NURS 321 HESI MATERNITY MATERNAL-CHILD NURSING] QUESTIONS AND CORRECT ANSWERS (VERIFIED
ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1-100
1. A nurse is assessing a client at 38 weeks gestation who reports a sudden gush of fluid from her vagina.
Which of the following findings is most important for the nurse to report to the healthcare provider
immediately?
A. Fetal heart rate of 155 beats per minute.
B. Maternal temperature of 100.8°F (38.2°C).
C. Clear, odorless fluid on the perineal pad.
D. Patient reports mild, irregular contractions.
🟢 B. Maternal temperature of 100.8°F (38.2°C).
🔴 RATIONALE: An elevated maternal temperature following rupture of membranes is a primary indicator of
chorioamnionitis, an intra-amniotic infection that poses significant risks to both mother and fetus. This requires
immediate reporting to initiate antibiotic therapy. The other findings are within normal limits or expected.
2. A postpartum client who is Rh-negative and has an Rh-positive infant is to receive Rho(D) immune
globulin. The nurse understands that the purpose of this medication is to:
A. Prevent the mother from forming antibodies against fetal Rh-positive blood cells.
B. Treat the infant for Rh incompatibility after birth.
C. Destroy the fetal Rh-positive red blood cells in the mother's circulation.
D. Promote the production of natural anti-Rh antibodies in the mother.
🟢 A. Prevent the mother from forming antibodies against fetal Rh-positive blood cells.
🔴 RATIONALE: Rho(D) immune globulin works by passively providing antibodies that bind to and destroy any
fetal Rh-positive RBCs that have entered the maternal circulation before the mother's own immune system can
,mount an active response and produce permanent anti-Rh antibodies. It is a prophylactic measure, not a
treatment for the infant.
3. A nurse is caring for a client in the active phase of labor. The electronic fetal monitor shows a recurrent
late decelerations. Which of the following is the nurse's priority action?
A. Increase the rate of the IV infusion.
B. Position the client on her left side.
C. Prepare for an emergency cesarean birth.
D. Administer oxygen at 2 L/min via nasal cannula.
🟢 B. Position the client on her left side.
🔴 RATIONALE: Late decelerations indicate uteroplacental insufficiency. The priority nursing action is to
improve placental perfusion. Positioning the client on her left side maximizes blood flow to the uterus and
placenta. This is the initial, immediate intervention before further steps like oxygen, IV fluids, or preparing for a
cesarean.
4. A newborn has an Apgar score of 8 at 1 minute of age. Which of the following findings would be most
consistent with this score?
A. The infant is pale with a slow heart rate of 80 bpm.
B. The infant has acrocyanosis, a heart rate of 130 bpm, and a strong cry.
C. The infant is flaccid and has no respiratory effort.
D. The infant has a weak cry and some flexion of extremities.
🟢 B. The infant has acrocyanosis, a heart rate of 130 bpm, and a strong cry.
🔴 RATIONALE: An Apgar score of 8 indicates the infant is in good condition, with only minor deviations from
normal. A heart rate over 100 bpm (score 2), a strong cry (score 2), and acrocyanosis (blue extremities, score 1
for color) would result in a score of approximately 8. The other options describe more severe depression.
,5. A nurse is providing teaching to a client who is 12 weeks pregnant about the signs of potential
complications. Which of the following symptoms should the nurse instruct the client to report to the
provider?
A. Breast tenderness.
B. Nasal stuffiness.
C. Visual disturbances.
D. Frequent urination.
🟢 C. Visual disturbances.
🔴 RATIONALE: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia and
should be reported immediately. Breast tenderness, nasal stuffiness, and frequent urination are common
discomforts of pregnancy and are not typically concerning.
6. A client at 35 weeks gestation is diagnosed with gestational hypertension. The nurse is monitoring her for
the development of preeclampsia. Which laboratory finding is most indicative of severe preeclampsia?
A. Blood urea nitrogen (BUN) 12 mg/dL.
B. Platelet count of 80,000/mm³.
C. Serum creatinine 0.8 mg/dL.
D. Hematocrit 35%.
🟢 B. Platelet count of 80,000/mm³.
