HESI MATERNITY 2 ACTUAL QUESTIONS WITH
VERIFIED SOLUTIONS
◉ 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.
Answer: 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.
Answer: 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?
A.The anterior fontanel closes at 2 to 4 months and the posterior
fontanel by the end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior
fontanel by the end of the second week.
C.The anterior fontanel closes at 8 to 11 months and the posterior
fontanel by the end of the first month.
D.The anterior fontanel closes at 12 to 18 months and the posterior
fontanel by the end of the second month.
Answer: D.The anterior fontanel closes at 12 to 18 months and the
posterior fontanel by the end of the second month
Rationale: In the normal infant, the anterior fontanel closes at 12 to
18 months of age and the posterior fontanel closes by the end of the
second month. These growth and development milestones are
, frequently included in questions on the licensure examination.
Options A, B, and C are incorrect.
◉ A client who is 3 days postpartum and breastfeeding asks the
nurse how to reduce breast engorgement. Which instruction should
the nurse provide?
A.Avoid using the breast pump.
B.Breastfeed the infant every 2 hours.
C.Reduce fluid intake for 24 hours.
D.Skip feedings to let the sore breasts rest..
Answer: B.Breastfeed the infant every 2 hours.
Rationale: The mother should be instructed to attempt feeding her
infant every 2 hours while massaging the breasts as the infant is
feeding. If the infant does not feed adequately and empty the breast,
using a breast pump helps extract the milk and relieve some of the
discomfort. Dehydration irritates swollen breast tissue. Skipping
feedings may cause further engorgement and discomfort.
VERIFIED SOLUTIONS
◉ 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.
Answer: 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.
Answer: 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?
A.The anterior fontanel closes at 2 to 4 months and the posterior
fontanel by the end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior
fontanel by the end of the second week.
C.The anterior fontanel closes at 8 to 11 months and the posterior
fontanel by the end of the first month.
D.The anterior fontanel closes at 12 to 18 months and the posterior
fontanel by the end of the second month.
Answer: D.The anterior fontanel closes at 12 to 18 months and the
posterior fontanel by the end of the second month
Rationale: In the normal infant, the anterior fontanel closes at 12 to
18 months of age and the posterior fontanel closes by the end of the
second month. These growth and development milestones are
, frequently included in questions on the licensure examination.
Options A, B, and C are incorrect.
◉ A client who is 3 days postpartum and breastfeeding asks the
nurse how to reduce breast engorgement. Which instruction should
the nurse provide?
A.Avoid using the breast pump.
B.Breastfeed the infant every 2 hours.
C.Reduce fluid intake for 24 hours.
D.Skip feedings to let the sore breasts rest..
Answer: B.Breastfeed the infant every 2 hours.
Rationale: The mother should be instructed to attempt feeding her
infant every 2 hours while massaging the breasts as the infant is
feeding. If the infant does not feed adequately and empty the breast,
using a breast pump helps extract the milk and relieve some of the
discomfort. Dehydration irritates swollen breast tissue. Skipping
feedings may cause further engorgement and discomfort.
