RN HESI MATERNITY EXAM QUESTIONS WITH CORRECTLY
SOLVED ANSWERS.
1) During a 26-week gestation prenatal exam, a client reports occasional dizziness and
_ _ _ _ _ _ _ _ _ _ _ _
light headiness when she is lying down. What intervention is best for the nurse to
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
recommend to this client. -- Correct Answer ✔✔ Elevate the head with two pillows
_ _ _ _ _ _ _ _ _ _ _ _ _
_while sleeping. _
2) 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 pressure 130/74. What action should the nurse _ _ _ _ _ _ _ _ _ _
implement? -- Correct Answer ✔✔ Document the vital signs in the record.
_ _ _ _ _ _ _ _ _ _ _
3) A primigravida arrives at the observation unit of the maternity unit because thinks is
_ _ _ _ _ _ _ _ _ _ _ _ _ _
in labor. The nurse applies the external fetal heart monitor and determines that the
_ _ _ _ _ _ _ _ _ _ _ _ _ _
fetal heart rate is 140 beats/minute and the contractions are occurring irregularly
_ _ _ _ _ _ _ _ _ _ _ _
every 10 to 15 minutes. What assessment finding confirms to the nurse that the
_ _ _ _ _ _ _ _ _ _ _ _ _ _
client is not labor at this time? -- Correct Answer ✔✔ Contractions decrease with
_ _ _ _ _ _ _ _ _ _ _ _ _ _
walking.
4) A 4-day postpartum client calls the clinic and reports that her nipples are so sore
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
that she does not know if she can continue to breastfeed her infant. What
_ _ _ _ _ _ _ _ _ _ _ _ _ _
instruction is best for the nurse to provide? -- Correct Answer ✔✔ Apply hot packs
_ _ _ _ _ _ _ _ _ _ _ _ _ _
_just before each feeding.
_ _ _
5) A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
solution should the nurse administer? (Enter numeric value only) -- Correct Answer
_ _ _ _ _ _ _ _ _ _ _
_✔✔ 13 _
,6) A newborn with myelomeningocele is admitted to the neonatal intensive care unit.
_ _ _ _ _ _ _ _ _ _ _ _
Which preoperative nursing intervention should the nurse implement first? --
_ _ _ _ _ _ _ _ _ _
Correct Answer ✔✔ Place the infant on the abdomen to protect the sac.
_ _ _ _ _ _ _ _ _ _ _ _
7) The mother of a 5-week-old tells the nurse that her baby has acne and asks if she
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which
_ _ _ _ _ _ _ _ _ _ _ _ _ _
answer should the nurse to provide? -- Correct Answer ✔✔ " Your baby may be
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
showing signs of a systemic disease and needs to be seen by a healthcare provider"
_ _ _ _ _ _ _ _ _ _ _ _ _ _
8) The healthcare provider prescribe Pitocin 2milliunits / min to induce labor for a
_ _ _ _ _ _ _ _ _ _ _ _ _
client at 41 weeks gestation. The nurse initiates an infusion of Lactated Ringer 1000
_ _ _ _ _ _ _ _ _ _ _ _ _ _
ml with Pitocin 10 units. How many ml/ hr should the nurse program the infusion
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
pump? -- Correct Answer ✔✔ 12
_ _ _ _ _
9) The nurse is counseling a patient who is at 6 weeks gestation and is experiencing
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
morning sickness , but does not want to take any drugs for this discomfort. Which
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
herbal supplement is likely to help this client with the nausea she is experiencing ?
_ _ _ _ _ _ _ _ _ _ _ _ _ _
A. Ginger
B. Chamomile
C. Peppermint
D. Ginko -- Correct Answer ✔✔ A. Ginger _ _ _ _ _ _
10) At 0600 while admitting a woman for a scheduled repeat c-section the client tells
_ _ _ _ _ _ _ _ _ _ _ _ _ _
the nurse that she had coffee at 0400 because she wanted avoid getting a headache.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
What action should the nurse take first?
