MATERNITY HESI CASE STUDY
ALL COMPLETE QUESTIONS
AND CORRECT ANSWERS
UPDATE 2026
QUESTIONwhat is the most likely reason a postpartum patient
would be hemorrhaging? - answer-uterine atony (a "boggy"
fundus)
QUESTIONWhat should be assessed immediately after fundus is
massaged and nurse has called for help? - answer-Assess for
bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125
mL/hour, which can contribute to diuresis. A distended bladder
impedes uterine contraction and contributes to excessive
bleeding. After the fundus is massaged, the bladder should be
checked for distention.
QUESTIONWhen the nurse conducts a gestational age
assessment, which findings may indicate postmaturity? (Select all
that apply. One, some, or all options may be correct.)
a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
,e. Deep creases at the base of the toes extending to the heels. -
answer-c. d. and e.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is
lost prior to birth. This results in the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending
from the base
QUESTIONThe infant has a reddish papular rash across his face.
How should the nurse respond when the client asks about the
rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
d. Good question. Let me take the infant's vital signs and examine
him - answer-c. A newborn rash is very common, but it will
disappear soon.
--> The infant rash, erythema toxicum, is very common and
usually disappears by the third day of life.
,The nurse performs the first assessment upon the client's arrival
to the postpartum unit. Where would the nurse expect to palpate
the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - answer-b.
1 cm above the umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the
umbilicus
QUESTIONFifteen minutes after the initial assessment, the nurse
finds the client disoriented and lying on her back in a pool of
vaginal blood, with the sheets beneath her saturated with blood.
Which action is most important for the nurse to implement
immediately?
a. Take vital signs
b. Massage the fundus
c. Check the bladder
d. Increase the IV rate - answer-b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's
hemorrhaging, massing the fundus is the most important
intervention. The nurse should also call for assistance due to the
amount of blood that has pooled under the client.
, QUESTIONWhich factor should alert the nurse to assess for the
risk of jaundice? - answer-trauma at birth
QUESTIONwhat is a normal bilirubin range for a newborn? -
answer-5-6 mg/dL
QUESTIONWhich instructions should the nurse include in the
discharge planning regarding the infant's jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
b. Holding the infant does not interrupt the phototherapy process.
c. A phototherapy blanket is more effective than the overhead
lights.
d. The length of time required for phototherapy intervention is
decreased. - answer-b. Holding the infant does not interrupt the
phototherapy process.
--> Although diapers can be worn, the blanket is placed next to
the skin on the trunk of the body to expose as much skin as
possible to the light.
--> The phototherapy blanket allows the infant to be held while the
process is continued.
QUESTIONA client in her first trimester is concerned about how
weight gain will affect her appearance and questions the nurse
concerning dietary restrictions. How much weight gain should the
nurse point out will be safe for this client with a low BMI? -
answer-28 to 40 pounds
ALL COMPLETE QUESTIONS
AND CORRECT ANSWERS
UPDATE 2026
QUESTIONwhat is the most likely reason a postpartum patient
would be hemorrhaging? - answer-uterine atony (a "boggy"
fundus)
QUESTIONWhat should be assessed immediately after fundus is
massaged and nurse has called for help? - answer-Assess for
bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125
mL/hour, which can contribute to diuresis. A distended bladder
impedes uterine contraction and contributes to excessive
bleeding. After the fundus is massaged, the bladder should be
checked for distention.
QUESTIONWhen the nurse conducts a gestational age
assessment, which findings may indicate postmaturity? (Select all
that apply. One, some, or all options may be correct.)
a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
,e. Deep creases at the base of the toes extending to the heels. -
answer-c. d. and e.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is
lost prior to birth. This results in the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending
from the base
QUESTIONThe infant has a reddish papular rash across his face.
How should the nurse respond when the client asks about the
rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
d. Good question. Let me take the infant's vital signs and examine
him - answer-c. A newborn rash is very common, but it will
disappear soon.
--> The infant rash, erythema toxicum, is very common and
usually disappears by the third day of life.
,The nurse performs the first assessment upon the client's arrival
to the postpartum unit. Where would the nurse expect to palpate
the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - answer-b.
1 cm above the umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the
umbilicus
QUESTIONFifteen minutes after the initial assessment, the nurse
finds the client disoriented and lying on her back in a pool of
vaginal blood, with the sheets beneath her saturated with blood.
Which action is most important for the nurse to implement
immediately?
a. Take vital signs
b. Massage the fundus
c. Check the bladder
d. Increase the IV rate - answer-b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's
hemorrhaging, massing the fundus is the most important
intervention. The nurse should also call for assistance due to the
amount of blood that has pooled under the client.
, QUESTIONWhich factor should alert the nurse to assess for the
risk of jaundice? - answer-trauma at birth
QUESTIONwhat is a normal bilirubin range for a newborn? -
answer-5-6 mg/dL
QUESTIONWhich instructions should the nurse include in the
discharge planning regarding the infant's jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
b. Holding the infant does not interrupt the phototherapy process.
c. A phototherapy blanket is more effective than the overhead
lights.
d. The length of time required for phototherapy intervention is
decreased. - answer-b. Holding the infant does not interrupt the
phototherapy process.
--> Although diapers can be worn, the blanket is placed next to
the skin on the trunk of the body to expose as much skin as
possible to the light.
--> The phototherapy blanket allows the infant to be held while the
process is continued.
QUESTIONA client in her first trimester is concerned about how
weight gain will affect her appearance and questions the nurse
concerning dietary restrictions. How much weight gain should the
nurse point out will be safe for this client with a low BMI? -
answer-28 to 40 pounds
