HESI PRACTICE EXAM QUESTIONS
WITH COMPLETE SOLUTIONS
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-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 couple has been trying to conceive for nine months without success. Which
information obtained from the clients is most likely to have an impact on the couple's
ability to conceive a child? - ANSWER-The use of lubricants has the potential to
affect fertility because some lubricants interfere with sperm motility.
A pregnant client tells the nurse that the first day of her last menstrual period was
August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? -
ANSWER-Since this woman's first day of her last normal menstrual period occurred
on August 2, 2006, the estimated date of delivery is May 9, 2007. Nägele's rule is
used to calculate the expected date of delivery, and is obtained by subtracting 3
months and adding 7 days beginning from the first day of the last normal menstrual
period.
A client with NO prenatal care arrives at the labor unit screaming, "The baby is
coming!" The nurse performs a vaginal examination that reveals the cervix is 3
centimeters dilated and 75% effaced. What additional information is most important
for the nurse to obtain? - ANSWER-Date of last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and
the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong
the pregnancy and administer corticosteroids to mature the lungs of the fetus.
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?
- ANSWER-A single sterile glove, an amniotic hook, and Doppler to check fetal heart
tones are the necessary equipment for performing an amniotomy.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing
is recommended for which purpose? - ANSWER-Alpha-fetoprotein (AFP) is a
screening test used in pregnancy. Elevated AFP may indicate an increased rish of
neural tube defects such as anencephaly and spinal bifida.
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-The client is
experiencing engorgement even though she is bottle-feeding her infant, and cold
compresses may help reduce discomfort. Lactation begins about the third day after
, delivery, so the mother should avoid any breast stimulation, which further stimulates
milk production. To aid in suppressing lactation, a well-fitting bra, should be worn to
support and bind the breasts.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing
actions? (Arrange in order.) - ANSWER-To stabilize the fetus, intrauterine
resuscitation is the first priority, and to enhance fetal blood supply, the laboring client
should be repositioned (1) to displace the gravid uterus and improve fetal perfusion.
Secondly, to optimize oxygenation of the circulatory blood volume, oxygen via face
mask (2) should be applied to the mother. Next, the IV fluids should be increased (3)
to expand the maternal circulating blood volume. Then, the primary healthcare
provider should be notified (4) for additional interventions to resolve the fetal stress.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn
nursery. What intervention should the nurse perform first? - ANSWER-To reduce
direct contact with the human immuno-virus in blood and body fluids on the
newborn's skin, a bath with an antimicrobial soap should be administered first.
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-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 provides intravascular fluid to maintain blood
pressure.
Client teaching is an important part of the maternity nurse's role. Which factor has
the greatest influence on successful teaching of the gravid client? - ANSWER-When
teaching any client, readiness to learn is the most important criterion. For example,
the client with severe morning sickness in the first trimester may not be "ready to
learn" about labor and delivery, but is probably very "ready to learn" about ways to
relieve morning sickness.
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 would
be most effective in preventing pooling of blood in the lower extremities? - ANSWER-
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
During a prenatal visit, the nurse discusses with a client the effects of smoking on
the fetus. When compared with nonsmokers, mothers who smoke during pregnancy
tend to produce infants who have.. - ANSWER-lower birth weights
Smoking is associated with low-birth-weight infants (B). Mothers are encouraged not
to smoke during pregnancy. To date, significant relationships have NOT been found
WITH COMPLETE SOLUTIONS
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-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 couple has been trying to conceive for nine months without success. Which
information obtained from the clients is most likely to have an impact on the couple's
ability to conceive a child? - ANSWER-The use of lubricants has the potential to
affect fertility because some lubricants interfere with sperm motility.
A pregnant client tells the nurse that the first day of her last menstrual period was
August 2, 2006. Based on Nägele's rule, what is the estimated date of delivery? -
ANSWER-Since this woman's first day of her last normal menstrual period occurred
on August 2, 2006, the estimated date of delivery is May 9, 2007. Nägele's rule is
used to calculate the expected date of delivery, and is obtained by subtracting 3
months and adding 7 days beginning from the first day of the last normal menstrual
period.
A client with NO prenatal care arrives at the labor unit screaming, "The baby is
coming!" The nurse performs a vaginal examination that reveals the cervix is 3
centimeters dilated and 75% effaced. What additional information is most important
for the nurse to obtain? - ANSWER-Date of last normal menstrual period.
Evaluating the gestation of the pregnancy takes priority. If the fetus is preterm and
the fetal heart pattern is reassuring, the healthcare provider may attempt to prolong
the pregnancy and administer corticosteroids to mature the lungs of the fetus.
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?
- ANSWER-A single sterile glove, an amniotic hook, and Doppler to check fetal heart
tones are the necessary equipment for performing an amniotomy.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing
is recommended for which purpose? - ANSWER-Alpha-fetoprotein (AFP) is a
screening test used in pregnancy. Elevated AFP may indicate an increased rish of
neural tube defects such as anencephaly and spinal bifida.
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-The client is
experiencing engorgement even though she is bottle-feeding her infant, and cold
compresses may help reduce discomfort. Lactation begins about the third day after
, delivery, so the mother should avoid any breast stimulation, which further stimulates
milk production. To aid in suppressing lactation, a well-fitting bra, should be worn to
support and bind the breasts.
During labor, the nurse determines that a full-term client is demonstrating late
decelerations. In which sequence should the nurse implement these nursing
actions? (Arrange in order.) - ANSWER-To stabilize the fetus, intrauterine
resuscitation is the first priority, and to enhance fetal blood supply, the laboring client
should be repositioned (1) to displace the gravid uterus and improve fetal perfusion.
Secondly, to optimize oxygenation of the circulatory blood volume, oxygen via face
mask (2) should be applied to the mother. Next, the IV fluids should be increased (3)
to expand the maternal circulating blood volume. Then, the primary healthcare
provider should be notified (4) for additional interventions to resolve the fetal stress.
A vaginally delivered infant of an HIV positive mother is admitted to the newborn
nursery. What intervention should the nurse perform first? - ANSWER-To reduce
direct contact with the human immuno-virus in blood and body fluids on the
newborn's skin, a bath with an antimicrobial soap should be administered first.
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-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 provides intravascular fluid to maintain blood
pressure.
Client teaching is an important part of the maternity nurse's role. Which factor has
the greatest influence on successful teaching of the gravid client? - ANSWER-When
teaching any client, readiness to learn is the most important criterion. For example,
the client with severe morning sickness in the first trimester may not be "ready to
learn" about labor and delivery, but is probably very "ready to learn" about ways to
relieve morning sickness.
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 would
be most effective in preventing pooling of blood in the lower extremities? - ANSWER-
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
During a prenatal visit, the nurse discusses with a client the effects of smoking on
the fetus. When compared with nonsmokers, mothers who smoke during pregnancy
tend to produce infants who have.. - ANSWER-lower birth weights
Smoking is associated with low-birth-weight infants (B). Mothers are encouraged not
to smoke during pregnancy. To date, significant relationships have NOT been found
