HESI MATERNAL-CHILD NURSING
Actual Exam QUESTIONS AND ANSWERS
2025 | 55 Questions | Pass Guaranteed - A+
Graded
Section 1: Antepartum Care
Questions 1-8
Question 1 A 32-year-old G2P1 at 34 weeks gestation presents with severe headache, visual
disturbances, and epigastric pain. Her blood pressure is 168/112 mmHg, and urine protein is 3+.
Which medication should the nurse prepare to administer immediately?
A. Hydralazine IV push B. Labetalol PO C. Magnesium sulfate IV loading dose [CORRECT]
D. Nifedipine SL
Correct Answer: C
Rationale: This patient exhibits signs of severe preeclampsia (BP ≥160/110 mmHg with
proteinuria plus neurological symptoms and epigastric pain). Magnesium sulfate is the
anticonvulsant of choice for seizure prophylaxis in preeclampsia/eclampsia and should be
administered immediately. While antihypertensives (A, B, D) may be used to lower BP, seizure
prevention takes priority in severe preeclampsia.
Question 2 A pregnant client at 16 weeks gestation asks the nurse about recommended weight
gain during pregnancy. The client's pre-pregnancy BMI was 28 kg/m². What is the appropriate
total weight gain recommendation?
A. 25-35 pounds B. 15-25 pounds [CORRECT] C. 11-20 pounds D. 28-40 pounds
Correct Answer: B
Rationale: For overweight women (BMI 25.0-29.9), the Institute of Medicine recommends a
total weight gain of 15-25 pounds (7-11.5 kg). Normal weight women (BMI 18.5-24.9) should
gain 25-35 pounds. Obese women (BMI ≥30) should gain 11-20 pounds. Underweight women
(BMI <18.5) should gain 28-40 pounds.
,Question 3 During a prenatal visit at 24 weeks gestation, the nurse palpates the fundus at which
location?
A. At the symphysis pubis B. At the level of the umbilicus [CORRECT] C. 2-3 cm above the
umbilicus D. At the xiphoid process
Correct Answer: B
Rationale: At 20-22 weeks, the fundus is typically at the umbilicus. At 24 weeks, it remains at or
slightly above the umbilicus. The fundus reaches the xiphoid process at 36 weeks. At 12 weeks,
it is at the symphysis pubis.
Question 4 A client at 28 weeks gestation has a 1-hour glucose challenge test result of 168
mg/dL. What is the appropriate nursing action?
A. Diagnose gestational diabetes and start dietary teaching B. Schedule a 3-hour oral glucose
tolerance test [CORRECT] C. Recheck fasting glucose in 2 weeks D. Start insulin therapy
immediately
Correct Answer: B
Rationale: A 1-hour glucose challenge test value ≥140 mg/dL requires follow-up with a
diagnostic 3-hour oral glucose tolerance test (OGTT). Values between 140-199 mg/dL are
abnormal but do not confirm gestational diabetes. Diagnosis requires two or more abnormal
values on the 3-hour OGTT.
Question 5 Which finding during pregnancy requires immediate notification of the healthcare
provider?
A. Mild ankle edema at the end of the day B. Increased vaginal discharge without odor C.
Persistent, severe headache with visual changes [CORRECT] D. Occasional Braxton Hicks
contractions
Correct Answer: C
Rationale: Persistent severe headache with visual changes (scotomata, blurred vision) are danger
signs of severe preeclampsia and require immediate evaluation. Mild ankle edema (A) is
common in pregnancy. Increased vaginal discharge (B) is normal unless accompanied by itching,
odor, or color change. Braxton Hicks contractions (D) are normal uterine practice contractions.
, Question 6 A pregnant client at 18 weeks gestation asks when she should expect to feel fetal
movements. What is the nurse's best response?
A. "You should have already felt movement by now" B. "Most women feel movement between
16-20 weeks gestation" [CORRECT] C. "Fetal movement is not felt until 28 weeks" D. "You
will only feel movement if this is not your first pregnancy"
Correct Answer: B
Rationale: Quickening (maternal perception of fetal movement) typically occurs between 16-20
weeks for nulliparous women and may be slightly earlier (14-18 weeks) for multiparous women.
It is not abnormal to not feel movement at 18 weeks, particularly for first-time mothers.
Question 7 A client with Rh-negative blood type is at 28 weeks gestation. What intervention is
required at this time?
A. Immediate delivery B. Administration of Rh immune globulin (RhoGAM) [CORRECT] C.
Amniocentesis to check fetal blood type D. No intervention until delivery
Correct Answer: B
Rationale: Rh-negative women should receive RhoGAM at 28 weeks gestation (antepartum
dose) and again within 72 hours after delivery if the infant is Rh-positive. This prevents
sensitization and protects future pregnancies.
Question 8 A pregnant client reports heartburn that worsens when lying down. Which suggestion
should the nurse provide?
A. "Take sodium bicarbonate tablets before meals" B. "Lie flat after eating to help digestion" C.
"Eat small, frequent meals and avoid lying down for 2 hours after eating" [CORRECT] D.
"Increase your intake of caffeinated beverages"
Correct Answer: C
Rationale: Heartburn in pregnancy is caused by progesterone relaxing the lower esophageal
sphincter and the growing uterus displacing the stomach. Small, frequent meals and avoiding
recumbency after eating are first-line recommendations. Sodium bicarbonate (A) contains
sodium and may cause fluid retention. Lying flat (B) worsens reflux. Caffeine (D) relaxes the
LES further.
