RN HESI Maternity
1. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The
.
nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What
assessment finding confirms to the nurse that the client is not labor at this time?
Correct answer Contractions decrease with walking.
2. A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the grieving
process which intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in privacy
C. Encourage the parents to seek counseling within the next few weeks
D. Assist the couple to request autopsy
Correct answer B. provide a time for the parents to hold their infant in privacy
What is the priority nursing assessment immediately following the birth of an infant with esophageal
atresia and a tracheoesophageal (the) fistula ?
A. body temperature
B. level of pain
C. time of first void
D. number of vessels in the cord
Correct answer A. body temperature
What is the most important assessment for the nurse to conduct following the administration of epidural
anesthesia to a client who is at 40-weeks gestation?
A. Level of pain sensation
B. Station of presenting part
,C. Variability of fetal heart rate
D. Maternal blood pressure
Correct answer D. Maternal blood pressure
A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml
with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse
program the infusion pump? (Enter numeric value only)
A. 120
B. 70
C. 65
D. 75
Correct answer D. 75
A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why
is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply)
A. Explain that newborns get milk from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
D. Suggest that the baby can also drink from a bottle
E. Clarify that breastfeeding is his mother's choice Correct answer A. Explain that newborns get milk
from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used?
A. Place the infant in side-lying to facilitate the exam
B. Hold the penis and retract the foreskin gently
C. Cleanse the penis with an antiseptic-soaked pad
D. Place the infant in warm room and use a calm approach
Correct answer D. Place the infant in warm room and use a calm approach
,The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What
maternal prescription is most important in preventing this fetus from developing respiratory distress
syndrome?
A. Betamethasone (Celestone) 12 mg deep IM
B. Butorphanol 1 mg IV push q2h PRN pain
C. Ampicillin 1 Gram IV push q8h
D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x3
Correct answer A. Betamethasone (Celestone) 12 mg deep IM
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent
urinary retention. The home health nurse notes that the child has developed episodes of sneezing,
urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change
Correct answer C. Change to latex-free gloves when handling infant
The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2
proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal
headache. Which medication should the nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate Correct answer D. Magnesium sulfate
A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse
notes the client's temperature to be 101.2F, with severe abdominal or uterine tenderness on palpation. The
nurse knows that these findings are indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection.
, Correct answer B. Chorioamnionitis
A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who tells the
nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no
tears. Which prescription is most important to implement?
A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket
Correct answer B. Infuse normal saline intravenously
A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention
should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises
Correct answer D. remove restraints one at a time to provide ROM exercises
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something
besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should
the nurse respond?
A. encourage the mother to schedule a developmental assessment of the infant
B. advise the mother to wait at least another month before starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
D. reassure the mother that the infant is old enough to eat iron-fortified cereal
Correct answer D. reassure the mother that the infant is old enough to eat iron-fortified cereal
1. A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The
.
nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140
beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What
assessment finding confirms to the nurse that the client is not labor at this time?
Correct answer Contractions decrease with walking.
2. A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the grieving
process which intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in privacy
C. Encourage the parents to seek counseling within the next few weeks
D. Assist the couple to request autopsy
Correct answer B. provide a time for the parents to hold their infant in privacy
What is the priority nursing assessment immediately following the birth of an infant with esophageal
atresia and a tracheoesophageal (the) fistula ?
A. body temperature
B. level of pain
C. time of first void
D. number of vessels in the cord
Correct answer A. body temperature
What is the most important assessment for the nurse to conduct following the administration of epidural
anesthesia to a client who is at 40-weeks gestation?
A. Level of pain sensation
B. Station of presenting part
,C. Variability of fetal heart rate
D. Maternal blood pressure
Correct answer D. Maternal blood pressure
A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml
with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse
program the infusion pump? (Enter numeric value only)
A. 120
B. 70
C. 65
D. 75
Correct answer D. 75
A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why
is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply)
A. Explain that newborns get milk from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
D. Suggest that the baby can also drink from a bottle
E. Clarify that breastfeeding is his mother's choice Correct answer A. Explain that newborns get milk
from their mothers in this way
B. Reassure the older brother that it does not hurt his mother
C. Remind him that his mother breastfed him too
The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used?
A. Place the infant in side-lying to facilitate the exam
B. Hold the penis and retract the foreskin gently
C. Cleanse the penis with an antiseptic-soaked pad
D. Place the infant in warm room and use a calm approach
Correct answer D. Place the infant in warm room and use a calm approach
,The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What
maternal prescription is most important in preventing this fetus from developing respiratory distress
syndrome?
A. Betamethasone (Celestone) 12 mg deep IM
B. Butorphanol 1 mg IV push q2h PRN pain
C. Ampicillin 1 Gram IV push q8h
D. Terbutaline (Brethine) 0.25 mg subcutaneously q15 minutes x3
Correct answer A. Betamethasone (Celestone) 12 mg deep IM
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent
urinary retention. The home health nurse notes that the child has developed episodes of sneezing,
urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change
Correct answer C. Change to latex-free gloves when handling infant
The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2
proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal
headache. Which medication should the nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate Correct answer D. Magnesium sulfate
A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse
notes the client's temperature to be 101.2F, with severe abdominal or uterine tenderness on palpation. The
nurse knows that these findings are indicative of what condition?
A. Round ligament strain
B. Chorioamnionitis
C. Abruptio placenta
D. Viral infection.
, Correct answer B. Chorioamnionitis
A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who tells the
nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no
tears. Which prescription is most important to implement?
A. Provide a bottle of electrolyte solution
B. Infuse normal saline intravenously
C. Administer an antipyretic rectally
D. Apply external cooling blanket
Correct answer B. Infuse normal saline intravenously
A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention
should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all times
C. obtain the HCP advice as to when the restraints should be removed
D. remove restraints one at a time to provide ROM exercises
Correct answer D. remove restraints one at a time to provide ROM exercises
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something
besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should
the nurse respond?
A. encourage the mother to schedule a developmental assessment of the infant
B. advise the mother to wait at least another month before starting any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
D. reassure the mother that the infant is old enough to eat iron-fortified cereal
Correct answer D. reassure the mother that the infant is old enough to eat iron-fortified cereal
