HESI-MATERNITY & PEDIATRICS
EXAM QUESTIONS WITH VERIFIED
ANSWERS
A newly pregnant client is crying loudly and reports to the clinic nurse over the phone
that she took a prescribed narcotic pain medication 4 weeks ago. What is the nurse's
next response? - ANSWER-"When did your last period begin?"
During stage two of labor, what assessments must the labor nurse perform? (Select
all that apply.) - ANSWER-Fetal heart rate before the contraction
Fetal heart rate during the contraction
Fetal heart rate after the contraction
Frequency of contractions
Duration of contractions
Uterine tone between contractions
A primigravida at term presents to the labor and delivery unit smiling and states to
the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds
it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes
are intact. Maternal vital signs are stable. What are the nursing actions for this
phase/stage of labor? (Select all that apply.) - ANSWER-Encourage the mother to
ambulate.
Have the mother use slow, deep breathing with contractions.
Encourage the mother to urinate every 1 to 2 hours.
A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. The head is really funny looking." Which response by the nurse is
best? - ANSWER-"That is normal. The head will return to a round shape within 7 to
10 days."
The nurse is providing care to a 1-hour-old neonate born to mother who took insulin
throughout her pregnancy. Which conditions will the nurse include in the infant's
assessment throughout its hospitalization? (Select all that apply.) - ANSWER-
Hypoglycemia
Respiratory distress syndrome
Congenital anomalies
A mother who is breastfeeding her baby receives instructions from the nurse. Which
instructions are most effective in preventing nipple soreness? (Select all that apply.) -
ANSWER-Massage a small amount of medical-grade lanolin into the nipple.
Ensure that the baby is positioned correctly for latching on.
The clinic nurse is performing a fundal height assessment on a client in her third
trimester. The client states to the nurse, "I am feeling very dizzy when you are
pressing on my belly." What are the nurse's best actions to this comment? (Select all
that apply.) - ANSWER-Turn the client to her left side.
State, "That is from your baby pressing down on your blood vessels."
,The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted
client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and
start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3
to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units.
What supplies will the nurse need to gather to start the infusion? (Select all that
apply.) - ANSWER-Three vials of oxytocin
Alcohol wipe
IV start kit
One or three mL syringe
The health care provider states to the nurse, the baby is in a left occiput anterior
(LOA) position. The laboring client asks, "What does that mean?" What descriptions
will the nurse use when teaching the client about the LOA fetal position? (Select all
that apply.) - ANSWER-"The baby's head is in your pelvis."
"That is the ideal fetal birthing position."
"The baby is looking down towards the floor"
The nurse is teaching a prenatal class about the structure of the pelvis and is using a
model of a pelvis in the presentation. Which statements will the nurse include in the
teaching plan? (Select all that apply.) - ANSWER-"The baby has to pass through the
true pelvis."
"The pelvis consists of three distinct features."
"The true pelvis is below the pelvic brim."
"The ischial spines determine how low the baby is located."
The nurse is providing care to a 1-hour-old infant. An assessment of gestational age
is performed and the nurse estimates the age at 39 to 40 weeks. What findings will
the nurse document in the infant's chart? (Select all that apply.) - ANSWER-Vernix in
the creases of the neck
Labia majora covers the labia minora.
A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in blood pressure. When the
client calls the clinic complaining of indigestion, which instruction should the nurse
provide? - ANSWER-Take your blood pressure now, and if it is seriously elevated,
go to the hospital.
A client in early labor is requesting pain medication. The health care provider
prescribes butorphanol 0.5 mg IV × 1 now. The only butorphanol available is in a
concentration of 2 mg/mL. How many mL will the nurse deliver to the client? -
ANSWER-0.25
A client at term presents to labor and delivery in spontaneous labor; contractions are
occurring every 3 to 4 minutes and they are 60 seconds in duration. The client states
to the nurse, "I think I have a break out of my genital herpes." What actions will the
nurse take next? (Select all that apply.) - ANSWER-Observe the client's perineum.
Contact the health care provider.
Assess ongoing acyclovir treatment.
,A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her
baby will become HIV infected. Which explanation should the nurse provide? -
ANSWER-HIV infection is determined at 18 months of age, when maternal HIV
antibodies are no longer present.
The nurse is counseling a client who wants to become pregnant. She tells the nurse
that she has a 36-day menstrual cycle and the first day of her last menstrual period
was January 8. When will the client's next fertile period occur? - ANSWER-January
29 to 30
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The
nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with
intact membranes. The monitor indicates that the FHR decelerates at the onset of
several contractions and returns to baseline before each contraction ends. Which
action should the nurse take next? - ANSWER-Continue to monitor labor progress.