🔴 RATIONALE: A platelet count below 100,000/mm³ is a key diagnostic criterion for severe preeclampsia,
indicating disseminated intravascular coagulation and HELLP syndrome. The other values are within normal
ranges for pregnancy.
7. A nurse is assessing a 24-hour-old newborn. Which of the following findings should the nurse report to
the healthcare provider?
A. A yellow tint to the sclera of the eyes.
, B. A soft, flat anterior fontanel.
C. A weight loss of 5% of birth weight.
D. A reddish-brown stain on the diaper.
🟢 A. A yellow tint to the sclera of the eyes.
🔴 RATIONALE: A yellow tint to the sclera (icterus) appearing within the first 24 hours is pathologic jaundice
and is always concerning. It can indicate hemolytic disease of the newborn (Rh/ABO incompatibility) or other
serious conditions, requiring immediate evaluation. Physiologic jaundice typically appears after 24 hours of life.
8. A client with a history of substance use disorder is in the active phase of labor. The nurse should anticipate
which of the following findings in the newborn?
A. Hyperactivity and a high-pitched cry.
B. Lethargy and poor feeding.
C. Hypothermia and bradycardia.
D. Respiratory depression and flaccidity.
🟢 A. Hyperactivity and a high-pitched cry.
🔴 RATIONALE: Infants born to mothers with opioid or other substance use disorders are at high risk for
neonatal abstinence syndrome (NAS), which presents with central nervous system hyperirritability, including a
high-pitched cry, tremors, and hyperactivity. Lethargy and respiratory depression are more consistent with
maternal anesthesia or the depressant effects of substances used in labor.
9. A nurse is preparing to administer vitamin K to a newborn. The nurse explains to the parents that the
purpose of this injection is to:
A. Prevent the development of iron deficiency anemia.
B. Prevent hemorrhagic disease of the newborn.
C. Help the baby's lungs mature and function properly.
D. Provide essential antibodies for immune protection.
ANSWERS) PLUS RATIONALES 2026 Q&A |LATEST EXAM UPDATE 2026/2027
SECTION ONE: QUESTIONS 1-100
1. A nurse is assessing a client at 38 weeks gestation who reports a sudden gush of fluid from her vagina.
Which of the following findings is most important for the nurse to report to the healthcare provider
immediately?
A. Fetal heart rate of 155 beats per minute.
B. Maternal temperature of 100.8°F (38.2°C).
C. Clear, odorless fluid on the perineal pad.
D. Patient reports mild, irregular contractions.
🟢 B. Maternal temperature of 100.8°F (38.2°C).
🔴 RATIONALE: An elevated maternal temperature following rupture of membranes is a primary indicator of
chorioamnionitis, an intra-amniotic infection that poses significant risks to both mother and fetus. This requires
immediate reporting to initiate antibiotic therapy. The other findings are within normal limits or expected.
2. A postpartum client who is Rh-negative and has an Rh-positive infant is to receive Rho(D) immune
globulin. The nurse understands that the purpose of this medication is to:
A. Prevent the mother from forming antibodies against fetal Rh-positive blood cells.
B. Treat the infant for Rh incompatibility after birth.
C. Destroy the fetal Rh-positive red blood cells in the mother's circulation.
D. Promote the production of natural anti-Rh antibodies in the mother.
🟢 A. Prevent the mother from forming antibodies against fetal Rh-positive blood cells.
🔴 RATIONALE: Rho(D) immune globulin works by passively providing antibodies that bind to and destroy any
fetal Rh-positive RBCs that have entered the maternal circulation before the mother's own immune system can
,mount an active response and produce permanent anti-Rh antibodies. It is a prophylactic measure, not a
treatment for the infant.
3. A nurse is caring for a client in the active phase of labor. The electronic fetal monitor shows a recurrent
late decelerations. Which of the following is the nurse's priority action?
A. Increase the rate of the IV infusion.
B. Position the client on her left side.
C. Prepare for an emergency cesarean birth.
D. Administer oxygen at 2 L/min via nasal cannula.
🟢 B. Position the client on her left side.
