HESI MATERNAL-CHILD NURSING
Version 4 Actual Exam QUESTIONS AND
ANSWERS 2026/2027 | 55 Questions | Pass
Guaranteed - A+ Graded
Section 1: Antepartum Care
Questions 1-8
Question 1
A 28-year-old G1P0 at 32 weeks gestation presents with complaints of headache, blurred vision,
and right upper quadrant pain. Her blood pressure is 160/110 mmHg, and urine dipstick shows
3+ protein. What is the priority nursing action?
A. Administer prescribed labetalol
B. Prepare for emergency cesarean section
C. Start magnesium sulfate infusion as ordered **[CORRECT]**
D. Insert Foley catheter
Correct Answer: C
Rationale: The patient is exhibiting classic signs of severe preeclampsia: blood pressure
≥160/110 mmHg, proteinuria (3+), headache, visual disturbances (blurred vision), and
epigastric/right upper quadrant pain. According to ACOG guidelines, magnesium sulfate is the
first-line medication for seizure prophylaxis in severe preeclampsia and eclampsia. While
antihypertensive therapy (A) may be indicated to lower blood pressure, seizure prevention takes
priority. Emergency cesarean section (B) may ultimately be necessary depending on gestational
age and maternal-fetal status, but it is not the immediate priority—stabilizing the mother and
preventing seizures comes first. Inserting a Foley catheter (D) may be needed for accurate urine
output monitoring, but initiating magnesium sulfate is the critical intervention to prevent
eclampsia, which carries significant maternal and fetal morbidity and mortality.
Question 2
A client at 28 weeks gestation has a 1-hour glucose tolerance test result of 155 mg/dL. What is
the next appropriate action?
A. Diagnose gestational diabetes
,B. Schedule a 3-hour glucose tolerance test **[CORRECT]**
C. Start insulin therapy
D. No further action needed
Correct Answer: B
Rationale: The 1-hour 50g glucose challenge test is a screening tool, not a diagnostic test. A
result between 140-199 mg/dL is considered abnormal and requires follow-up with a 3-hour
100g oral glucose tolerance test (OGTT) for definitive diagnosis of gestational diabetes mellitus
(GDM). Making a diagnosis (A) based solely on the screening test is inappropriate and could
lead to unnecessary treatment or anxiety. Starting insulin therapy (C) is premature without a
confirmed diagnosis and would require glucose monitoring and dietary modifications first.
Taking no further action (D) is incorrect because an abnormal screening result necessitates
diagnostic testing to identify women who need treatment to prevent macrosomia, birth trauma,
and other complications. The 3-hour OGTT requires fasting and measures glucose at fasting, 1-
hour, 2-hour, and 3-hour intervals, with two or more abnormal values confirming GDM.
Question 3
A pregnant client at 12 weeks gestation reports nausea and vomiting, especially in the morning.
Which dietary suggestion should the nurse offer?
A. Skip breakfast to avoid nausea
B. Eat dry crackers before getting out of bed **[CORRECT]**
C. Drink large amounts of fluid with meals
D. Avoid eating until afternoon
Correct Answer: B
Rationale: Morning sickness affects approximately 70-80% of pregnant women and typically
resolves by 16-20 weeks. Evidence-based interventions include eating small, frequent meals and
consuming dry, bland carbohydrates (such as crackers or toast) before rising from bed to help
absorb gastric acid and settle the stomach. Skipping breakfast (A) or avoiding eating until
afternoon (D) can worsen nausea due to hypoglycemia and increased gastric acid on an empty
stomach. Drinking large amounts of fluid with meals (C) can distend the stomach and trigger the
gastrocolic reflex, potentially increasing nausea and vomiting. Additional recommendations
include avoiding spicy or fatty foods, getting fresh air, and considering ginger or vitamin B6
supplementation if approved by the healthcare provider.
Question 4
, The nurse is providing education to a pregnant client about danger signs during pregnancy.
