MATERNITY HESI TEST BANK
ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
GRADED A+
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her
symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. -
ANSWER- D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
,These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure
is completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - ANSWER- C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that
may indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the
cervix is favorable. The fluid should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is not specific
for AROM. Option B is monitored hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be determined for all clients in labor.
,A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery.
In developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - ANSWER- B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn ⏴24 hours old. Acrocyanosis (blue
color of the hands and feet) is a common finding in newborns; it occurs because the
capillary system is immature. Milia are small white papules present on the nose and
chin that are caused by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called erythema toxicum neonatorum,
a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
, B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the
infant. - ANSWER- A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement,
and breastfeeding during mastitis facilitates the complete emptying of engorged
breasts, eliminating the pressure on the inflamed breast tissue. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C will not
relieve the engorgement on the affected side. Option D will not decrease antibiotic
effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention
of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
ACTUAL EXAM QUESTIONS AND
CORRECT ANSWERS WITH RATIONALES
GRADED A+
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her
symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. -
ANSWER- D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
,These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure
is completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - ANSWER- C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that
may indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the
cervix is favorable. The fluid should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is not specific
for AROM. Option B is monitored hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be determined for all clients in labor.
,A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery.
In developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - ANSWER- B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn ⏴24 hours old. Acrocyanosis (blue
color of the hands and feet) is a common finding in newborns; it occurs because the
capillary system is immature. Milia are small white papules present on the nose and
chin that are caused by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called erythema toxicum neonatorum,
a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
, B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the
infant. - ANSWER- A.Breastfeed the infant, ensuring that both breasts are completely
emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement,
and breastfeeding during mastitis facilitates the complete emptying of engorged
breasts, eliminating the pressure on the inflamed breast tissue. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C will not
relieve the engorgement on the affected side. Option D will not decrease antibiotic
effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day
tells the nurse that her feet have begun to swell. Which instruction will aid in the prevention
of pooling of blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
