HESI MATERNITY NEWBORN
2024-2025 TEST BANK LATEST
UPDATED EXAM VERSION
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of
this accumulation of blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage
(Ans - A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn,
usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary
bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common variation of the
newborn. Options B and D both involve intracranial bleeding and could not be detected by
physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
, D.Apply baby lotion after the baby's daily bath
(Ans - C.Allow the cord to air-dry as much as possible.
Rationale: Recent studies have indicated that air drying or plain water
application may be equal to or more effective than alcohol in the cord healing process. Options
A, B, and D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What information
should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.
(Ans - C.Place petroleum ointment around the glans with each diaper
change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any urine
or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the
healing surface. Prepackaged wipes often contain other products that may irritate the site. The
yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an
infective process and should not be removed. If bleeding occurs at home, the client should be
instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call
the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in
preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously,
to stop her labor contractions.
What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
,C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth
(Ans - C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-
adrenergic receptors 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. Option A is not a side effect. Options B and D are side effects of
magnesium sulfate.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction
is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing.
(Ans - C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect
positioning of the infant on the breast for latching on. The baby's body is in alignment with the
ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast.
Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from
the stretching of the Cooper ligament. Option B is important but is not necessary for all women.
Option D helps soften an engorged breast and encourages correct infant latching on but is not the
best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?"
Which explanation is appropriate?
A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."
, C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry."
D."If you're concerned, you might consider bottle feeding so that you can monitor intake."
(Ans - B."Your milk is sufficient if the baby is voiding pale, strawcolored
urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and f requent (>6 to 10
times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative
of adequate nutrition, most home scales do not measure this accurately, and the suggestion will
likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's
milk production. Option D does not address the client's question.
The client comes to the hospital assuming she is in labor. Which assessment findings by the
nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions
(Ans –
A.Pain in the lower back that radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of
false labor.
Which statement made by the client indicates that the mother understands the limitations of
breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
2024-2025 TEST BANK LATEST
UPDATED EXAM VERSION
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of
this accumulation of blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage
(Ans - A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn,
usually arises within the first 24 hours after delivery. Trauma from delivery causes capillary
bleeding between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common variation of the
newborn. Options B and D both involve intracranial bleeding and could not be detected by
physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
, D.Apply baby lotion after the baby's daily bath
(Ans - C.Allow the cord to air-dry as much as possible.
Rationale: Recent studies have indicated that air drying or plain water
application may be equal to or more effective than alcohol in the cord healing process. Options
A, B, and D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What information
should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs.
(Ans - C.Place petroleum ointment around the glans with each diaper
change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any urine
or feces, and petroleum ointment should be applied to prevent the diaper from sticking to the
healing surface. Prepackaged wipes often contain other products that may irritate the site. The
yellow exudate, which covers the glans penis as the area heals and epithelializes, is not an
infective process and should not be removed. If bleeding occurs at home, the client should be
instructed to apply gentle pressure to the site of the bleeding with sterile gauze squares and call
the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in
preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously,
to stop her labor contractions.
What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
,C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth
(Ans - C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-
adrenergic receptors 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. Option A is not a side effect. Options B and D are side effects of
magnesium sulfate.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction
is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing.
(Ans - C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect
positioning of the infant on the breast for latching on. The baby's body is in alignment with the
ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast.
Option A helps prevent chafing, and nonbinding support aids in prevention of discomfort from
the stretching of the Cooper ligament. Option B is important but is not necessary for all women.
Option D helps soften an engorged breast and encourages correct infant latching on but is not the
best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?"
Which explanation is appropriate?
A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times a day."
, C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry."
D."If you're concerned, you might consider bottle feeding so that you can monitor intake."
(Ans - B."Your milk is sufficient if the baby is voiding pale, strawcolored
urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and f requent (>6 to 10
times/day), if the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative
of adequate nutrition, most home scales do not measure this accurately, and the suggestion will
likely make the mother anxious. Option C causes nipple confusion and diminishes the mother's
milk production. Option D does not address the client's question.
The client comes to the hospital assuming she is in labor. Which assessment findings by the
nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions
(Ans –
A.Pain in the lower back that radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of
false labor.
Which statement made by the client indicates that the mother understands the limitations of
breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