Which sign should be reported immediately?
A. Mild ankle swelling at the end of the day
B. Braxton Hicks contractions
C. Blurred vision **[CORRECT]**
D. Increased vaginal discharge
Correct Answer: C
Rationale: Blurred vision is a danger sign that may indicate severe preeclampsia or impending
eclampsia, requiring immediate medical evaluation. Visual disturbances (scotomata, blurred
vision, flashing lights) result from cerebral edema and vasospasm affecting the retinal vessels.
Mild ankle edema (A) is a common physiological change in pregnancy due to increased fluid
volume and venous stasis; however, sudden or severe edema of the face, hands, or rapid weight
gain requires evaluation. Braxton Hicks contractions (B) are irregular, painless uterine
contractions that are a normal preparation for labor. Increased vaginal discharge (D) is common
in pregnancy due to increased estrogen and cervical vascularity; however, discharge
accompanied by itching, odor, bleeding, or color changes requires assessment. Other danger
signs requiring immediate reporting include vaginal bleeding, severe headache, epigastric pain,
rupture of membranes, decreased fetal movement, and persistent vomiting.
Question 5
A pregnant client at 18 weeks gestation asks when she should expect to feel fetal movement.
What is the nurse's best response?
A. "You should have felt movement by 12 weeks."
B. "Most women feel movement between 18-20 weeks." **[CORRECT]**
C. "Fetal movement is not felt until 28 weeks."
D. "Movement is only felt in the third trimester."
Correct Answer: B
Rationale: Quickening, or the first perception of fetal movement, typically occurs between 18-20
weeks gestation for nulliparous women and may be felt slightly earlier (16-18 weeks) in
multiparous women who can distinguish fetal movement from other sensations. Before 12 weeks
(A), the fetus is too small and movements too weak to be perceived. Waiting until 28 weeks (C)
or the third trimester (D) significantly overestimates the timeline and would cause unnecessary
anxiety. Once quickening begins, the mother should be taught to monitor fetal movement
Version 4 Actual Exam QUESTIONS AND
ANSWERS 2026/2027 | 55 Questions | Pass
Guaranteed - A+ Graded
Section 1: Antepartum Care
Questions 1-8
Question 1
A 28-year-old G1P0 at 32 weeks gestation presents with complaints of headache, blurred vision,
and right upper quadrant pain. Her blood pressure is 160/110 mmHg, and urine dipstick shows
3+ protein. What is the priority nursing action?
A. Administer prescribed labetalol
B. Prepare for emergency cesarean section
C. Start magnesium sulfate infusion as ordered **[CORRECT]**
D. Insert Foley catheter
Correct Answer: C
Rationale: The patient is exhibiting classic signs of severe preeclampsia: blood pressure
≥160/110 mmHg, proteinuria (3+), headache, visual disturbances (blurred vision), and
epigastric/right upper quadrant pain. According to ACOG guidelines, magnesium sulfate is the
first-line medication for seizure prophylaxis in severe preeclampsia and eclampsia. While
antihypertensive therapy (A) may be indicated to lower blood pressure, seizure prevention takes
priority. Emergency cesarean section (B) may ultimately be necessary depending on gestational
age and maternal-fetal status, but it is not the immediate priority—stabilizing the mother and
preventing seizures comes first. Inserting a Foley catheter (D) may be needed for accurate urine
output monitoring, but initiating magnesium sulfate is the critical intervention to prevent
eclampsia, which carries significant maternal and fetal morbidity and mortality.
Question 2
A client at 28 weeks gestation has a 1-hour glucose tolerance test result of 155 mg/dL. What is
the next appropriate action?
