge
under the right hip to deflect the uterus, increase the rate of the main line IVinfusion, and
administer oxygen by face mask at 10-12 L/min. If the blood pressureremains low,
especially if it further decreases, the anesthesiologist/healthcare provider should be notified
immediately.
15) A client at 28-weeks gestation calls the antepartum clinic and states that she is experiencing
a small amount of vaginal bleeding which she describes as bright red. She further states that
she is not experiencing any uterine contractions or abdominalpain. What instruction should
the nurse provide?
3
, MATERNITY HESI TEST BANK STUDY GUIDE Q & Approved
Come to the clinic today for an ultrasound
Third trimester painless bleeding is characteristic of a placenta previa. Bright red bleeding
may be intermittent, occur in gushes, or be continuous. Rarely is the first incidence life-
threatening, nor cause for hypovolemic shock. Diagnosis is confirmedby transabdominal
ultrasound.
16) 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 hasthe highest
priority?
Put the newborn to breast
Putting the newborn to breast will help contract the uterus and prevent apostpartum
hemorrhage--this intervention has the highest priority.
17) A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The clientasks the
nurse, "Why must I stay in bed all the time?" Which response is best for the nurse to provide
this client?
Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
To help preserve cardiac reserves, the woman may need to restrict her activitiesand
complete bedrest is often prescribed.
18) 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?
Gonorrhea
Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hoursafter
birth to prevent ophthalmic neonatorum, an infection caused by gonorrhea, and inclusion
conjunctivitis, an infection caused by chlamydia. The infant may be exposedto these bacteria
when passing through the birth canal.
19) 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 toensure conception?
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 is the best time for
conception. The human ovum can be fertilized 16 to 24 hoursafter ovulation.
4
