HESI OB MATERNITY ANSWERS AND QUESTIONS
SET A+
✔✔The nurse identifies crepitus when examining the chest of a newborn who was
delivered vaginally. Which further assessment should the nurse perform?
A. Elicit a positive scarf sign on the affected side
B. Observe for an asymmetrical Moro (startle) reflex
C. Watch for swelling of fingers on the affected side
D. Note paralysis of affected extremity and muscles - ✔✔B. Observe for an
asymmetrical Moro (startle) reflex
The most common neonatal birth trauma due to a vaginal delivery is fracture of the
clavicle. Although an infant may be asymptomatic, a fractured clavicle should be
suspected if an infant has limited use of the affected arm, malposition of the arm, an
asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries
when the arm is moved.
✔✔A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks
gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine).
Which assessment is the highest priority for the nurse to monitor during the
administration of this drug?
A. Materna blood pressure and respirations
B. Maternal and fetal heart rates
C. Hourly urinary output
D. Deep tendon relfexes - ✔✔B. Maternal and fetal heart rates
Monitoring maternal and fetal heart rates is most important when terbutaline is being
administered. Terbutaline acts as a sympathomimetic agent that stimulates both beta 1
receptors (causing tachycardia, a side effect of the drug) and stimulation of beta 2
receptors (causing uterine relaxation, a desired effect of the drug).
✔✔A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks
gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg
,subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
A. Drowsiness and bradycardia
B. Depressed reflexes and increased respirations
C. Tachycardia and a feeling of nervousness
D. A flushed, warm feeling and a dry mouth - ✔✔C. Tachycardia and a feeling of
nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
✔✔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 with 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.
✔✔A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when
she could use a home pregnancy test to diagnose pregnancy. Which response
appropriate?
A. "A home pregnancy test can be used right after your missed period."
B. "These tests are most accurate after you have missed your second period."
C. "Home pregnancy tests often give false positives and should not be trusted."
D. "The test can provide accurate information when used right after ovulation." - ✔✔A.
"A home pregnancy test can be used right after your missed period."
Home urine tests are based on the chemical detection of human chorionic
gonadotrophin, which begins to increase 6 to 8 days after conception, and is best
detected at 2 weeks gestation or immediately after the first missed period.
✔✔The nurse observes a new mother is rooming-in and caring for her newborn infant.
Which observation indicates the need for further teaching?
A. Cuddles the baby close to her
B. Rocks and soothes the infant in her arms
C. Places the infant prone in the bassinet
, D. Wraps the baby in a warm blanket after bathing - ✔✔C. Places the infant prone in the
bassinet
The mother should be instructed to avoid placing the infant prone which is associated
with an increased incidence of sudden infant death syndrome (SIDS).
✔✔The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule
for a client whose last menstrual period started on December 1. Which date is most
accurate?
A. August 1
B. August 10
C. September 3
D. September 8 - ✔✔D. September 8
✔✔A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation will the nurse provide?
A. "Weigh the baby daily, and if she is gaining weight, she is eating enough."
B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a
day."
C. "Offer the baby extra bottle milk after her feeding, and see if she is still hungry."
D. "If you're concerned, you might consider bottle feeding so that you can monitor her
intake." - ✔✔B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to
10 times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is
adequately hydrated.
✔✔A client with gestational hypertenstion is in active labor and receiving an infusion of
magnesium sulfate. Which drug should the nurse have available for signs of potential
toxicity?
A. Oxytocin (Pitocin)
B. Calcium gluconate
C. Terbutaline (Brethine)
D. Naloxone (Narcan) - ✔✔B. Calcium gluconate
✔✔Which nursing intervention would be most helpful in relieving postpartum uterine
contractions or "afterpains?"
A. Lying prone with a pillow on the abdomen
B. Using a breast pump
C. Massaging the abdomen
D. Giving oxytocic medications - ✔✔A. Lying prone with a pillow on the abdomen
SET A+
✔✔The nurse identifies crepitus when examining the chest of a newborn who was
delivered vaginally. Which further assessment should the nurse perform?
