MATERNITY HESI COMPREHENSIVE ANSWERS AND
QUESTIONS SET A+
✔✔The nurse is caring for a woman with a previously diagnosed heart disease who is in
the second stage of labor. Which assessment findings are of greatest concern?
a. edema, basilar rales, and an irregular pulse
b. Increased urinary output, and tachycardia
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate, and hypertension - ✔✔a. Edema, basilar rales, and an irregular
pulse
Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and
require immediate intervention.
✔✔The nurse is teaching a woman how to use her basal body temperature (BBT)
pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates
the occurrence of ovulation, and therefor, the best time for intercourse to ensure
conception?
a. Between the time the temperature falls and rises
b. Between 36 and 48 hours after the temperature rises
c. When the temperature falls and remains low for 36 hours
d. Within 72 hours before the temperature falls - ✔✔a. Between the time the
temperature falls and rises
In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to
72 hours after ovulation, when the corpus luteum of the ruptured ovary produces
progesterone. Therefore, intercourse between the time of the temperature fall and rise
(A) is the best time for conception.
✔✔A client who is in the second trimester of pregnancy tells the nurse that she wants to
use herbal therapy. Which response is best for the nurse to provide?
a. Herbs are a corner stone of good health to include in your treatment
b. Touch is also therapeutic in relieving discomfort and anxiety
c. Your healthcare provider should direct treatment options for herbal therapy
,d. It is important that you want to take part in your care - ✔✔d. It is important that you
want to take part in your care
The emphasis of alternative and complementary therapies, such as herbal therapy, is
that the client is viewed as a whole being, capable of decision-making and an integral
part of the health care team, so (D) recognizes the client's request.
✔✔A mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective to prevent nipple soreness?
a. Wear a cotton bra
b. Increase nursing time gradually
c. Correctly place the infant on the breast
d. Manually express a small amount of milk before nursing - ✔✔c. Correctly place the
infant on the breast
The most common cause of nipple soreness is incorrect positioning (C) of the infant on
the breast, e.g., grasping too little of the areola or grasping on the nipple.
✔✔The nurse is counseling a woman who wants to become pregnant. The woman tells
the nurse that she has a 36-day menstrual cycle and the first day of her menstrual
period was January *. The nurse correctly calculates that the woman's next fertile period
is
a. January 14-15
b. January 22-23
c. January 30-31
d. February 6-7 - ✔✔c. January 30-31
This woman can expect her next period to begin 36 days from the first day of her last
menstrual period - the cycle begins at the first day of the cycle and continues to the first
day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation
occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this
woman would occur January 31 (C).
✔✔The nurse should encourage the laboring client to begin pushing when
a. there is only an anterior or posterior lip of cervix left
b. the client describes the need to have a bowel movement
c. the cervix is completely dilated
d. the cervix is completely effaced - ✔✔c. the cervix is completely dilated
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated (A, B, and D), the cervix can become edematous and may never completely
dilate, necessitating an operative delivery. Many primigravidas begin active labor 100%
effaced and then proceed to dilate.
,✔✔One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased
from small to large and her fundus is boggy despite massage. The client's pulse is 84
beats/minute and blood pressure is 156/96. The healthcare provider prescribes
Methergine 0.2 mg IM x 1. What action should the nurse take immediately?
a. Give the medication as prescribed and monitor for efficacy
b. Encourage the client to breastfeed rather than bottle feed
c. Have the client empty her bladder and massage the fundus
d. Call the healthcare provider to question the prescription - ✔✔d. Call the healthcare
provider to question the prescription
Methergine is contraindicated for clients with elevated blood pressure, so the nurse
should contact the healthcare provider and question the prescription (D).
✔✔A newborn, whose mother is HIV positive, is scheduled for follow-up assessments.
The nurse knows that the most likely presenting symptom for a pediatric client with
AIDS is:
a. shortness of breath
b. joint pain
c. a persistent cold
d. organomegaly - ✔✔c. a persistent cold
Respiratory tract infections commonly occur in the pediatric population. However, the
child iwth AIDS has a decreased ability to defend the body against these infections and
often the presenting symptom of a child with AIDS is a persistent cold (C).