Section 2: Intrapartum Care
Actual Exam QUESTIONS AND ANSWERS
2025 | 55 Questions | Pass Guaranteed - A+
Graded
Section 1: Antepartum Care
Questions 1-8
Question 1 A 32-year-old G2P1 at 34 weeks gestation presents with severe headache, visual
disturbances, and epigastric pain. Her blood pressure is 168/112 mmHg, and urine protein is 3+.
Which medication should the nurse prepare to administer immediately?
A. Hydralazine IV push B. Labetalol PO C. Magnesium sulfate IV loading dose [CORRECT]
D. Nifedipine SL
Correct Answer: C
Rationale: This patient exhibits signs of severe preeclampsia (BP ≥160/110 mmHg with
proteinuria plus neurological symptoms and epigastric pain). Magnesium sulfate is the
anticonvulsant of choice for seizure prophylaxis in preeclampsia/eclampsia and should be
administered immediately. While antihypertensives (A, B, D) may be used to lower BP, seizure
prevention takes priority in severe preeclampsia.
Question 2 A pregnant client at 16 weeks gestation asks the nurse about recommended weight
gain during pregnancy. The client's pre-pregnancy BMI was 28 kg/m². What is the appropriate
total weight gain recommendation?
A. 25-35 pounds B. 15-25 pounds [CORRECT] C. 11-20 pounds D. 28-40 pounds
Correct Answer: B
Rationale: For overweight women (BMI 25.0-29.9), the Institute of Medicine recommends a
total weight gain of 15-25 pounds (7-11.5 kg). Normal weight women (BMI 18.5-24.9) should
gain 25-35 pounds. Obese women (BMI ≥30) should gain 11-20 pounds. Underweight women
(BMI <18.5) should gain 28-40 pounds.
,Question 3 During a prenatal visit at 24 weeks gestation, the nurse palpates the fundus at which
location?
A. At the symphysis pubis B. At the level of the umbilicus [CORRECT] C. 2-3 cm above the
umbilicus D. At the xiphoid process
Correct Answer: B
Rationale: At 20-22 weeks, the fundus is typically at the umbilicus. At 24 weeks, it remains at or
slightly above the umbilicus. The fundus reaches the xiphoid process at 36 weeks. At 12 weeks,
it is at the symphysis pubis.
Question 4 A client at 28 weeks gestation has a 1-hour glucose challenge test result of 168
mg/dL. What is the appropriate nursing action?
A. Diagnose gestational diabetes and start dietary teaching B. Schedule a 3-hour oral glucose
tolerance test [CORRECT] C. Recheck fasting glucose in 2 weeks D. Start insulin therapy
immediately
Correct Answer: B
Rationale: A 1-hour glucose challenge test value ≥140 mg/dL requires follow-up with a
diagnostic 3-hour oral glucose tolerance test (OGTT). Values between 140-199 mg/dL are
abnormal but do not confirm gestational diabetes. Diagnosis requires two or more abnormal
values on the 3-hour OGTT.
Question 5 Which finding during pregnancy requires immediate notification of the healthcare
provider?
A. Mild ankle edema at the end of the day B. Increased vaginal discharge without odor C.
Persistent, severe headache with visual changes [CORRECT] D. Occasional Braxton Hicks
contractions
Correct Answer: C
Rationale: Persistent severe headache with visual changes (scotomata, blurred vision) are danger
signs of severe preeclampsia and require immediate evaluation. Mild ankle edema (A) is
common in pregnancy. Increased vaginal discharge (B) is normal unless accompanied by itching,
odor, or color change. Braxton Hicks contractions (D) are normal uterine practice contractions.
, Question 6 A pregnant client at 18 weeks gestation asks when she should expect to feel fetal
movements. What is the nurse's best response?
A. "You should have already felt movement by now" B. "Most women feel movement between
16-20 weeks gestation" [CORRECT] C. "Fetal movement is not felt until 28 weeks" D. "You
will only feel movement if this is not your first pregnancy"
Correct Answer: B
Rationale: Quickening (maternal perception of fetal movement) typically occurs between 16-20
weeks for nulliparous women and may be slightly earlier (14-18 weeks) for multiparous women.
It is not abnormal to not feel movement at 18 weeks, particularly for first-time mothers.
Question 7 A client with Rh-negative blood type is at 28 weeks gestation. What intervention is
required at this time?
A. Immediate delivery B. Administration of Rh immune globulin (RhoGAM) [CORRECT] C.
Amniocentesis to check fetal blood type D. No intervention until delivery
Correct Answer: B
Rationale: Rh-negative women should receive RhoGAM at 28 weeks gestation (antepartum
dose) and again within 72 hours after delivery if the infant is Rh-positive. This prevents
sensitization and protects future pregnancies.
Question 8 A pregnant client reports heartburn that worsens when lying down. Which suggestion
should the nurse provide?
A. "Take sodium bicarbonate tablets before meals" B. "Lie flat after eating to help digestion" C.
"Eat small, frequent meals and avoid lying down for 2 hours after eating" [CORRECT] D.
"Increase your intake of caffeinated beverages"
Correct Answer: C
Rationale: Heartburn in pregnancy is caused by progesterone relaxing the lower esophageal
sphincter and the growing uterus displacing the stomach. Small, frequent meals and avoiding
recumbency after eating are first-line recommendations. Sodium bicarbonate (A) contains
sodium and may cause fluid retention. Lying flat (B) worsens reflux. Caffeine (D) relaxes the
LES further.
Section 2: Intrapartum Care
