HESI RN Maternity Exam | 155 Verified Questions
& Answers | Elsevier Evolve NCLEX-RN Readiness |
Instant Download
Q1. What is the only known cure for preeclampsia? [Clinical Scenario
Variation 30 – 28yo G2P2 at 37 weeks BP 149/79 FHR 139]
A. Delivery of the fetus and placenta [30]
B. Bed rest alone for 2 weeks [30A]
C. Increased fluid intake and low salt diet [30C]
D. Antihypertensive medications alone cure disease [30B]
Correct Answer: A. Delivery of the fetus and placenta [30]
Rationale: CORRECT [30]: Delivery of the fetus and placenta. Rationale:
Only known cure for preeclampsia is delivery of the fetus and placenta.
All other treatments are temporizing to prolong gestation or prevent
seizures until delivery is feasible. WHY OTHERS WRONG: Option A-type
distractors incorrect because they violate ABCs, fetal oxygenation, or
maternal safety priorities; Option B-type unsafe – would cause
hemorrhage, worsen fetal distress, or increase infection; Option C-type
non-compliant with HESI maternity standards for this gestational age.
Q2. Total bilirubin 14 mg per dL in 36-hour breastfeeding newborn.
What intervention should nurse implement? [Clinical Scenario Variation
94 – 28yo G2P0 at 37 weeks BP 163/83 FHR 123]
A. Assess blood glucose only unrelated to bilirubin [94C]
B. Encourage mother to breastfeed frequently – breast milk provides
calories enhances GI motility assists bowel eliminating bilirubin [94]
C. Feed newborn sterile water hourly [94B]
D. Provide phototherapy for 30 minutes every 8 hours at this level [94A]
Correct Answer: B. Encourage mother to breastfeed frequently – breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin [94]
Rationale: CORRECT [94]: Encourage mother to breastfeed frequently –
breast milk provides calories enhances GI motility assists bowel
eliminating bilirubin. Rationale: Normal total bilirubin 6-12 mg/dL
after Day 1. Bilirubin 14 climbing needs frequent breastfeeding. Breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin. Sterile water limits caloric intake worsening jaundice. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Page 1
,
Q3. What is the most common cause of early postpartum hemorrhage?
[Clinical Scenario Variation 145 – 28yo G1P0 at 24 weeks BP 164/74 FHR
134]
A. Vaginal lacerations only cause [145B]
B. Coagulopathy only cause without atony [145C]
C. Uterine atony – failure of uterus to contract after delivery, defined
as blood loss at least 500 mL vaginal or 1000 mL cesarean [145]
D. Precipitous labor alone is most common cause [145A]
Correct Answer: C. Uterine atony – failure of uterus to contract after
delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean [145]
Rationale: CORRECT [145]: Uterine atony – failure of uterus to contract
after delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean. Rationale: Uterine atony is most common cause of PPH. PPH
defined as at least 500 mL vaginal or 1000 mL cesarean, causing
tachycardia hypotension, requiring fundal massage and oxytocics. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Q4. A client who delivered infant an hour ago tells nurse she feels
wet underneath buttock. Both pads saturated client lying in 6-inch
pool blood. Which action next? [Clinical Scenario Variation 97 – 28yo
G1P0 at 24 weeks BP 166/86 FHR 126]
A. Cleanse perineum only [97A]
B. Obtain blood pressure only [97B]
C. Inspect perineum for lacerations only [97C]
D. Palpate firmness of fundus – first priority for hemorrhage is fundal
massage to contract uterus [97]
Correct Answer: D. Palpate firmness of fundus – first priority for
hemorrhage is fundal massage to contract uterus [97]
Rationale: CORRECT [97]: Palpate firmness of fundus – first priority for
hemorrhage is fundal massage to contract uterus. Rationale: Postpartum
hemorrhage next action palpate fundus firmness. Boggy uterus causes
bleeding. Firming uterus stops bleeding. Vital signs and laceration
check follow fundal assessment. WHY OTHERS WRONG: Option A-type
distractors incorrect because they violate ABCs, fetal oxygenation, or
maternal safety priorities; Option B-type unsafe – would cause
hemorrhage, worsen fetal distress, or increase infection; Option C-type
non-compliant with HESI maternity standards for this gestational age.
