Red HESI Test bank Maternity Latest
Exam
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. Which is the correct description of this client that should be documented in the
medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1 - ANSWER-C.Gravida 2, para 0
Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0.
Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not
take into account the current pregnancy, nor does option B, which also counts the miscarriage as a
"para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth - ANSWER-C.Tachycardia and a feeling of nervousness
,Red HESI Test bank Maternity Latest
Exam
Rationale: 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.
Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse
that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the
lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - ANSWER-C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous
return. Option A would increase venous return from varicose veins in the lower extremities but would
be of little help with swelling. Option B might be helpful with generalized edema but is not specific for
edematous lower extremities. Option D does not address venous return, and there is no indication in
the question that constrictive clothing is a problem.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and
occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each
contraction and returns to baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
, Red HESI Test bank Maternity Latest
Exam
D.Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER-B.Determine cervical dilation and
effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are
a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to
stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A
sterile vaginal examination places the client at risk for infection and should be performed when the
client exhibits signs of progressing labor, which is not indicated at this time.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. -
ANSWER-A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the
inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast
tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a
small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She
further states that she is not experiencing any uterine contractions or abdominal pain. What instruction
should the nurse provide?
A.Come to the clinic today for an ultrasound.
Exam
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. Which is the correct description of this client that should be documented in the
medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1 - ANSWER-C.Gravida 2, para 0
Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0.
Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not
take into account the current pregnancy, nor does option B, which also counts the miscarriage as a
"para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth - ANSWER-C.Tachycardia and a feeling of nervousness
,Red HESI Test bank Maternity Latest
Exam
Rationale: 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.
Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse
that her feet have begun to swell. Which instruction will aid in the prevention of pooling of blood in the
lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - ANSWER-C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous
return. Option A would increase venous return from varicose veins in the lower extremities but would
be of little help with swelling. Option B might be helpful with generalized edema but is not specific for
edematous lower extremities. Option D does not address venous return, and there is no indication in
the question that constrictive clothing is a problem.
A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and
occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each
contraction and returns to baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
, Red HESI Test bank Maternity Latest
Exam
D.Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER-B.Determine cervical dilation and
effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that occur every 2 to 3
minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are
a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to
stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A
sterile vaginal examination places the client at risk for infection and should be performed when the
client exhibits signs of progressing labor, which is not indicated at this time.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. -
ANSWER-A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding
during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the
inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast
tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has just experienced a
small amount of vaginal bleeding, which she describes as bright red. The bleeding has subsided. She
further states that she is not experiencing any uterine contractions or abdominal pain. What instruction
should the nurse provide?
A.Come to the clinic today for an ultrasound.
