TEST BANK FOR HESI Maternity. LATEST
UPDATED VERSION 2025/2026
An expectant father tells the nurse he fears that his wife is "losing her mind." He
states that she is constantly rubbing her abdomen and talking to the baby and
that she actually reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - answer-D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
because the behaviors displayed are normal.
,The nurse is preparing a laboring client for an amniotomy. Immediately after the
procedure is completed, it is most important for the nurse to obtain which
information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - answer-C. Fetal heart rate (FHR)
When preparing a class on newborn care for expectant parents, which is correct
for the nurse to teach concerning the newborn infant born at term gestation?
A.Milia are red marks made by forceps and will disappear within 7 to 10 days.
B.Meconium is the first stool and is usually yellow gold in color.
C.Vernix is a white cheesy substance, predominantly located in the skin folds.
D.Pseudostrabismus found in newborns is treated by minor surgery. - answer-
C.Vernix is a white cheesy substance, predominantly located in the skin folds.
,Rationale:
Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are
not red marks made by forceps but are white pinpoint spots usually found over
the nose and chin that represent blockage of the sebaceous glands. Meconium is
the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is
normal at birth through the third or fourth month and does not require surgery.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after
spontaneous rupture of the membranes, the nurse notes several sudden
decreases in the fetal heart rate with quick return to baseline, with and without
contractions. Based on this fetal heart rate pattern, which intervention is best for
the nurse to implement?
A.Turn the client to her side.
B.Begin oxygen by nasal cannula at 2 L/min.
C.Place the client in a slight Trendelenburg position.
D.Assess for cervical dilation. - answer-C. Place the client in a slight Trendelenburg
position.
Rationale:The goal is to relieve pressure on the umbilical cord, and placing the
client in a slight Trendelenburg position is most likely to relieve that pressure. The
FHR pattern is indicative of a variable fetal heart rate deceleration, which is
typically caused by cord compression and can occur with or without contractions.
Option A may be helpful but is not as likely to relieve the pressure as the
Trendelenburg position. Option B is not helpful with cord compression. Option D
, is not the priority intervention at this time. After repositioning the client, a vaginal
examination is indicated to rule out cord prolapse and assess for cervical change.
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if
her baby will become HIV-infected. Which explanation should the nurse provide?
A.Most infants of HIV-positive women will continue to test positive for HIV
antibodies.
B.Infants who have HIV-positive mothers carry the virus and will eventually
develop the disease.
C.Medication taken during pregnancy to reduce the mother's viral load ensures
that the infant is HIV-negative.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies
are no longer present. - answer-D.HIV infection is determined at 18 months of
age, when maternal HIV antibodies are no longer present.
Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies
from the mother, so the evaluation of an infant for the HIV virus is determined at
18 months of age, when all the maternal antibodies are no longer in the infant's
blood. Passive HIV antibodies disappear in the infant within 18 months of age.
Option B is inaccurate. Although administration of HIV medication during
pregnancy can significantly reduce the risk of vertical transmission, treatment
does not ensure that the virus will not become manifest in the infant.
UPDATED VERSION 2025/2026
An expectant father tells the nurse he fears that his wife is "losing her mind." He
states that she is constantly rubbing her abdomen and talking to the baby and
that she actually reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - answer-D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
because the behaviors displayed are normal.
,The nurse is preparing a laboring client for an amniotomy. Immediately after the
procedure is completed, it is most important for the nurse to obtain which
information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - answer-C. Fetal heart rate (FHR)
When preparing a class on newborn care for expectant parents, which is correct
for the nurse to teach concerning the newborn infant born at term gestation?
A.Milia are red marks made by forceps and will disappear within 7 to 10 days.
B.Meconium is the first stool and is usually yellow gold in color.
C.Vernix is a white cheesy substance, predominantly located in the skin folds.
D.Pseudostrabismus found in newborns is treated by minor surgery. - answer-
C.Vernix is a white cheesy substance, predominantly located in the skin folds.
,Rationale:
Vernix, found in the folds of the skin, is a characteristic of term infants. Milia are
not red marks made by forceps but are white pinpoint spots usually found over
the nose and chin that represent blockage of the sebaceous glands. Meconium is
the first stool, but it is tarry black, not yellow. Pseudostrabismus (crossed eyes) is
normal at birth through the third or fourth month and does not require surgery.
Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after
spontaneous rupture of the membranes, the nurse notes several sudden
decreases in the fetal heart rate with quick return to baseline, with and without
contractions. Based on this fetal heart rate pattern, which intervention is best for
the nurse to implement?
A.Turn the client to her side.
B.Begin oxygen by nasal cannula at 2 L/min.
C.Place the client in a slight Trendelenburg position.
D.Assess for cervical dilation. - answer-C. Place the client in a slight Trendelenburg
position.
Rationale:The goal is to relieve pressure on the umbilical cord, and placing the
client in a slight Trendelenburg position is most likely to relieve that pressure. The
FHR pattern is indicative of a variable fetal heart rate deceleration, which is
typically caused by cord compression and can occur with or without contractions.
Option A may be helpful but is not as likely to relieve the pressure as the
Trendelenburg position. Option B is not helpful with cord compression. Option D
, is not the priority intervention at this time. After repositioning the client, a vaginal
examination is indicated to rule out cord prolapse and assess for cervical change.
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if
her baby will become HIV-infected. Which explanation should the nurse provide?
A.Most infants of HIV-positive women will continue to test positive for HIV
antibodies.
B.Infants who have HIV-positive mothers carry the virus and will eventually
develop the disease.
C.Medication taken during pregnancy to reduce the mother's viral load ensures
that the infant is HIV-negative.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies
are no longer present. - answer-D.HIV infection is determined at 18 months of
age, when maternal HIV antibodies are no longer present.
Rationale: All newborns of HIV-positive mothers receive passive HIV antibodies
from the mother, so the evaluation of an infant for the HIV virus is determined at
18 months of age, when all the maternal antibodies are no longer in the infant's
blood. Passive HIV antibodies disappear in the infant within 18 months of age.
Option B is inaccurate. Although administration of HIV medication during
pregnancy can significantly reduce the risk of vertical transmission, treatment
does not ensure that the virus will not become manifest in the infant.