Page 2
,
Q5. Which action should nurse implement when preparing to measure
fundal height of pregnant client? [Clinical Scenario Variation 93 –
28yo G1P2 at 36 weeks BP 162/82 FHR 122]
A. Have client empty bladder – full bladder displaces uterus and affects
measurement accuracy [93]
B. Request client lie on left side only [93A]
C. Give cold juice to stimulate fetal movement [93C]
D. Perform Leopold maneuvers first before emptying [93B]
Correct Answer: A. Have client empty bladder – full bladder displaces
uterus and affects measurement accuracy [93]
Rationale: CORRECT [93]: Have client empty bladder – full bladder
displaces uterus and affects measurement accuracy. Rationale: Fundal
height measurement requires empty bladder. Full bladder elevates and
displaces uterus giving inaccurate gestational age assessment. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Q6. Total bilirubin 14 mg per dL in 36-hour breastfeeding newborn.
What intervention should nurse implement? [Clinical Scenario Variation
54 – 28yo G2P2 at 29 weeks BP 123/83 FHR 123]
A. Assess blood glucose only unrelated to bilirubin [54C]
B. Encourage mother to breastfeed frequently – breast milk provides
calories enhances GI motility assists bowel eliminating bilirubin [54]
C. Feed newborn sterile water hourly [54B]
D. Provide phototherapy for 30 minutes every 8 hours at this level [54A]
Correct Answer: B. Encourage mother to breastfeed frequently – breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin [54]
Rationale: CORRECT [54]: Encourage mother to breastfeed frequently –
breast milk provides calories enhances GI motility assists bowel
eliminating bilirubin. Rationale: Normal total bilirubin 6-12 mg/dL
after Day 1. Bilirubin 14 climbing needs frequent breastfeeding. Breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin. Sterile water limits caloric intake worsening jaundice. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Page 3
,
Q7. What is the most common cause of early postpartum hemorrhage?
A. Precipitous labor alone is most common cause [5A]
B. Coagulopathy only cause without atony [5C]
C. Uterine atony – failure of uterus to contract after delivery, defined
as blood loss at least 500 mL vaginal or 1000 mL cesarean [5]
D. Vaginal lacerations only cause [5B]
Correct Answer: C. Uterine atony – failure of uterus to contract after
delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean [5]
Rationale: CORRECT [5]: Uterine atony – failure of uterus to contract
after delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean. Rationale: Uterine atony is most common cause of PPH. PPH
defined as at least 500 mL vaginal or 1000 mL cesarean, causing
tachycardia hypotension, requiring fundal massage and oxytocics. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Q8. Normal newborn anterior fontanel closes at what age and posterior
fontanel? [Clinical Scenario Variation 78 – 28yo G2P2 at 37 weeks BP
147/87 FHR 147]
A. Anterior 8-11 months posterior end first month [78C]
B. Anterior 5-7 months posterior end second week [78B]
C. Anterior 2-4 months posterior end first week [78A]
D. Anterior fontanel closes at 12 to 18 months posterior by end of
second month [78]
Correct Answer: D. Anterior fontanel closes at 12 to 18 months
posterior by end of second month [78]
Rationale: CORRECT [78]: Anterior fontanel closes at 12 to 18 months
posterior by end of second month. Rationale: Anterior fontanel closes 12
to 18 months posterior by end second month. Knowledge important for
parent teaching about infant head growth and assessment of increased
intracranial pressure. WHY OTHERS WRONG: Option A-type distractors
incorrect because they violate ABCs, fetal oxygenation, or maternal
safety priorities; Option B-type unsafe – would cause hemorrhage, worsen
fetal distress, or increase infection; Option C-type non-compliant with
HESI maternity standards for this gestational age.
