MATERNITY HESI TEST BANK
(COMBINED RED HESI AND OTHER
SOURCES) EXAM QUESTIONS AND
ANSWERS
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.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. In a newborn, what is the most
likely cause of this accumulation of blood between the periosteum and skull that does
not cross the suture line?
A. Cephalhematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage - Answer-A.
Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding
,between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common variation
of the newborn. Options B and D both involve intracranial bleeding and could not be
detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home?
A. Wash the cord frequently with mild soap and water.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
E. Apply baby lotion after the baby's daily bath - Answer-C. Allow the cord to air-dry as
much as possible.
Rationale: Recent studies have indicated that air drying or plain water application may
be equal to or more effective than alcohol in the cord healing process. Options A, B, and
D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B. Wash off the yellow exudate on the glans once every day to prevent infection.
C. Place petroleum ointment around the glans with each diaper change and cleansing.
D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding
occurs. - Answer-C. Place petroleum ointment around the glans with each diaper
change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove
any urine or feces, and petroleum ointment should be applied to prevent the diaper from
sticking to the healing surface. Prepackaged wipes often contain other products that
may irritate the site. The yellow exudate, which covers the glans penis as the area heals
and epithelializes, is not an infective process and should not be removed. If bleeding
occurs at home, the client should be instructed to apply gentle pressure to the site of the
bleeding with sterile gauze squares and call the health care provider.
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
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 mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing. - Answer-C.Ensure that the
baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the
infant on the breast for latching on. The baby's body is in alignment with the ears,
shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the
breast. Option A helps prevent chafing, and nonbinding support aids in prevention of
discomfort from the stretching of the Cooper ligament. Option B is important but is not
necessary for all women. Option D helps soften an engorged breast and encourages
correct infant latching on but is not the best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times
a day."
C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry."
, D."If you're concerned, you might consider bottle feeding so that you can monitor
intake." - Answer-B."Your milk is sufficient if the baby is voiding pale, straw-colored
urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if
the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of
adequate nutrition, most home scales do not measure this accurately, and the
suggestion will likely make the mother anxious. Option C causes nipple confusion and
diminishes the mother's milk production. Option D does not address the client's
question.
The client comes to the hospital assuming she is in labor. Which assessment findings
by the nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions - Answer-A.Pain in the lower back that
radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of false labor.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk."
C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - Answer-A."Breastfeeding my infant consistently
every 3 to 4 hours stops ovulation and my period."
(COMBINED RED HESI AND OTHER
SOURCES) EXAM QUESTIONS AND
ANSWERS
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.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. In a newborn, what is the most
likely cause of this accumulation of blood between the periosteum and skull that does
not cross the suture line?
A. Cephalhematoma, which is caused by forceps trauma
B. Subarachnoid hematoma, which requires immediate drainage
C. Molding, which is caused by pressure during labor
D. Subdural hematoma, which can result in lifelong damage - Answer-A.
Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises
within the first 24 hours after delivery. Trauma from delivery causes capillary bleeding
,between the periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days,
caused by pressure on the cranium during vaginal delivery, and is a common variation
of the newborn. Options B and D both involve intracranial bleeding and could not be
detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home?
A. Wash the cord frequently with mild soap and water.
B. Cover the cord with a sterile dressing.
C. Allow the cord to air-dry as much as possible.
E. Apply baby lotion after the baby's daily bath - Answer-C. Allow the cord to air-dry as
much as possible.
Rationale: Recent studies have indicated that air drying or plain water application may
be equal to or more effective than alcohol in the cord healing process. Options A, B, and
D are incorrect because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B. Wash off the yellow exudate on the glans once every day to prevent infection.
C. Place petroleum ointment around the glans with each diaper change and cleansing.
D. Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding
occurs. - Answer-C. Place petroleum ointment around the glans with each diaper
change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove
any urine or feces, and petroleum ointment should be applied to prevent the diaper from
sticking to the healing surface. Prepackaged wipes often contain other products that
may irritate the site. The yellow exudate, which covers the glans penis as the area heals
and epithelializes, is not an infective process and should not be removed. If bleeding
occurs at home, the client should be instructed to apply gentle pressure to the site of the
bleeding with sterile gauze squares and call the health care provider.
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
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 mother who is breastfeeding her baby receives instructions from the nurse. Which
instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing. - Answer-C.Ensure that the
baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the
infant on the breast for latching on. The baby's body is in alignment with the ears,
shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the
breast. Option A helps prevent chafing, and nonbinding support aids in prevention of
discomfort from the stretching of the Cooper ligament. Option B is important but is not
necessary for all women. Option D helps soften an engorged breast and encourages
correct infant latching on but is not the best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate?
A."Weigh the baby daily, and if she is gaining weight, she is getting enough to eat."
B."Your milk is sufficient if the baby is voiding pale, straw-colored urine six to ten times
a day."
C."Offer the baby extra bottled milk after her feeding and see if she still seems hungry."
, D."If you're concerned, you might consider bottle feeding so that you can monitor
intake." - Answer-B."Your milk is sufficient if the baby is voiding pale, straw-colored
urine six to ten times a day."
Rationale: The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day), if
the infant is adequately hydrated. Although a weight gain of 30 g/day is indicative of
adequate nutrition, most home scales do not measure this accurately, and the
suggestion will likely make the mother anxious. Option C causes nipple confusion and
diminishes the mother's milk production. Option D does not address the client's
question.
The client comes to the hospital assuming she is in labor. Which assessment findings
by the nurse would indicate that the client is in true labor? (Select all that apply.)
A.Pain in the lower back that radiates to abdomen
B.Contractions decreased in frequency with ambulation
C.Progressive cervical dilation and effacement
D.Discomfort localized in the abdomen
E.Regular and rhythmic painful contractions - Answer-A.Pain in the lower back that
radiates to abdomen
C.Progressive cervical dilation and effacement
E.Regular and rhythmic painful contractions
Rationale: These are all signs of true labor. Options B and D are signs of false labor.
Which statement made by the client indicates that the mother understands the
limitations of breastfeeding her newborn?
A."Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my
period."
B."Breastfeeding my baby immediately after drinking alcohol is safer than waiting for
the alcohol to clear my breast milk."
C."I can start smoking cigarettes while breastfeeding because it will not affect my
breast milk."
D."When I take a warm shower after I breastfeed, it relieves the pain from being
engorged between breastfeedings. - Answer-A."Breastfeeding my infant consistently
every 3 to 4 hours stops ovulation and my period."