🔴 RATIONALE: Late decelerations indicate uteroplacental insufficiency. The priority nursing action is to
improve placental perfusion. Positioning the client on her left side maximizes blood flow to the uterus and
placenta. This is the initial, immediate intervention before further steps like oxygen, IV fluids, or preparing for a
cesarean.
4. A newborn has an Apgar score of 8 at 1 minute of age. Which of the following findings would be most
consistent with this score?
A. The infant is pale with a slow heart rate of 80 bpm.
B. The infant has acrocyanosis, a heart rate of 130 bpm, and a strong cry.
C. The infant is flaccid and has no respiratory effort.
D. The infant has a weak cry and some flexion of extremities.
🟢 B. The infant has acrocyanosis, a heart rate of 130 bpm, and a strong cry.
🔴 RATIONALE: An Apgar score of 8 indicates the infant is in good condition, with only minor deviations from
normal. A heart rate over 100 bpm (score 2), a strong cry (score 2), and acrocyanosis (blue extremities, score 1
for color) would result in a score of approximately 8. The other options describe more severe depression.
,5. A nurse is providing teaching to a client who is 12 weeks pregnant about the signs of potential
complications. Which of the following symptoms should the nurse instruct the client to report to the
provider?
A. Breast tenderness.
B. Nasal stuffiness.
C. Visual disturbances.
D. Frequent urination.
🟢 C. Visual disturbances.
🔴 RATIONALE: Visual disturbances, such as blurred vision or seeing spots, can be a sign of preeclampsia and
should be reported immediately. Breast tenderness, nasal stuffiness, and frequent urination are common
discomforts of pregnancy and are not typically concerning.
6. A client at 35 weeks gestation is diagnosed with gestational hypertension. The nurse is monitoring her for
the development of preeclampsia. Which laboratory finding is most indicative of severe preeclampsia?
A. Blood urea nitrogen (BUN) 12 mg/dL.
B. Platelet count of 80,000/mm³.
C. Serum creatinine 0.8 mg/dL.
D. Hematocrit 35%.
🟢 B. Platelet count of 80,000/mm³.
🔴 RATIONALE: A platelet count below 100,000/mm³ is a key diagnostic criterion for severe preeclampsia,
indicating disseminated intravascular coagulation and HELLP syndrome. The other values are within normal
ranges for pregnancy.
7. A nurse is assessing a 24-hour-old newborn. Which of the following findings should the nurse report to
the healthcare provider?
A. A yellow tint to the sclera of the eyes.
, B. A soft, flat anterior fontanel.
C. A weight loss of 5% of birth weight.
D. A reddish-brown stain on the diaper.
🟢 A. A yellow tint to the sclera of the eyes.
🔴 RATIONALE: A yellow tint to the sclera (icterus) appearing within the first 24 hours is pathologic jaundice
and is always concerning. It can indicate hemolytic disease of the newborn (Rh/ABO incompatibility) or other
serious conditions, requiring immediate evaluation. Physiologic jaundice typically appears after 24 hours of life.
8. A client with a history of substance use disorder is in the active phase of labor. The nurse should anticipate
which of the following findings in the newborn?
A. Hyperactivity and a high-pitched cry.
B. Lethargy and poor feeding.
C. Hypothermia and bradycardia.
D. Respiratory depression and flaccidity.
🟢 A. Hyperactivity and a high-pitched cry.
🔴 RATIONALE: Infants born to mothers with opioid or other substance use disorders are at high risk for
neonatal abstinence syndrome (NAS), which presents with central nervous system hyperirritability, including a
high-pitched cry, tremors, and hyperactivity. Lethargy and respiratory depression are more consistent with
maternal anesthesia or the depressant effects of substances used in labor.
9. A nurse is preparing to administer vitamin K to a newborn. The nurse explains to the parents that the
purpose of this injection is to:
A. Prevent the development of iron deficiency anemia.
B. Prevent hemorrhagic disease of the newborn.
C. Help the baby's lungs mature and function properly.
D. Provide essential antibodies for immune protection.