_ _ _ _ _ _
A. Ensure preoperative lab results are available _ _ _ _ _
B. Start IV prescribed Lactated ringers _ _ _ _
C. Inform the anesthesia care provider _ _ _ _
D. Contact the client obstetrician -- Correct Answer ✔✔ C. Inform the _ _ _ _ _ _ _ _ _ _ _
anesthesia care provider _ _
11) A mother spontaneously delivers her infant in a taxi cab on the way to the hospital.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
The emergency room nurse reports that the mother has active herpes (HSVII)
_ _ _ _ _ _ _ _ _ _ _ _
lesion on the vulva. What intervention should the nurse implement first when
_ _ _ _ _ _ _ _ _ _ _ _
admitting the neonate in the nursery? _ _ _ _ _
, A. Obtain blood specimen for serum glucose level
_ _ _ _ _ _
B. Document the temperature on the flow sheet _ _ _ _ _ _
C. Place newborn in the isolation area of the nursery
_ _ _ _ _ _ _ _
D. Administer Vitamin K injection -- Correct Answer ✔✔ C. Place newborn in _ _ _ _ _ _ _ _ _ _ _ _
the isolation area of the nursery
_ _ _ _ _
12) A primipara has delivered a stillborn fetus at 30 weeks gestation. To assess the
_ _ _ _ _ _ _ _ _ _ _ _ _ _
parents in the grieving process which intervention is most for the nurse to
_ _ _ _ _ _ _ _ _ _ _ _ _
implement ? _
A. explain the possible cause of the fetal demise _ _ _ _ _ _ _
B. Provide a time for the parents to hold their infant in privacy _ _ _ _ _ _ _ _ _ _ _
C. Encourage the parents to seek counseling within the next few weeks _ _ _ _ _ _ _ _ _ _
D. Assist the couple to request autopsy -- Correct Answer ✔✔ B. provide a
_ _ _ _ _ _ _ _ _ _ _ _ _
time for the parents to hold their infant in privacy
_ _ _ _ _ _ _ _ _
13) An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which
_ _ _ _ _ _ _ _ _ _ _ _ _
action should the nurse implement first?
_ _ _ _ _
A. Administer morphine sulphate.
_ _ _
B. Start IV fluids.
_ _ _
C. Place the infant in a knee-chest position
_ _ _ _ _ _ _
D. Provide 100% oxygen by face mask. -- Correct Answer ✔✔ C. Place the infant
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
in a knee-chest position
_ _ _
14) A one-day-old neonate develops a cephalohematoma. The nurse should closely
_ _ _ _ _ _ _ _ _ _
assess this neonate for which common complication?
_ _ _ _ _ _ _
A. jaundice
B. poor appetite _
C. brain damage _
D. hypoglycemia -- Correct Answer ✔✔ A. jaundice _ _ _ _ _ _
15) The nurse is reviewing the serum laboratory finding for a 5-day-old infant with
_ _ _ _ _ _ _ _ _ _ _ _ _
congenital adrenal hyperplasia. Which laboratory results should be reported to the
_ _ _ _ _ _ _ _ _ _ _
healthcare provider immediately? _ _
A. Bilirubin of 1.5 mg/dl _ _ _
B. Glucose of 80 mg/dl _ _ _
, C. Potassium of 4.5 mEq/L _ _ _
D. Sodium of 119 mEq/L -- Correct Answer ✔✔ D. Sodium of 119 mEq/L
_ _ _ _ _ _ _ _ _ _ _ _
16) At 39-weeks gestation, a multigravida is having a non-stress test (NST). The fetal
_ _ _ _ _ _ _ _ _ _ _ _ _
heart rate (FHR) has remained nonreactive during the 30 minutes of evaluation.
_ _ _ _ _ _ _ _ _ _ _ _
Based on this finding, which action should the nurse implement?