The postpartum client is preparing for discharge. She states to the nurse, "I have not
had a bowel movement yet." What are the nurse's recommendations for this client?
(Select all that apply.) - ANSWER-"Drink no less than 5, 8-ounce glasses of water or
non-caffeine beverages per day."
"Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears."
"Since it is nice outside, take a 15-minute walk two to three times a day."
The nurse is teaching care of the newborn to a childbirth preparation class and
describes the need for administering antibiotic ointment into the eyes of the newborn.
An expectant father asks, "What type of disease causes infections in babies that can
be prevented by using this ointment?" Which response by the nurse is accurate?
(Select all that apply.) - ANSWER-Gonorrhea
Chlamydia
The nurse is teaching the pregnant client about fetal growth and development. Which
client statements indicate understanding of the teaching? (Select all that apply.) -
ANSWER-My baby gets oxygen through the placenta.
The amniotic fluid helps with muscle development.
My baby will gain about a half a pound per week after 36 weeks.
The nurse is providing care for a laboring client with a GTPAL of 65005 at term.
Which assessments will the nurse include in this client's plan of care for after
delivery? (Select all that apply.) - ANSWER-Fundal assessment should be made
every 5 minutes for 30 minutes after delivery of the placenta.
Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta.
Place the infant to breast immediately after delivery
The clinic nurse is providing care to a client at 28 weeks gestation. The client asks,
"What does my baby look like now?" How will the nurse respond? (Select all that
apply.) - ANSWER-"Your baby weighs about 2.5 pounds."
"The baby's arms are bent at the elbows."
"Your baby can open and close its eyes now."
, When preparing a class on newborn care for expectant parents, which is correct for
the nurse to teach concerning the newborn infant born at term gestation? -
ANSWER-Vernix is a white cheesy substance, predominantly located in the skin
folds.
The nurse is providing care to a client who just delivered her sixth term infant. In
addition to routine postpartum care, what additional priority nursing action will the
nurse include in this client's plan of care? - ANSWER-Weigh the peri pads before
and after placement to the peri area.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal
delivery. In developing a plan of care, the nurse should give the highest priority to
which finding? - ANSWER-Skin color that is slightly jaundiced
Which client statement indicates that she understands the instructions of
breastfeeding her newborn? (Select all that apply.) - ANSWER-"Breastfeeding my
infant consistently every 3 to 4 hours decreases the likelihood of me ovulating."
"I should avoid foods that usually give me gas."
"When I feed my baby, I should start on the breast the baby stopped on last."
"I should drink fluids when breastfeeding my baby, especially at night."
Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home? - ANSWER-Allow the cord to air-dry as
much as possible.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. What is the next
nursing action? - ANSWER-Put the newborn to the breast immediately.
The nurse is discussing the timing of the next prenatal visit for the client at 34 weeks
gestation. If the current visit occurred on April 4, which statement indicates the client
understands the teaching? - ANSWER-"I can come in on April 18."
The clinic nurse is performing an assessment on a client who is 20 weeks gestation,
which was confirmed by ultrasound. When performing the fundal height assessment,
where will the nurse start palpating the abdomen? - ANSWER-At the umbilicus
A new mother who has been insulin dependent for eight years just delivered
spontaneously an 8 pound, 4 ounce infant/3740 grams infant. The nurse obtains a
blood glucose reading of 112 mg/dL when the infant is 8 hours old. What is the best
nursing action for this client? - ANSWER-Document the finding in the client's chart.
A new mother asks the nurse, "How do I know that my baby is getting enough breast
milk?" Which explanation is most appropriate? - ANSWER-"Your milk is sufficient if
the baby is voiding pale, straw-colored urine six to ten times a day."
An induction of labor is planned for the client with diabetes mellitus and dependent
on insulin since the age of 10. The nurse is gathering supplies to care for the client
during the induction. What supplies will the nurse gather? (Select all that apply.) -
ANSWER-An fusion pump for 3 lines
EXAM QUESTIONS WITH VERIFIED
ANSWERS
A newly pregnant client is crying loudly and reports to the clinic nurse over the phone
that she took a prescribed narcotic pain medication 4 weeks ago. What is the nurse's
next response? - ANSWER-"When did your last period begin?"