A. Diagnose gestational diabetes
,B. Schedule a 3-hour glucose tolerance test **[CORRECT]**
C. Start insulin therapy
D. No further action needed
Correct Answer: B
Rationale: The 1-hour 50g glucose challenge test is a screening tool, not a diagnostic test. A
result between 140-199 mg/dL is considered abnormal and requires follow-up with a 3-hour
100g oral glucose tolerance test (OGTT) for definitive diagnosis of gestational diabetes mellitus
(GDM). Making a diagnosis (A) based solely on the screening test is inappropriate and could
lead to unnecessary treatment or anxiety. Starting insulin therapy (C) is premature without a
confirmed diagnosis and would require glucose monitoring and dietary modifications first.
Taking no further action (D) is incorrect because an abnormal screening result necessitates
diagnostic testing to identify women who need treatment to prevent macrosomia, birth trauma,
and other complications. The 3-hour OGTT requires fasting and measures glucose at fasting, 1-
hour, 2-hour, and 3-hour intervals, with two or more abnormal values confirming GDM.
Question 3
A pregnant client at 12 weeks gestation reports nausea and vomiting, especially in the morning.
Which dietary suggestion should the nurse offer?
A. Skip breakfast to avoid nausea
B. Eat dry crackers before getting out of bed **[CORRECT]**
C. Drink large amounts of fluid with meals
D. Avoid eating until afternoon
Correct Answer: B
Rationale: Morning sickness affects approximately 70-80% of pregnant women and typically
resolves by 16-20 weeks. Evidence-based interventions include eating small, frequent meals and
consuming dry, bland carbohydrates (such as crackers or toast) before rising from bed to help
absorb gastric acid and settle the stomach. Skipping breakfast (A) or avoiding eating until
afternoon (D) can worsen nausea due to hypoglycemia and increased gastric acid on an empty
stomach. Drinking large amounts of fluid with meals (C) can distend the stomach and trigger the
gastrocolic reflex, potentially increasing nausea and vomiting. Additional recommendations
include avoiding spicy or fatty foods, getting fresh air, and considering ginger or vitamin B6
supplementation if approved by the healthcare provider.
Question 4
, The nurse is providing education to a pregnant client about danger signs during pregnancy.
Which sign should be reported immediately?
A. Mild ankle swelling at the end of the day
B. Braxton Hicks contractions
C. Blurred vision **[CORRECT]**
D. Increased vaginal discharge
Correct Answer: C
Rationale: Blurred vision is a danger sign that may indicate severe preeclampsia or impending
eclampsia, requiring immediate medical evaluation. Visual disturbances (scotomata, blurred
vision, flashing lights) result from cerebral edema and vasospasm affecting the retinal vessels.
Mild ankle edema (A) is a common physiological change in pregnancy due to increased fluid
volume and venous stasis; however, sudden or severe edema of the face, hands, or rapid weight
gain requires evaluation. Braxton Hicks contractions (B) are irregular, painless uterine
contractions that are a normal preparation for labor. Increased vaginal discharge (D) is common
in pregnancy due to increased estrogen and cervical vascularity; however, discharge
accompanied by itching, odor, bleeding, or color changes requires assessment. Other danger
signs requiring immediate reporting include vaginal bleeding, severe headache, epigastric pain,
rupture of membranes, decreased fetal movement, and persistent vomiting.
Question 5
A pregnant client at 18 weeks gestation asks when she should expect to feel fetal movement.
What is the nurse's best response?
A. "You should have felt movement by 12 weeks."
B. "Most women feel movement between 18-20 weeks." **[CORRECT]**
C. "Fetal movement is not felt until 28 weeks."
D. "Movement is only felt in the third trimester."
Correct Answer: B
Rationale: Quickening, or the first perception of fetal movement, typically occurs between 18-20
weeks gestation for nulliparous women and may be felt slightly earlier (16-18 weeks) in
multiparous women who can distinguish fetal movement from other sensations. Before 12 weeks
(A), the fetus is too small and movements too weak to be perceived. Waiting until 28 weeks (C)
or the third trimester (D) significantly overestimates the timeline and would cause unnecessary
anxiety. Once quickening begins, the mother should be taught to monitor fetal movement
