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Exam (elaborations)

Maternity HESI Questions and Correct Answers & Latest Updated

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Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: o :## Continue to monitor (normal). 20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants further evaluation? o :## Too much weight gain, gestational weight gain should only be approx 10.3 lbs. . Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"? o :## Active movement and lusty cry. 24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say... o :## If your baby's urine is straw colored , then she is feeding well. . 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate o :## Inspect perineal and rectal area. Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx? o :## Fluid volume excess. RATIONALE: 3rd spacing. 2 | P a g e : 2 0 2 4 / 2 0 2 5 G r a d e A + Master01: DO NOT COPY AND PASTE!! August 25, 2024 Latest Update Cesarean - hemorrhage risk assessment? o :## Check for fundal firmness Q15 min. RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery. Q15 min checks stimulate fundus to contract and prevents bleeding. Water broke, umbilical cord is on perineum, what does nurse do? o :## Place pt in trendelenburg. RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up the presenting part as much as possible. Primipara 20 week, schedule u/s, what's the reason for the u/s? o :## To evaluate fetal growth and to determine gestational age. Assessing a 3 day old with cephalohematoma. What intervention is highest priority? o :## Examine Q8 hrs for jaundice (look for hyperbilirubinemia). RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown. 40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia. What would be a therapeutic response to the injection? o :## Increased HR and decrease in oral secretions. Newborn assessment that indicates a cardiac problem? o :## RR 78/min. RATIONALE: Normal respiratory rate for a newborn is 40 - 60. 3 | P a g e : 2 0 2 4 / 2 0 2 5 G r a d e A + Master01: DO NOT COPY AND PASTE!! August 25, 2024 Latest Update Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give? o :## Give 1.5 tabs. Sore nipples on day 2 of breastfeeding. o :## Assess infants position while feedin

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Maternity HESI

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Uploaded on
August 25, 2024
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Written in
2024/2025
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1|Page: 2024/2025 Grade A+




Maternity HESI Questions and Correct Answers
& Latest Updated
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet:


o :## Continue to monitor (normal).



20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What

warrants further evaluation?


o :## Too much weight gain, gestational weight gain should only be approx 10.3 lbs.



. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"?


o :## Active movement and lusty cry.



24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say...


o :## If your baby's urine is straw colored , then she is feeding well.



. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate


o :## Inspect perineal and rectal area.



Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing

Dx?


o :## Fluid volume excess.
RATIONALE: 3rd spacing.




Master01: DO NOT COPY AND PASTE!! August 25, 2024 Latest Update

, 2|Page: 2024/2025 Grade A+


Cesarean - hemorrhage risk assessment?


o :## Check for fundal firmness Q15 min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after

delivery. Q15 min checks stimulate fundus to contract and prevents bleeding.




Water broke, umbilical cord is on perineum, what does nurse do?


o :## Place pt in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding

up the presenting part as much as possible.




Primipara 20 week, schedule u/s, what's the reason for the u/s?


o :## To evaluate fetal growth and to determine gestational age.



Assessing a 3 day old with cephalohematoma. What intervention is highest priority?


o :## Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.




40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled

anesthesia. What would be a therapeutic response to the injection?


o :## Increased HR and decrease in oral secretions.



Newborn assessment that indicates a cardiac problem?


o :## RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.


Master01: DO NOT COPY AND PASTE!! August 25, 2024 Latest Update

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