During stage two of labor, what assessments must the labor nurse perform? (Select
all that apply.) - ANSWER-Fetal heart rate before the contraction
Fetal heart rate during the contraction
Fetal heart rate after the contraction
Frequency of contractions
Duration of contractions
Uterine tone between contractions
A primigravida at term presents to the labor and delivery unit smiling and states to
the nurse, "I am in labor." The nurse assesses the client's cervical dilation and finds
it is 2/50%/-1. The fetal heart rate is stable at 135 to 145 beats/min, and membranes
are intact. Maternal vital signs are stable. What are the nursing actions for this
phase/stage of labor? (Select all that apply.) - ANSWER-Encourage the mother to
ambulate.
Have the mother use slow, deep breathing with contractions.
Encourage the mother to urinate every 1 to 2 hours.
A new mother who has just had her first baby says to the nurse, "I saw the baby in
the recovery room. The head is really funny looking." Which response by the nurse is
best? - ANSWER-"That is normal. The head will return to a round shape within 7 to
10 days."
The nurse is providing care to a 1-hour-old neonate born to mother who took insulin
throughout her pregnancy. Which conditions will the nurse include in the infant's
assessment throughout its hospitalization? (Select all that apply.) - ANSWER-
Hypoglycemia
Respiratory distress syndrome
Congenital anomalies
A mother who is breastfeeding her baby receives instructions from the nurse. Which
instructions are most effective in preventing nipple soreness? (Select all that apply.) -
ANSWER-Massage a small amount of medical-grade lanolin into the nipple.
Ensure that the baby is positioned correctly for latching on.
The clinic nurse is performing a fundal height assessment on a client in her third
trimester. The client states to the nurse, "I am feeling very dizzy when you are
pressing on my belly." What are the nurse's best actions to this comment? (Select all
that apply.) - ANSWER-Turn the client to her left side.
State, "That is from your baby pressing down on your blood vessels."
,The nurse is preparing an infusion of oxytocin to induce labor for a newly admitted
client. The order reads, place 30 units of oxytocin in 500 mL of normal saline and
start at 1 mL/hour. Increase by 1 mL every 30 minutes until contractions are every 3
to 4 minutes. Oxytoxin is packaged in a glass vial that reads, 1 mL contains 10 units.
What supplies will the nurse need to gather to start the infusion? (Select all that
apply.) - ANSWER-Three vials of oxytocin
Alcohol wipe
IV start kit
One or three mL syringe
The health care provider states to the nurse, the baby is in a left occiput anterior
(LOA) position. The laboring client asks, "What does that mean?" What descriptions
will the nurse use when teaching the client about the LOA fetal position? (Select all
that apply.) - ANSWER-"The baby's head is in your pelvis."
"That is the ideal fetal birthing position."
"The baby is looking down towards the floor"
The nurse is teaching a prenatal class about the structure of the pelvis and is using a
model of a pelvis in the presentation. Which statements will the nurse include in the
teaching plan? (Select all that apply.) - ANSWER-"The baby has to pass through the
true pelvis."
"The pelvis consists of three distinct features."
"The true pelvis is below the pelvic brim."
"The ischial spines determine how low the baby is located."
The nurse is providing care to a 1-hour-old infant. An assessment of gestational age
is performed and the nurse estimates the age at 39 to 40 weeks. What findings will
the nurse document in the infant's chart? (Select all that apply.) - ANSWER-Vernix in
the creases of the neck
Labia majora covers the labia minora.
A client at 30 weeks of gestation is on bed rest at home because of increased blood
pressure. The home health nurse has taught her how to take her own blood pressure
and gave her parameters to judge a significant increase in blood pressure. When the
client calls the clinic complaining of indigestion, which instruction should the nurse
provide? - ANSWER-Take your blood pressure now, and if it is seriously elevated,
go to the hospital.
A client in early labor is requesting pain medication. The health care provider
prescribes butorphanol 0.5 mg IV × 1 now. The only butorphanol available is in a
concentration of 2 mg/mL. How many mL will the nurse deliver to the client? -
ANSWER-0.25
A client at term presents to labor and delivery in spontaneous labor; contractions are
occurring every 3 to 4 minutes and they are 60 seconds in duration. The client states
to the nurse, "I think I have a break out of my genital herpes." What actions will the
nurse take next? (Select all that apply.) - ANSWER-Observe the client's perineum.
Contact the health care provider.
Assess ongoing acyclovir treatment.
,A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her
baby will become HIV infected. Which explanation should the nurse provide? -
ANSWER-HIV infection is determined at 18 months of age, when maternal HIV
antibodies are no longer present.