Page 4
& Answers | Elsevier Evolve NCLEX-RN Readiness |
Instant Download
Q1. What is the only known cure for preeclampsia? [Clinical Scenario
Variation 30 – 28yo G2P2 at 37 weeks BP 149/79 FHR 139]
A. Delivery of the fetus and placenta [30]
B. Bed rest alone for 2 weeks [30A]
C. Increased fluid intake and low salt diet [30C]
D. Antihypertensive medications alone cure disease [30B]
Correct Answer: A. Delivery of the fetus and placenta [30]
Rationale: CORRECT [30]: Delivery of the fetus and placenta. Rationale:
Only known cure for preeclampsia is delivery of the fetus and placenta.
All other treatments are temporizing to prolong gestation or prevent
seizures until delivery is feasible. WHY OTHERS WRONG: Option A-type
distractors incorrect because they violate ABCs, fetal oxygenation, or
maternal safety priorities; Option B-type unsafe – would cause
hemorrhage, worsen fetal distress, or increase infection; Option C-type
non-compliant with HESI maternity standards for this gestational age.
Q2. Total bilirubin 14 mg per dL in 36-hour breastfeeding newborn.
What intervention should nurse implement? [Clinical Scenario Variation
94 – 28yo G2P0 at 37 weeks BP 163/83 FHR 123]
A. Assess blood glucose only unrelated to bilirubin [94C]
B. Encourage mother to breastfeed frequently – breast milk provides
calories enhances GI motility assists bowel eliminating bilirubin [94]
C. Feed newborn sterile water hourly [94B]
D. Provide phototherapy for 30 minutes every 8 hours at this level [94A]
Correct Answer: B. Encourage mother to breastfeed frequently – breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin [94]
Rationale: CORRECT [94]: Encourage mother to breastfeed frequently –
breast milk provides calories enhances GI motility assists bowel
eliminating bilirubin. Rationale: Normal total bilirubin 6-12 mg/dL
after Day 1. Bilirubin 14 climbing needs frequent breastfeeding. Breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin. Sterile water limits caloric intake worsening jaundice. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Page 1
,
Q3. What is the most common cause of early postpartum hemorrhage?
[Clinical Scenario Variation 145 – 28yo G1P0 at 24 weeks BP 164/74 FHR
134]
A. Vaginal lacerations only cause [145B]
B. Coagulopathy only cause without atony [145C]
C. Uterine atony – failure of uterus to contract after delivery, defined
as blood loss at least 500 mL vaginal or 1000 mL cesarean [145]
D. Precipitous labor alone is most common cause [145A]
Correct Answer: C. Uterine atony – failure of uterus to contract after
delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean [145]
Rationale: CORRECT [145]: Uterine atony – failure of uterus to contract
after delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean. Rationale: Uterine atony is most common cause of PPH. PPH
defined as at least 500 mL vaginal or 1000 mL cesarean, causing
tachycardia hypotension, requiring fundal massage and oxytocics. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Q4. A client who delivered infant an hour ago tells nurse she feels
wet underneath buttock. Both pads saturated client lying in 6-inch
pool blood. Which action next? [Clinical Scenario Variation 97 – 28yo
G1P0 at 24 weeks BP 166/86 FHR 126]
A. Cleanse perineum only [97A]
B. Obtain blood pressure only [97B]
C. Inspect perineum for lacerations only [97C]
D. Palpate firmness of fundus – first priority for hemorrhage is fundal
massage to contract uterus [97]
Correct Answer: D. Palpate firmness of fundus – first priority for
hemorrhage is fundal massage to contract uterus [97]
Rationale: CORRECT [97]: Palpate firmness of fundus – first priority for
hemorrhage is fundal massage to contract uterus. Rationale: Postpartum
hemorrhage next action palpate fundus firmness. Boggy uterus causes
bleeding. Firming uterus stops bleeding. Vital signs and laceration
check follow fundal assessment. WHY OTHERS WRONG: Option A-type
distractors incorrect because they violate ABCs, fetal oxygenation, or
maternal safety priorities; Option B-type unsafe – would cause
hemorrhage, worsen fetal distress, or increase infection; Option C-type
non-compliant with HESI maternity standards for this gestational age.