✔✔A healthcare provider informs the charge nurse of a labor and delivery unit that a
client is coming to the unit with suspected abruptio placentae. What findings should the
charge nurse expect the client to demonstrate? (Select all that apply)
a. Dark, red vaginal bleeding
b. Lower back pain
c. Premature rupture of membranes
d. Increased uterine irritability
e. Bilateral pitting edema
f. A rigid abdomen - ✔✔a. Dark, red vaginal bleeding
d. Increased uterine irritability
f. A rigid abdomen
The symptoms of abruptio placentae include dark red vaginal bleeding (A), increased
uterine irritability (D), and a rigid abdomen (F).
✔✔The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP
110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse implement?
a. Insert an internal fetal monitor
, b. Assess for cervical changes q1h
c. Monitor bleeding from IV sites
d. Perform Leopold's maneuvers - ✔✔c. Monitor bleeding from IV sites
Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is
presenting with signs of placental abruption. Disseminated intravascular coagulation
(DIC) is a complication of placental abruption, characterized by abnormal bleeding.
✔✔A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge?
a. Supplementary iron is more efficiently utilized during pregnancy
b. It it difficult to consume 18 mg of additional iron by diet alone
c. Iron absorption is decreased in the GI tract during pregnancy
d. Iron is needed to prevent megaloblastic anemia in the last trimester - ✔✔b. It is
difficult to consume 18 mg of additional iron by diet alone
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and
to meet the demands of pregnancy is difficult (B) so iron supplements are often
recommended.
✔✔A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin)
to augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions?
a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
a. Early labor with contractions every 5 minutes, lasting 40 seconds each
c. Active labor with contractions every 31 minutes, lasting 60 seconds each
d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each -
✔✔a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
Contractions pattern (A) describes hyperstimulation and an inadequate resting time
between contractions to allow for placental perfusion. The oxytocin infusion should be
discontinued.
✔✔Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
a. She eagerly reaches for the infant, undresses the infants, and examines the infant
completely
b. Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips
c. Her arms and hands receive the infant and she then cuddles the infant to her own
body
d. She eagerly reaches for the infant and then holds the infant close to her own body -
✔✔b. Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips
QUESTIONS SET A+
✔✔The nurse is caring for a woman with a previously diagnosed heart disease who is in
the second stage of labor. Which assessment findings are of greatest concern?
a. edema, basilar rales, and an irregular pulse
b. Increased urinary output, and tachycardia
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate, and hypertension - ✔✔a. Edema, basilar rales, and an irregular
pulse
Edema, basilar rales, and an irregular pulse (A) indicate cardiac decompensation and
require immediate intervention.
✔✔The nurse is teaching a woman how to use her basal body temperature (BBT)
pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates
the occurrence of ovulation, and therefor, the best time for intercourse to ensure
conception?
a. Between the time the temperature falls and rises
b. Between 36 and 48 hours after the temperature rises
c. When the temperature falls and remains low for 36 hours
d. Within 72 hours before the temperature falls - ✔✔a. Between the time the
temperature falls and rises
In most women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to
72 hours after ovulation, when the corpus luteum of the ruptured ovary produces
progesterone. Therefore, intercourse between the time of the temperature fall and rise
(A) is the best time for conception.
✔✔A client who is in the second trimester of pregnancy tells the nurse that she wants to
use herbal therapy. Which response is best for the nurse to provide?
a. Herbs are a corner stone of good health to include in your treatment
b. Touch is also therapeutic in relieving discomfort and anxiety
c. Your healthcare provider should direct treatment options for herbal therapy
,d. It is important that you want to take part in your care - ✔✔d. It is important that you
want to take part in your care
The emphasis of alternative and complementary therapies, such as herbal therapy, is
that the client is viewed as a whole being, capable of decision-making and an integral
part of the health care team, so (D) recognizes the client's request.
✔✔A mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective to prevent nipple soreness?
a. Wear a cotton bra
b. Increase nursing time gradually
c. Correctly place the infant on the breast
d. Manually express a small amount of milk before nursing - ✔✔c. Correctly place the
infant on the breast
The most common cause of nipple soreness is incorrect positioning (C) of the infant on
the breast, e.g., grasping too little of the areola or grasping on the nipple.