A. Elicit a positive scarf sign on the affected side
B. Observe for an asymmetrical Moro (startle) reflex
C. Watch for swelling of fingers on the affected side
D. Note paralysis of affected extremity and muscles - ✔✔B. Observe for an
asymmetrical Moro (startle) reflex
The most common neonatal birth trauma due to a vaginal delivery is fracture of the
clavicle. Although an infant may be asymptomatic, a fractured clavicle should be
suspected if an infant has limited use of the affected arm, malposition of the arm, an
asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries
when the arm is moved.
✔✔A 30-year-old gravida 2, para 1 client is admitted to the hospital at 26-weeks
gestation in preterm labor. She is started on an IV solution of terbutaline (Brethine).
Which assessment is the highest priority for the nurse to monitor during the
administration of this drug?
A. Materna blood pressure and respirations
B. Maternal and fetal heart rates
C. Hourly urinary output
D. Deep tendon relfexes - ✔✔B. Maternal and fetal heart rates
Monitoring maternal and fetal heart rates is most important when terbutaline is being
administered. Terbutaline acts as a sympathomimetic agent that stimulates both beta 1
receptors (causing tachycardia, a side effect of the drug) and stimulation of beta 2
receptors (causing uterine relaxation, a desired effect of the drug).
✔✔A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks
gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg
,subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
A. Drowsiness and bradycardia
B. Depressed reflexes and increased respirations
C. Tachycardia and a feeling of nervousness
D. A flushed, warm feeling and a dry mouth - ✔✔C. Tachycardia and a feeling of
nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
✔✔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 with 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.
✔✔A woman who thinks she could be pregnant calls her neighbor, a nurse, to ask when
she could use a home pregnancy test to diagnose pregnancy. Which response
appropriate?
A. "A home pregnancy test can be used right after your missed period."
B. "These tests are most accurate after you have missed your second period."
C. "Home pregnancy tests often give false positives and should not be trusted."
D. "The test can provide accurate information when used right after ovulation." - ✔✔A.
"A home pregnancy test can be used right after your missed period."
Home urine tests are based on the chemical detection of human chorionic
gonadotrophin, which begins to increase 6 to 8 days after conception, and is best
detected at 2 weeks gestation or immediately after the first missed period.
✔✔The nurse observes a new mother is rooming-in and caring for her newborn infant.
Which observation indicates the need for further teaching?
A. Cuddles the baby close to her
B. Rocks and soothes the infant in her arms
C. Places the infant prone in the bassinet
, D. Wraps the baby in a warm blanket after bathing - ✔✔C. Places the infant prone in the
bassinet
The mother should be instructed to avoid placing the infant prone which is associated
with an increased incidence of sudden infant death syndrome (SIDS).
✔✔The nurse is calculating the estimated date of confinement (EDC) using Ngele's rule
for a client whose last menstrual period started on December 1. Which date is most
accurate?
A. August 1
B. August 10
C. September 3
D. September 8 - ✔✔D. September 8
✔✔A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation will the nurse provide?
A. "Weigh the baby daily, and if she is gaining weight, she is eating enough."
B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a
day."
C. "Offer the baby extra bottle milk after her feeding, and see if she is still hungry."
D. "If you're concerned, you might consider bottle feeding so that you can monitor her
intake." - ✔✔B. "Your milk is sufficient if the baby is voiding pale straw-colored urine 6 to
10 times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if the infant is
adequately hydrated.
✔✔A client with gestational hypertenstion is in active labor and receiving an infusion of
magnesium sulfate. Which drug should the nurse have available for signs of potential
toxicity?
A. Oxytocin (Pitocin)
B. Calcium gluconate
C. Terbutaline (Brethine)
D. Naloxone (Narcan) - ✔✔B. Calcium gluconate
✔✔Which nursing intervention would be most helpful in relieving postpartum uterine
contractions or "afterpains?"
A. Lying prone with a pillow on the abdomen
B. Using a breast pump
C. Massaging the abdomen
D. Giving oxytocic medications - ✔✔A. Lying prone with a pillow on the abdomen
