Maternity HESI
The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The
nurse observes red marks on the head with swelling that does not cross the suture line. Which
condition should the nurse documents in the medical record?
a. caput succedaneum
b. hydrocephalus
c. cephalhematoma
d. microcephaly - ANS c. cephalhematoma
A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that
began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal
bleeding. Fetal rate of 130 - 140 beats per minute, no contractions and no complaints of pain
what is the most likely cause of these client's bleeding.
A. abruptio placenta
b. placenta previa
c. normal blood show indicting induction of labor
d. a ruptured blood vessel in the vaginal vault - ANS b. placenta previa
A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours.
Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the
hospital. which assessment warrants immediate intervention by the nurse.
a. Fetal heart rate 60 bpm
b. ruptured amniotic membrane
c. onset of uterine contractions
d. leaking amniotic fluid - ANS a. Fetal heart rate 60 bpm
A client at 37 weeks gestation presents to labor and delivery with contractions every two
minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the
nurse should recognize the clients is prohibiting symptoms of which condition?
a. genital warts
b. syphilis
c. herpes simplex virus
d. german measles - ANS c. herpes simplex virus
The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor
which maternity description is most important in preventing this fetus from developing
respiratory distress syndrome.
, a. Ampicillin 2 gram IV push q8h
b. Betamethasone 12 mg deep IM
c. Terbutaline 0.25 mg subcutaneously q15 minutes x3
d. Butorphanol tartrate 1mg IV push q2h PRN - ANS b. Betamethasone 12 mg deep IM
A 16 yo gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of
eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include
in this client's nursing care plan?
a. Allow liberal family visitation
b. Keep an airway at the bedside
c. Assess temperature every hour
d. Monitor blood pressure, pulse, and respiration every 4 hours - ANS b. Keep an airway at the
bedside
At 12 hours after the birth of a healthy infant the mother complains of feeling constant vaginal
pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia.
which action should nurse take?
a. check the suprapubic area for distention
b. inform the client to take a warm stiz bath
c. inspect clients perineal and rectal areas
d. Apply a fresh pad and check in 1 hour - ANS c. inspect clients perineal and rectal areas
If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma in a
motor vehicle collision. Which assessment finding is most important for the nurse to report to the
health care provider?
a. Fetal HR at 162 bpm
b. Mild contractions every 10 minutes
c. Trace of protein in the urine
d. Positive fetal hemoglobin testing - ANS b. Mild contractions every 10 minutes
In The Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old
infant as a gestational age of 42 weeks. Based on this finding which intervention is most
important for the nurse to implement.
a. Provide blow by oxygen
b. Provide a capillary blood glucose
c. draw arterial blood gases
d. Apply a pulse oximeter to the foot. - ANS b. Provide a capillary blood glucose
The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The
nurse observes red marks on the head with swelling that does not cross the suture line. Which
condition should the nurse documents in the medical record?
a. caput succedaneum
b. hydrocephalus
c. cephalhematoma
d. microcephaly - ANS c. cephalhematoma
A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that
began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal
bleeding. Fetal rate of 130 - 140 beats per minute, no contractions and no complaints of pain
what is the most likely cause of these client's bleeding.
A. abruptio placenta
b. placenta previa
c. normal blood show indicting induction of labor
d. a ruptured blood vessel in the vaginal vault - ANS b. placenta previa
A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours.
Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the
hospital. which assessment warrants immediate intervention by the nurse.
a. Fetal heart rate 60 bpm
b. ruptured amniotic membrane
c. onset of uterine contractions
d. leaking amniotic fluid - ANS a. Fetal heart rate 60 bpm
A client at 37 weeks gestation presents to labor and delivery with contractions every two
minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. the
nurse should recognize the clients is prohibiting symptoms of which condition?
a. genital warts
b. syphilis
c. herpes simplex virus
d. german measles - ANS c. herpes simplex virus
The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor
which maternity description is most important in preventing this fetus from developing
respiratory distress syndrome.
, a. Ampicillin 2 gram IV push q8h
b. Betamethasone 12 mg deep IM
c. Terbutaline 0.25 mg subcutaneously q15 minutes x3
d. Butorphanol tartrate 1mg IV push q2h PRN - ANS b. Betamethasone 12 mg deep IM
A 16 yo gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of
eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include
in this client's nursing care plan?
a. Allow liberal family visitation
b. Keep an airway at the bedside
c. Assess temperature every hour
d. Monitor blood pressure, pulse, and respiration every 4 hours - ANS b. Keep an airway at the
bedside
At 12 hours after the birth of a healthy infant the mother complains of feeling constant vaginal
pressure. The nurse determines the fundus is firm and at midline with moderate rubra lochia.
which action should nurse take?
a. check the suprapubic area for distention
b. inform the client to take a warm stiz bath
c. inspect clients perineal and rectal areas
d. Apply a fresh pad and check in 1 hour - ANS c. inspect clients perineal and rectal areas
If primigravida at 36 weeks gestation who is RH negative experienced abdominal trauma in a
motor vehicle collision. Which assessment finding is most important for the nurse to report to the
health care provider?
a. Fetal HR at 162 bpm
b. Mild contractions every 10 minutes
c. Trace of protein in the urine
d. Positive fetal hemoglobin testing - ANS b. Mild contractions every 10 minutes
In The Ballard Gestational Age Assessment Tool, the nurse determines that a 15-month-old
infant as a gestational age of 42 weeks. Based on this finding which intervention is most
important for the nurse to implement.
a. Provide blow by oxygen
b. Provide a capillary blood glucose
c. draw arterial blood gases
d. Apply a pulse oximeter to the foot. - ANS b. Provide a capillary blood glucose