_ _ _ _ _ _ _ _ _
A. Initiate an intravenous infusion _ _ _
B. Observe the FHR pattern for 30 more minutes _ _ _ _ _ _ _
C. Schedule a biophysical profile _ _ _
D. Place an acoustic stimulator on the abdomen -- Correct Answer ✔✔ D.
_ _ _ _ _ _ _ _ _ _ _ _
Place an acoustic stimulator on the abdomen
_ _ _ _ _ _
17) A community health nurse visits a family in which a 16-year-old unmarried daughter
_ _ _ _ _ _ _ _ _ _ _ _ _
is pregnant with her first child and is at 32-weeks gestation. The client tells the
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
nurse that she has been having intermittent back pain since the night before. What is
_ _ _ _ _ _ _ _ _ _ _ _ _ _
_ the priority nursing intervention?
_ _ _
A. Ask the clients mother to call an ambulance for transport to the hospital
_ _ _ _ _ _ _ _ _ _ _ _ _
immediately.
B. Determine what physical activities the client has performed for the past 24 _ _ _ _ _ _ _ _ _ _ _ _
hours
C. Teach the client if she has experienced any recent changes in vaginal
_ _ _ _ _ _ _ _ _ _ _ _
discharge. -- Correct Answer ✔✔ C. Teach the client if she has experienced _ _ _ _ _ _ _ _ _ _ _ _ _
any recent changes in vaginal discharge.
_ _ _ _ _
18) What is the priority nursing assessment immediately following the birth of an infant
_ _ _ _ _ _ _ _ _ _ _ _ _
with esophageal atresia and a tracheoesophageal (the) fistula ?
_ _ _ _ _ _ _ _
A. body temperature _
B. level of pain _ _
C. time of first void
_ _ _
D. number of vessels in the cord -- Correct Answer ✔✔ A. body temperature
_ _ _ _ _ _ _ _ _ _ _ _
19) What is the most important assessment for the nurse to conduct following the
_ _ _ _ _ _ _ _ _ _ _ _ _
administration of epidural anesthesia to a client who is at 40-weeks gestation?
_ _ _ _ _ _ _ _ _ _ _
A. Level of pain sensation _ _ _
B. Station of presenting part _ _ _
SOLVED ANSWERS.
1) During a 26-week gestation prenatal exam, a client reports occasional dizziness and
_ _ _ _ _ _ _ _ _ _ _ _
light headiness when she is lying down. What intervention is best for the nurse to
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
recommend to this client. -- Correct Answer ✔✔ Elevate the head with two pillows
_ _ _ _ _ _ _ _ _ _ _ _ _
_while sleeping. _
2) 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 pressure 130/74. What action should the nurse _ _ _ _ _ _ _ _ _ _
implement? -- Correct Answer ✔✔ Document the vital signs in the record.
_ _ _ _ _ _ _ _ _ _ _
3) A primigravida arrives at the observation unit of the maternity unit because thinks is
_ _ _ _ _ _ _ _ _ _ _ _ _ _
in labor. The nurse applies the external fetal heart monitor and determines that the
_ _ _ _ _ _ _ _ _ _ _ _ _ _
fetal heart rate is 140 beats/minute and the contractions are occurring irregularly
_ _ _ _ _ _ _ _ _ _ _ _
every 10 to 15 minutes. What assessment finding confirms to the nurse that the
_ _ _ _ _ _ _ _ _ _ _ _ _ _
client is not labor at this time? -- Correct Answer ✔✔ Contractions decrease with
_ _ _ _ _ _ _ _ _ _ _ _ _ _
walking.
4) A 4-day postpartum client calls the clinic and reports that her nipples are so sore
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
that she does not know if she can continue to breastfeed her infant. What
_ _ _ _ _ _ _ _ _ _ _ _ _ _
instruction is best for the nurse to provide? -- Correct Answer ✔✔ Apply hot packs
_ _ _ _ _ _ _ _ _ _ _ _ _ _
_just before each feeding.
_ _ _
5) A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
solution should the nurse administer? (Enter numeric value only) -- Correct Answer
_ _ _ _ _ _ _ _ _ _ _
_✔✔ 13 _
,6) A newborn with myelomeningocele is admitted to the neonatal intensive care unit.