Page 2
,
Q5. Which action should nurse implement when preparing to measure
fundal height of pregnant client? [Clinical Scenario Variation 93 –
28yo G1P2 at 36 weeks BP 162/82 FHR 122]
A. Have client empty bladder – full bladder displaces uterus and affects
measurement accuracy [93]
B. Request client lie on left side only [93A]
C. Give cold juice to stimulate fetal movement [93C]
D. Perform Leopold maneuvers first before emptying [93B]
Correct Answer: A. Have client empty bladder – full bladder displaces
uterus and affects measurement accuracy [93]
Rationale: CORRECT [93]: Have client empty bladder – full bladder
displaces uterus and affects measurement accuracy. Rationale: Fundal
height measurement requires empty bladder. Full bladder elevates and
displaces uterus giving inaccurate gestational age assessment. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Q6. Total bilirubin 14 mg per dL in 36-hour breastfeeding newborn.
What intervention should nurse implement? [Clinical Scenario Variation
54 – 28yo G2P2 at 29 weeks BP 123/83 FHR 123]
A. Assess blood glucose only unrelated to bilirubin [54C]
B. Encourage mother to breastfeed frequently – breast milk provides
calories enhances GI motility assists bowel eliminating bilirubin [54]
C. Feed newborn sterile water hourly [54B]
D. Provide phototherapy for 30 minutes every 8 hours at this level [54A]
Correct Answer: B. Encourage mother to breastfeed frequently – breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin [54]
Rationale: CORRECT [54]: Encourage mother to breastfeed frequently –
breast milk provides calories enhances GI motility assists bowel
eliminating bilirubin. Rationale: Normal total bilirubin 6-12 mg/dL
after Day 1. Bilirubin 14 climbing needs frequent breastfeeding. Breast
milk provides calories enhances GI motility assists bowel eliminating
bilirubin. Sterile water limits caloric intake worsening jaundice. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Page 3
,
Q7. What is the most common cause of early postpartum hemorrhage?
A. Precipitous labor alone is most common cause [5A]
B. Coagulopathy only cause without atony [5C]
C. Uterine atony – failure of uterus to contract after delivery, defined
as blood loss at least 500 mL vaginal or 1000 mL cesarean [5]
D. Vaginal lacerations only cause [5B]
Correct Answer: C. Uterine atony – failure of uterus to contract after
delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean [5]
Rationale: CORRECT [5]: Uterine atony – failure of uterus to contract
after delivery, defined as blood loss at least 500 mL vaginal or 1000 mL
cesarean. Rationale: Uterine atony is most common cause of PPH. PPH
defined as at least 500 mL vaginal or 1000 mL cesarean, causing
tachycardia hypotension, requiring fundal massage and oxytocics. WHY
OTHERS WRONG: Option A-type distractors incorrect because they violate
ABCs, fetal oxygenation, or maternal safety priorities; Option B-type
unsafe – would cause hemorrhage, worsen fetal distress, or increase
infection; Option C-type non-compliant with HESI maternity standards for
this gestational age.
Q8. Normal newborn anterior fontanel closes at what age and posterior
fontanel? [Clinical Scenario Variation 78 – 28yo G2P2 at 37 weeks BP
147/87 FHR 147]
A. Anterior 8-11 months posterior end first month [78C]
B. Anterior 5-7 months posterior end second week [78B]
C. Anterior 2-4 months posterior end first week [78A]
D. Anterior fontanel closes at 12 to 18 months posterior by end of
second month [78]
Correct Answer: D. Anterior fontanel closes at 12 to 18 months
posterior by end of second month [78]
Rationale: CORRECT [78]: Anterior fontanel closes at 12 to 18 months
posterior by end of second month. Rationale: Anterior fontanel closes 12
to 18 months posterior by end second month. Knowledge important for
parent teaching about infant head growth and assessment of increased
intracranial pressure. WHY OTHERS WRONG: Option A-type distractors
incorrect because they violate ABCs, fetal oxygenation, or maternal
safety priorities; Option B-type unsafe – would cause hemorrhage, worsen
fetal distress, or increase infection; Option C-type non-compliant with
HESI maternity standards for this gestational age.
Page 4
