MATERNITY HESI CORRECT EXAMS ANSWERS AND
QUESTIONS SET A+
✔✔Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk."
C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - ✔✔A."Breastfeeding my infant consistently every 3
to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method. Option B is incorrect because alcohol
can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk.
Taking a warm shower will stimulate the production of milk, which will be more painful
after breastfeedings.
✔✔A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. She sure has a funny-looking head." Which response by the nurse is
best?
A."This is not an unusually shaped head, especially for a first baby."
B."It may look odd, but newborn babies are often born with heads like that."
,C."That is normal. The head will return to a round shape within 7 to 10 days."
D."Your pelvis was too small, so the head had to adjust to the birth canal." - ✔✔C."That
is normal. The head will return to a round shape within 7 to 10 days."
Rationale: Option C reassures the mother that this is normal in the newborn and
provides correct information regarding the return to a normal shape. Although option A
is correct, it implies that the client should not worry. Any implied or spoken "don't worry"
is usually the wrong answer. Option B is condescending and dismissing; the mother is
seeking reassurance and information. Option D is a negative statement and implies that
molding is the mother's fault.
✔✔Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the
nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - ✔✔C.Place the client in a lateral position.
Rationale: The nurse should immediately turn the client to a lateral position or place a
pillow or wedge under one hip to deflect the uterus. Other immediate interventions
include increasing the rate of the main line IV infusion and administering oxygen by
facemask. If the blood pressure remains low after these interventions or decreases
further, the anesthesiologist or health care provider should be notified immediately. To
continue to monitor blood pressure without taking further action could constitute
malpractice. Option D may also be warranted, but such action is based on hospital
protocol.
✔✔The nurse is teaching a new mother about diet and breastfeeding. Which instruction
is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - ✔✔A.Avoid alcohol because it is
excreted in breast milk.
,Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and cognitive
impairment for the infant. Options B, C, and D should also be included in diet teaching
for a breastfeeding mother; however, because these do not involve safety of the infant,
they do not have the same degree of importance as option A.
✔✔A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright red.
The bleeding has subsided. She further states that she is not experiencing any uterine
contractions or abdominal pain. What instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection
(UTI). - ✔✔A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright
red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by
intense uterine pain indicates abruptio placenta, which is life threatening to the mother
and fetus. If those symptoms were described, option B would be appropriate. Option C
does not address the cause of the symptoms. The client is not describing symptoms of
a UTI.
✔✔A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.
Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration.
The fetal heart rate increases with each contraction and returns to baseline after the
contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion. - ✔✔B.Determine cervical dilation
and effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur
every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal
stress. FHR accelerations are a normal response to contractions, so the oxytocin
, (Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal
examination places the client at risk for infection and should be performed when the
client exhibits signs of progressing labor, which is not indicated at this time.
✔✔A client who delivered by cesarean section 24 hours ago is using a patient-
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips
only since surgery. She is now complaining of nausea and bloating and states that
because she has had nothing to eat, she is too weak to breastfeed her infant. Which
nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
D.Fatigue related to cesarean delivery and physical care demands of infant -
✔✔C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and
immobility is the priority nursing diagnosis and addresses the potential problem of a
paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is
not as important as impaired motility.
✔✔The nurse is counseling a client who wants to become pregnant. She tells the nurse
that she has a 36-day menstrual cycle and the first day of her last menstrual period was
January 8. When will the client's next fertile period occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7 - ✔✔C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first day of
her last menstrual period. Her next period would begin on February 12. Ovulation
occurs 14 days before the first day of the menstrual period. The client can expect
ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
✔✔In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close. Which
statement is accurate regarding the timing of closure of an infant's fontanels that should
be included in this teaching plan?
QUESTIONS SET A+
✔✔Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk."
C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - ✔✔A."Breastfeeding my infant consistently every 3
to 4 hours stops ovulation and my period."
Rationale: Continuous breastfeeding on a 3- to 4-hour schedule during the day will
cause a release of prolactin, which will suppress ovulation and menses, but is not
completely effective as a birth control method. Option B is incorrect because alcohol
can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk.
Taking a warm shower will stimulate the production of milk, which will be more painful
after breastfeedings.
✔✔A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. She sure has a funny-looking head." Which response by the nurse is
best?
A."This is not an unusually shaped head, especially for a first baby."
B."It may look odd, but newborn babies are often born with heads like that."
,C."That is normal. The head will return to a round shape within 7 to 10 days."
D."Your pelvis was too small, so the head had to adjust to the birth canal." - ✔✔C."That
is normal. The head will return to a round shape within 7 to 10 days."
Rationale: Option C reassures the mother that this is normal in the newborn and
provides correct information regarding the return to a normal shape. Although option A
is correct, it implies that the client should not worry. Any implied or spoken "don't worry"
is usually the wrong answer. Option B is condescending and dismissing; the mother is
seeking reassurance and information. Option D is a negative statement and implies that
molding is the mother's fault.
✔✔Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should the
nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - ✔✔C.Place the client in a lateral position.
Rationale: The nurse should immediately turn the client to a lateral position or place a
pillow or wedge under one hip to deflect the uterus. Other immediate interventions
include increasing the rate of the main line IV infusion and administering oxygen by
facemask. If the blood pressure remains low after these interventions or decreases
further, the anesthesiologist or health care provider should be notified immediately. To
continue to monitor blood pressure without taking further action could constitute
malpractice. Option D may also be warranted, but such action is based on hospital
protocol.
✔✔The nurse is teaching a new mother about diet and breastfeeding. Which instruction
is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - ✔✔A.Avoid alcohol because it is
excreted in breast milk.
,Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and cognitive
impairment for the infant. Options B, C, and D should also be included in diet teaching
for a breastfeeding mother; however, because these do not involve safety of the infant,
they do not have the same degree of importance as option A.
✔✔A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright red.
The bleeding has subsided. She further states that she is not experiencing any uterine
contractions or abdominal pain. What instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract infection
(UTI). - ✔✔A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa. Bright
red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incident life threatening or cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound. Bleeding that has a sudden onset and is accompanied by
intense uterine pain indicates abruptio placenta, which is life threatening to the mother
and fetus. If those symptoms were described, option B would be appropriate. Option C
does not address the cause of the symptoms. The client is not describing symptoms of
a UTI.
✔✔A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.
Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration.
The fetal heart rate increases with each contraction and returns to baseline after the
contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion. - ✔✔B.Determine cervical dilation
and effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur
every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal
stress. FHR accelerations are a normal response to contractions, so the oxytocin
, (Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal
examination places the client at risk for infection and should be performed when the
client exhibits signs of progressing labor, which is not indicated at this time.
✔✔A client who delivered by cesarean section 24 hours ago is using a patient-
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips
only since surgery. She is now complaining of nausea and bloating and states that
because she has had nothing to eat, she is too weak to breastfeed her infant. Which
nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
D.Fatigue related to cesarean delivery and physical care demands of infant -
✔✔C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and
immobility is the priority nursing diagnosis and addresses the potential problem of a
paralytic ileus. Options A and B are both caused by impaired bowel motility. Option D is
not as important as impaired motility.
✔✔The nurse is counseling a client who wants to become pregnant. She tells the nurse
that she has a 36-day menstrual cycle and the first day of her last menstrual period was
January 8. When will the client's next fertile period occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7 - ✔✔C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first day of
her last menstrual period. Her next period would begin on February 12. Ovulation
occurs 14 days before the first day of the menstrual period. The client can expect
ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
✔✔In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close. Which
statement is accurate regarding the timing of closure of an infant's fontanels that should
be included in this teaching plan?