✔✔The nurse is counseling a woman who wants to become pregnant. The woman tells
the nurse that she has a 36-day menstrual cycle and the first day of her menstrual
period was January *. The nurse correctly calculates that the woman's next fertile period
is
a. January 14-15
b. January 22-23
c. January 30-31
d. February 6-7 - ✔✔c. January 30-31
This woman can expect her next period to begin 36 days from the first day of her last
menstrual period - the cycle begins at the first day of the cycle and continues to the first
day of the next cycle. Her next period would, therefore, begin on February 13. Ovulation
occurs 14 days before the first day of the menstrual period. Therefore, ovulation for this
woman would occur January 31 (C).
✔✔The nurse should encourage the laboring client to begin pushing when
a. there is only an anterior or posterior lip of cervix left
b. the client describes the need to have a bowel movement
c. the cervix is completely dilated
d. the cervix is completely effaced - ✔✔c. the cervix is completely dilated
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated (A, B, and D), the cervix can become edematous and may never completely
dilate, necessitating an operative delivery. Many primigravidas begin active labor 100%
effaced and then proceed to dilate.
,✔✔One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased
from small to large and her fundus is boggy despite massage. The client's pulse is 84
beats/minute and blood pressure is 156/96. The healthcare provider prescribes
Methergine 0.2 mg IM x 1. What action should the nurse take immediately?
a. Give the medication as prescribed and monitor for efficacy
b. Encourage the client to breastfeed rather than bottle feed
c. Have the client empty her bladder and massage the fundus
d. Call the healthcare provider to question the prescription - ✔✔d. Call the healthcare
provider to question the prescription
Methergine is contraindicated for clients with elevated blood pressure, so the nurse
should contact the healthcare provider and question the prescription (D).
✔✔A newborn, whose mother is HIV positive, is scheduled for follow-up assessments.
The nurse knows that the most likely presenting symptom for a pediatric client with
AIDS is:
a. shortness of breath
b. joint pain
c. a persistent cold
d. organomegaly - ✔✔c. a persistent cold
Respiratory tract infections commonly occur in the pediatric population. However, the
child iwth AIDS has a decreased ability to defend the body against these infections and
often the presenting symptom of a child with AIDS is a persistent cold (C).
✔✔A healthcare provider informs the charge nurse of a labor and delivery unit that a
client is coming to the unit with suspected abruptio placentae. What findings should the
charge nurse expect the client to demonstrate? (Select all that apply)
a. Dark, red vaginal bleeding
b. Lower back pain
c. Premature rupture of membranes
d. Increased uterine irritability
e. Bilateral pitting edema
f. A rigid abdomen - ✔✔a. Dark, red vaginal bleeding
d. Increased uterine irritability
f. A rigid abdomen
The symptoms of abruptio placentae include dark red vaginal bleeding (A), increased
uterine irritability (D), and a rigid abdomen (F).
✔✔The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP
110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse implement?
a. Insert an internal fetal monitor
, b. Assess for cervical changes q1h
c. Monitor bleeding from IV sites
d. Perform Leopold's maneuvers - ✔✔c. Monitor bleeding from IV sites
Monitoring bleeding from peripheral sites (C) is the priority intervention. This client is
presenting with signs of placental abruption. Disseminated intravascular coagulation
(DIC) is a complication of placental abruption, characterized by abnormal bleeding.
✔✔A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge?
a. Supplementary iron is more efficiently utilized during pregnancy
b. It it difficult to consume 18 mg of additional iron by diet alone
c. Iron absorption is decreased in the GI tract during pregnancy
d. Iron is needed to prevent megaloblastic anemia in the last trimester - ✔✔b. It is
difficult to consume 18 mg of additional iron by diet alone
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and
to meet the demands of pregnancy is difficult (B) so iron supplements are often
recommended.
✔✔A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin)
to augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions?
a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
a. Early labor with contractions every 5 minutes, lasting 40 seconds each
c. Active labor with contractions every 31 minutes, lasting 60 seconds each
d. Active labor with contractions every 2 to 3 minutes, lasting 70 to 80 seconds each -
✔✔a. Transition labor with contractions every 2 minutes, lasting 90 seconds each
Contractions pattern (A) describes hyperstimulation and an inadequate resting time
between contractions to allow for placental perfusion. The oxytocin infusion should be
discontinued.
✔✔Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
a. She eagerly reaches for the infant, undresses the infants, and examines the infant
completely
b. Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips
c. Her arms and hands receive the infant and she then cuddles the infant to her own
body
d. She eagerly reaches for the infant and then holds the infant close to her own body -
✔✔b. Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips
