HESI REVIEW TEST-MATERNITY,
EVOLVE OBSTETRICS/MATERNITY
PRACTICE EXAM, HESI MATERNITY
QUESTIONS AND ANSWERS
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in her lower back. Which intervention should
the nurse implement? - Answer-Apply firm pressure to sacral area. The discomfort of
back labor can be minimized by the application of firm pressure to the sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her
bag of water has broken. The nurse identifies the presence of meconium fluid on the
perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What
action should the nurse implement next? - Answer-Complete a sterile vaginal exam. A
vaginal exam (A) should be performed after the rupture of membranes to determine the
presence of a prolapsed cord.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks
gestation. The nurse determines that the client is not having contractions, the fetal heart
rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action
should the nurse take? - Answer-Ask the client if she has felt any fetal movement.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my
first child, but I would like to try with this baby." Which intervention is best for the nurse
to implement first? - Answer-Provide assistance to the mother to begin breastfeeding as
soon as possible after delivery.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client
is coming to the unit with suspected abruptio placentae. What findings should the
charge nurse expect the client to demonstrate? (Select all that apply.) - Answer-Dark,
red vaginal bleeding.
Increased uterine irritability.
A rigid abdomen.
The nurse is teaching care of the newborn to a group of prospective parents and
describes the need for administering antibiotic ointment into the eyes of the newborn.
Which infectious organism will this treatment prevent from harming the infant? - Answer-
Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye
within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by
gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C).
,In evaluating the respiratory effort of a one-hour-old infant using the Silverman-
Anderson Index, the nurse determines the infant has synchronized chest and abdominal
movement, just visible lower chest retractions, just visible xiphoid retractions, minimal
and transient nasal flaring, and an expiratory grunt heard only on auscultation. What
Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value
only.) - Answer-A Silverman-Anderson Index has five categories with scores of 0, 1, or
2. The total score ranges from 0 to 10. Four of the these assessment findings should
receive a score of 1, and the 5th finding (synchronized chest and abdominal movement)
receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant
has no dyspnea, a total score of 10 indicates maximum respiratory distress.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern
as a tool to assist her in conceiving a child. Which temperature pattern indicates the
occurrence of ovulation, and therefore, the best time for intercourse to ensure
conception? - Answer-Between the time the temperature falls and rises. In most
women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours
after ovulation, when the corpus luteum of the ruptured ovary produces progesterone.
Therefore, intercourse between the time of the temperature fall and rise (A) is the best
time for conception.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation should the nurse provide? - Answer-Your milk is
sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. The urine
will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant is
adequately hydrated.
A 28-year-old client in active labor complains of cramps in her leg. What intervention
should the nurse implement? - Answer-Extend the leg and dorsiflex the foot.
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client
is capable) (B), and putting the heel of the foot on the floor is the best means of
relieving leg cramps.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted
for observation. She is contracting irregularly and demonstrates underlying uterine
irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based
on these data, which intervention should the nurse implement first? - Answer-Obtain a
specimen for urine analysis. Obtaining a urine analysis (C) should be done first because
preterm clients with uterine irritability and contractions are often suffering from a urinary
tract infection, and this should be ruled out first.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the
postpartum unit. Which nursing plan is best in assisting this mother to bond with her
newborn infant? - Answer-Meet the mother's physical needs and demonstrate warmth
toward the infant. It is most important to meet the mother's requirement for attention to
her needs so that she can begin infant care-taking (D).
,The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform? - Answer-Observe for
an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a
vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a
fractured clavicle should be suspected if an infant has limited use of the affected arm,
malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal
swelling or tenderness, or cries when the arm is moved.
A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge? - Answer-It is difficult to consume 18 mg of additional iron by diet alone.
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and
to meet the demands of pregnancy is difficult (B) so iron supplements are often
recommended.
The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP
110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse implement? - Answer-Monitor
bleeding from IV sites. Monitoring bleeding from peripheral sites (C) is the priority
intervention. This client is presenting with signs of placental abruption. Disseminated
intravascular coagulation (DIC) is a complication of placental abruptio, characterized by
abnormal bleeding.
In developing a teaching plan for expectant parents, the nurse plans to include
information about when the parents can expect the infant's fontanels to close. The nurse
bases the explanation on knowledge that for the normal newborn, the - Answer-anterior
fontanel closes at 12 to 18 months and the posterior by the end of the second month. In
the normal infant the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel by the end of the second month (D).
The nurse is performing a gestational age assessment on a full-term newborn during
the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment,
the nurse determines that the neonate has a maturity rating of 40-weeks. What findings
should the nurse identify to determine if the neonate is small for gestational age (SGA)?
(Select all that apply.) - Answer-Admission weight of 4 pounds, 15 ounces (2244
grams).
Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved? -
Answer-A decrease in respiratory rate from 24 to 16.
, Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory
rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic
effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.) - Answer-A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine contractions or
"afterpains?" - Answer-Lying prone with a pillow on the abdomen. Lying prone (A) keeps
the fundus contracted and is especially useful with multiparas, who commonly
experience afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to
augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions? - Answer-Transition labor with contractions every 2 minutes,
lasting 90 seconds each.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull
pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and
initiates an IV. Thirty minutes after admission, the client reports feeling a sharp
abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart
rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse
implement next? - Answer-Increase IV rate. The client is demonstrating symptoms of
blood loss, probably the result of an ectopic pregnancy, which occurs at approximately
14-weeks gestation when embryonic growth expands the fallopian tube causing its
rupture, and can result in hemorrage and hypovolemic shock. Increasing the IV infusion
rate (C) provides intravascular fluid to maintain blood pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment,
the nurse determines that both breasts are swollen, warm, and tender upon palpation.
What action should the nurse take? - Answer-Apply cold compresses to both breasts for
comfort. The client is experiencing engorgement even though she is bottle-feeding her
infant, and cold compresses (A) may help reduce discomfort. Lactation begins about the
third day after delivery, so the mother should avoid any breast stimulation,
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The
nurse explains to the client that her vaginal discharge will change from red to pink and
then to white. The client asks, "What if I start having red bleeding after it changes?"
What should the nurse instruct the client to do? - Answer-Reduce activity level and
notify the healthcare provider. Lochia should progress in stages from rubra (red) to
serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually
indicates subinvolution or infection. If such a sign occurs, the mother should notify the
clinic/healthcare provider and reduce her activity to conserve energy (A).
EVOLVE OBSTETRICS/MATERNITY
PRACTICE EXAM, HESI MATERNITY
QUESTIONS AND ANSWERS
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin)
secondary infusion and complains of pain in her lower back. Which intervention should
the nurse implement? - Answer-Apply firm pressure to sacral area. The discomfort of
back labor can be minimized by the application of firm pressure to the sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her
bag of water has broken. The nurse identifies the presence of meconium fluid on the
perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What
action should the nurse implement next? - Answer-Complete a sterile vaginal exam. A
vaginal exam (A) should be performed after the rupture of membranes to determine the
presence of a prolapsed cord.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks
gestation. The nurse determines that the client is not having contractions, the fetal heart
rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action
should the nurse take? - Answer-Ask the client if she has felt any fetal movement.
Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding my
first child, but I would like to try with this baby." Which intervention is best for the nurse
to implement first? - Answer-Provide assistance to the mother to begin breastfeeding as
soon as possible after delivery.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client
is coming to the unit with suspected abruptio placentae. What findings should the
charge nurse expect the client to demonstrate? (Select all that apply.) - Answer-Dark,
red vaginal bleeding.
Increased uterine irritability.
A rigid abdomen.
The nurse is teaching care of the newborn to a group of prospective parents and
describes the need for administering antibiotic ointment into the eyes of the newborn.
Which infectious organism will this treatment prevent from harming the infant? - Answer-
Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye
within 2 hours after birth to prevent ophthalmica neonatorum, an infection caused by
gonorrhea, and inclusion conjunctivitis, an infection caused by chlamydia (C).
,In evaluating the respiratory effort of a one-hour-old infant using the Silverman-
Anderson Index, the nurse determines the infant has synchronized chest and abdominal
movement, just visible lower chest retractions, just visible xiphoid retractions, minimal
and transient nasal flaring, and an expiratory grunt heard only on auscultation. What
Silverman-Anderson score should the nurse assign to this infant? (Enter numeral value
only.) - Answer-A Silverman-Anderson Index has five categories with scores of 0, 1, or
2. The total score ranges from 0 to 10. Four of the these assessment findings should
receive a score of 1, and the 5th finding (synchronized chest and abdominal movement)
receives a score of 0. Therefore, the total score is 4. A total score of 0 means the infant
has no dyspnea, a total score of 10 indicates maximum respiratory distress.
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern
as a tool to assist her in conceiving a child. Which temperature pattern indicates the
occurrence of ovulation, and therefore, the best time for intercourse to ensure
conception? - Answer-Between the time the temperature falls and rises. In most
women, the BBT drops slightly 24 to 36 hours before ovulation and rises 24 to 72 hours
after ovulation, when the corpus luteum of the ruptured ovary produces progesterone.
Therefore, intercourse between the time of the temperature fall and rise (A) is the best
time for conception.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation should the nurse provide? - Answer-Your milk is
sufficient if the baby is voiding pale straw-colored urine 6 to 10 times a day. The urine
will be dilute (straw-colored) and frequent (>6 to 10 times/day) (B), if the infant is
adequately hydrated.
A 28-year-old client in active labor complains of cramps in her leg. What intervention
should the nurse implement? - Answer-Extend the leg and dorsiflex the foot.
Dorsiflexing the foot by pushing the sole of the foot forward or by standing (if the client
is capable) (B), and putting the heel of the foot on the floor is the best means of
relieving leg cramps.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted
for observation. She is contracting irregularly and demonstrates underlying uterine
irritability. Vaginal examination reveals that her cervix is closed, thick, and high. Based
on these data, which intervention should the nurse implement first? - Answer-Obtain a
specimen for urine analysis. Obtaining a urine analysis (C) should be done first because
preterm clients with uterine irritability and contractions are often suffering from a urinary
tract infection, and this should be ruled out first.
A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the
postpartum unit. Which nursing plan is best in assisting this mother to bond with her
newborn infant? - Answer-Meet the mother's physical needs and demonstrate warmth
toward the infant. It is most important to meet the mother's requirement for attention to
her needs so that she can begin infant care-taking (D).
,The nurse identifies crepitus when examining the chest of a newborn who was delivered
vaginally. Which further assessment should the nurse perform? - Answer-Observe for
an asymmetrical Moro (startle) reflex. The most common neonatal birth trauma due to a
vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a
fractured clavicle should be suspected if an infant has limited use of the affected arm,
malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal
swelling or tenderness, or cries when the arm is moved.
A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge? - Answer-It is difficult to consume 18 mg of additional iron by diet alone.
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron and
to meet the demands of pregnancy is difficult (B) so iron supplements are often
recommended.
The nurse assesses a client admitted to the labor and delivery unit and obtains the
following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP
110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these
assessment findings, what intervention should the nurse implement? - Answer-Monitor
bleeding from IV sites. Monitoring bleeding from peripheral sites (C) is the priority
intervention. This client is presenting with signs of placental abruption. Disseminated
intravascular coagulation (DIC) is a complication of placental abruptio, characterized by
abnormal bleeding.
In developing a teaching plan for expectant parents, the nurse plans to include
information about when the parents can expect the infant's fontanels to close. The nurse
bases the explanation on knowledge that for the normal newborn, the - Answer-anterior
fontanel closes at 12 to 18 months and the posterior by the end of the second month. In
the normal infant the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel by the end of the second month (D).
The nurse is performing a gestational age assessment on a full-term newborn during
the first hour of transition using the Ballard (Dubowitz) scale. Based on this assessment,
the nurse determines that the neonate has a maturity rating of 40-weeks. What findings
should the nurse identify to determine if the neonate is small for gestational age (SGA)?
(Select all that apply.) - Answer-Admission weight of 4 pounds, 15 ounces (2244
grams).
Head to heel length of 17 inches (42.5 cm).
Frontal occipital circumference of 12.5 inches (31.25 cm).
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved? -
Answer-A decrease in respiratory rate from 24 to 16.
, Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory
rate (C) indicates that the drug is effective. (Respiratory rate below 12 indicates toxic
effects.)
The nurse is preparing a client with a term pregnancy who is in active labor for an
amniotomy. What equipment should the nurse have available at the client's bedside?
(Select all that apply.) - Answer-A sterile glove.
An amnihook.
Lubricant.
Which nursing intervention is most helpful in relieving postpartum uterine contractions or
"afterpains?" - Answer-Lying prone with a pillow on the abdomen. Lying prone (A) keeps
the fundus contracted and is especially useful with multiparas, who commonly
experience afterpains due to lack of uterine tone.
A 42-week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to
augment early labor. The nurse should discontinue the oxytocin infusion for which
pattern of contractions? - Answer-Transition labor with contractions every 2 minutes,
lasting 90 seconds each.
At 14-weeks gestation, a client arrives at the Emergency Center complaining of a dull
pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and
initiates an IV. Thirty minutes after admission, the client reports feeling a sharp
abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart
rate of 120 beats/minute, and a blood pressure of 86/48. Which action should the nurse
implement next? - Answer-Increase IV rate. The client is demonstrating symptoms of
blood loss, probably the result of an ectopic pregnancy, which occurs at approximately
14-weeks gestation when embryonic growth expands the fallopian tube causing its
rupture, and can result in hemorrage and hypovolemic shock. Increasing the IV infusion
rate (C) provides intravascular fluid to maintain blood pressure.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment,
the nurse determines that both breasts are swollen, warm, and tender upon palpation.
What action should the nurse take? - Answer-Apply cold compresses to both breasts for
comfort. The client is experiencing engorgement even though she is bottle-feeding her
infant, and cold compresses (A) may help reduce discomfort. Lactation begins about the
third day after delivery, so the mother should avoid any breast stimulation,
The nurse is providing discharge teaching for a client who is 24 hours postpartum. The
nurse explains to the client that her vaginal discharge will change from red to pink and
then to white. The client asks, "What if I start having red bleeding after it changes?"
What should the nurse instruct the client to do? - Answer-Reduce activity level and
notify the healthcare provider. Lochia should progress in stages from rubra (red) to
serosa (pinkish) to alba (whitish), and not return to red. The return to rubra usually
indicates subinvolution or infection. If such a sign occurs, the mother should notify the
clinic/healthcare provider and reduce her activity to conserve energy (A).