_ _ _ _ _ _ _ _ _ _ _ _
Which preoperative nursing intervention should the nurse implement first? --
_ _ _ _ _ _ _ _ _ _
Correct Answer ✔✔ Place the infant on the abdomen to protect the sac.
_ _ _ _ _ _ _ _ _ _ _ _
7) The mother of a 5-week-old tells the nurse that her baby has acne and asks if she
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which
_ _ _ _ _ _ _ _ _ _ _ _ _ _
answer should the nurse to provide? -- Correct Answer ✔✔ " Your baby may be
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
showing signs of a systemic disease and needs to be seen by a healthcare provider"
_ _ _ _ _ _ _ _ _ _ _ _ _ _
8) The healthcare provider prescribe Pitocin 2milliunits / min to induce labor for a
_ _ _ _ _ _ _ _ _ _ _ _ _
client at 41 weeks gestation. The nurse initiates an infusion of Lactated Ringer 1000
_ _ _ _ _ _ _ _ _ _ _ _ _ _
ml with Pitocin 10 units. How many ml/ hr should the nurse program the infusion
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
pump? -- Correct Answer ✔✔ 12
_ _ _ _ _
9) The nurse is counseling a patient who is at 6 weeks gestation and is experiencing
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
morning sickness , but does not want to take any drugs for this discomfort. Which
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
herbal supplement is likely to help this client with the nausea she is experiencing ?
_ _ _ _ _ _ _ _ _ _ _ _ _ _
A. Ginger
B. Chamomile
C. Peppermint
D. Ginko -- Correct Answer ✔✔ A. Ginger _ _ _ _ _ _
10) At 0600 while admitting a woman for a scheduled repeat c-section the client tells
_ _ _ _ _ _ _ _ _ _ _ _ _ _
the nurse that she had coffee at 0400 because she wanted avoid getting a headache.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
What action should the nurse take first?
_ _ _ _ _ _
A. Ensure preoperative lab results are available _ _ _ _ _
B. Start IV prescribed Lactated ringers _ _ _ _
C. Inform the anesthesia care provider _ _ _ _
D. Contact the client obstetrician -- Correct Answer ✔✔ C. Inform the _ _ _ _ _ _ _ _ _ _ _
anesthesia care provider _ _
11) A mother spontaneously delivers her infant in a taxi cab on the way to the hospital.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
The emergency room nurse reports that the mother has active herpes (HSVII)
_ _ _ _ _ _ _ _ _ _ _ _
lesion on the vulva. What intervention should the nurse implement first when
_ _ _ _ _ _ _ _ _ _ _ _
admitting the neonate in the nursery? _ _ _ _ _
, A. Obtain blood specimen for serum glucose level
_ _ _ _ _ _
B. Document the temperature on the flow sheet _ _ _ _ _ _
C. Place newborn in the isolation area of the nursery
_ _ _ _ _ _ _ _
D. Administer Vitamin K injection -- Correct Answer ✔✔ C. Place newborn in _ _ _ _ _ _ _ _ _ _ _ _
the isolation area of the nursery
_ _ _ _ _
12) A primipara has delivered a stillborn fetus at 30 weeks gestation. To assess the
_ _ _ _ _ _ _ _ _ _ _ _ _ _
parents in the grieving process which intervention is most for the nurse to
_ _ _ _ _ _ _ _ _ _ _ _ _
implement ? _
A. explain the possible cause of the fetal demise _ _ _ _ _ _ _
B. Provide a time for the parents to hold their infant in privacy _ _ _ _ _ _ _ _ _ _ _
C. Encourage the parents to seek counseling within the next few weeks _ _ _ _ _ _ _ _ _ _
D. Assist the couple to request autopsy -- Correct Answer ✔✔ B. provide a
_ _ _ _ _ _ _ _ _ _ _ _ _
time for the parents to hold their infant in privacy
_ _ _ _ _ _ _ _ _
13) An infant with tetralogy of Fallot becomes acutely cyanotic and hyper apneic. Which
_ _ _ _ _ _ _ _ _ _ _ _ _
action should the nurse implement first?