The nurse is counseling a client who wants to become pregnant. She tells the nurse
that she has a 36-day menstrual cycle and the first day of her last menstrual period
was January 8. When will the client's next fertile period occur? - ANSWER-January
29 to 30
The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The
nurse determines that the client is dilated 7 cm and is 100% effaced at 0 station, with
intact membranes. The monitor indicates that the FHR decelerates at the onset of
several contractions and returns to baseline before each contraction ends. Which
action should the nurse take next? - ANSWER-Continue to monitor labor progress.
The postpartum client is preparing for discharge. She states to the nurse, "I have not
had a bowel movement yet." What are the nurse's recommendations for this client?
(Select all that apply.) - ANSWER-"Drink no less than 5, 8-ounce glasses of water or
non-caffeine beverages per day."
"Make sure you eat 4 to 5 servings if high fiber foods a day, like broccoli and pears."
"Since it is nice outside, take a 15-minute walk two to three times a day."
The nurse is teaching care of the newborn to a childbirth preparation class and
describes the need for administering antibiotic ointment into the eyes of the newborn.
An expectant father asks, "What type of disease causes infections in babies that can
be prevented by using this ointment?" Which response by the nurse is accurate?
(Select all that apply.) - ANSWER-Gonorrhea
Chlamydia
The nurse is teaching the pregnant client about fetal growth and development. Which
client statements indicate understanding of the teaching? (Select all that apply.) -
ANSWER-My baby gets oxygen through the placenta.
The amniotic fluid helps with muscle development.
My baby will gain about a half a pound per week after 36 weeks.
The nurse is providing care for a laboring client with a GTPAL of 65005 at term.
Which assessments will the nurse include in this client's plan of care for after
delivery? (Select all that apply.) - ANSWER-Fundal assessment should be made
every 5 minutes for 30 minutes after delivery of the placenta.
Assess for lochia every 5 minutes for 30 minutes after delivery of the placenta.
Place the infant to breast immediately after delivery
The clinic nurse is providing care to a client at 28 weeks gestation. The client asks,
"What does my baby look like now?" How will the nurse respond? (Select all that
apply.) - ANSWER-"Your baby weighs about 2.5 pounds."
"The baby's arms are bent at the elbows."
"Your baby can open and close its eyes now."
, When preparing a class on newborn care for expectant parents, which is correct for
the nurse to teach concerning the newborn infant born at term gestation? -
ANSWER-Vernix is a white cheesy substance, predominantly located in the skin
folds.
The nurse is providing care to a client who just delivered her sixth term infant. In
addition to routine postpartum care, what additional priority nursing action will the
nurse include in this client's plan of care? - ANSWER-Weigh the peri pads before
and after placement to the peri area.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal
delivery. In developing a plan of care, the nurse should give the highest priority to
which finding? - ANSWER-Skin color that is slightly jaundiced
Which client statement indicates that she understands the instructions of
breastfeeding her newborn? (Select all that apply.) - ANSWER-"Breastfeeding my
infant consistently every 3 to 4 hours decreases the likelihood of me ovulating."
"I should avoid foods that usually give me gas."
"When I feed my baby, I should start on the breast the baby stopped on last."
"I should drink fluids when breastfeeding my baby, especially at night."
Prior to discharge, what instructions should the nurse give to parents regarding the
newborn's umbilical cord care at home? - ANSWER-Allow the cord to air-dry as
much as possible.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. What is the next
nursing action? - ANSWER-Put the newborn to the breast immediately.
The nurse is discussing the timing of the next prenatal visit for the client at 34 weeks
gestation. If the current visit occurred on April 4, which statement indicates the client
understands the teaching? - ANSWER-"I can come in on April 18."
The clinic nurse is performing an assessment on a client who is 20 weeks gestation,
which was confirmed by ultrasound. When performing the fundal height assessment,
where will the nurse start palpating the abdomen? - ANSWER-At the umbilicus
A new mother who has been insulin dependent for eight years just delivered
spontaneously an 8 pound, 4 ounce infant/3740 grams infant. The nurse obtains a
blood glucose reading of 112 mg/dL when the infant is 8 hours old. What is the best
nursing action for this client? - ANSWER-Document the finding in the client's chart.
A new mother asks the nurse, "How do I know that my baby is getting enough breast
milk?" Which explanation is most appropriate? - ANSWER-"Your milk is sufficient if
the baby is voiding pale, straw-colored urine six to ten times a day."
An induction of labor is planned for the client with diabetes mellitus and dependent
on insulin since the age of 10. The nurse is gathering supplies to care for the client
during the induction. What supplies will the nurse gather? (Select all that apply.) -
ANSWER-An fusion pump for 3 lines