_ _ _ _ _
A. Administer morphine sulphate.
_ _ _
B. Start IV fluids.
_ _ _
C. Place the infant in a knee-chest position
_ _ _ _ _ _ _
D. Provide 100% oxygen by face mask. -- Correct Answer ✔✔ C. Place the infant
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
in a knee-chest position
_ _ _
14) A one-day-old neonate develops a cephalohematoma. The nurse should closely
_ _ _ _ _ _ _ _ _ _
assess this neonate for which common complication?
_ _ _ _ _ _ _
A. jaundice
B. poor appetite _
C. brain damage _
D. hypoglycemia -- Correct Answer ✔✔ A. jaundice _ _ _ _ _ _
15) The nurse is reviewing the serum laboratory finding for a 5-day-old infant with
_ _ _ _ _ _ _ _ _ _ _ _ _
congenital adrenal hyperplasia. Which laboratory results should be reported to the
_ _ _ _ _ _ _ _ _ _ _
healthcare provider immediately? _ _
A. Bilirubin of 1.5 mg/dl _ _ _
B. Glucose of 80 mg/dl _ _ _
, C. Potassium of 4.5 mEq/L _ _ _
D. Sodium of 119 mEq/L -- Correct Answer ✔✔ D. Sodium of 119 mEq/L
_ _ _ _ _ _ _ _ _ _ _ _
16) At 39-weeks gestation, a multigravida is having a non-stress test (NST). The fetal
_ _ _ _ _ _ _ _ _ _ _ _ _
heart rate (FHR) has remained nonreactive during the 30 minutes of evaluation.
_ _ _ _ _ _ _ _ _ _ _ _
Based on this finding, which action should the nurse implement?
_ _ _ _ _ _ _ _ _
A. Initiate an intravenous infusion _ _ _
B. Observe the FHR pattern for 30 more minutes _ _ _ _ _ _ _
C. Schedule a biophysical profile _ _ _
D. Place an acoustic stimulator on the abdomen -- Correct Answer ✔✔ D.
_ _ _ _ _ _ _ _ _ _ _ _
Place an acoustic stimulator on the abdomen
_ _ _ _ _ _
17) A community health nurse visits a family in which a 16-year-old unmarried daughter
_ _ _ _ _ _ _ _ _ _ _ _ _
is pregnant with her first child and is at 32-weeks gestation. The client tells the
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
nurse that she has been having intermittent back pain since the night before. What is
_ _ _ _ _ _ _ _ _ _ _ _ _ _
_ the priority nursing intervention?
_ _ _
A. Ask the clients mother to call an ambulance for transport to the hospital
_ _ _ _ _ _ _ _ _ _ _ _ _
immediately.
B. Determine what physical activities the client has performed for the past 24 _ _ _ _ _ _ _ _ _ _ _ _
hours
C. Teach the client if she has experienced any recent changes in vaginal
_ _ _ _ _ _ _ _ _ _ _ _
discharge. -- Correct Answer ✔✔ C. Teach the client if she has experienced _ _ _ _ _ _ _ _ _ _ _ _ _
any recent changes in vaginal discharge.
_ _ _ _ _
18) What is the priority nursing assessment immediately following the birth of an infant
_ _ _ _ _ _ _ _ _ _ _ _ _
with esophageal atresia and a tracheoesophageal (the) fistula ?
_ _ _ _ _ _ _ _
A. body temperature _
B. level of pain _ _
C. time of first void
_ _ _
D. number of vessels in the cord -- Correct Answer ✔✔ A. body temperature
_ _ _ _ _ _ _ _ _ _ _ _
19) What is the most important assessment for the nurse to conduct following the
_ _ _ _ _ _ _ _ _ _ _ _ _
administration of epidural anesthesia to a client who is at 40-weeks gestation?
_ _ _ _ _ _ _ _ _ _ _
A. Level of pain sensation _ _ _
B. Station of presenting part _ _ _
