HESI RN MATERNITY ASSIGNMENT
EXAM QUESTIONS WITH CORRECT
ANSWERS
The nurse is assessing a full-term newborn's breathing pattern. Which findings
should the nurse assess further? (Select all that apply) - ANSWER-B. Chest
breathing with nasal flaring
C. Diaphragmatic with chest retraction
F. Grunting heard with a stethoscope
What action should the nurse implement when caring for a newborn receiving
phototherapy?
-reposition every 6 hr
-place eye shield over eyes
-limit intake of formula
-apply oil based lotion to skin - ANSWER-B. Place an eyeshield over the eyes
Which finding indicates to the nurse that a 4 day old infant is receiving adequate
breast milk?
-gain 1-2 oz per week
-saturates 6-8 diapers per day
-rests for 6 hours b/w feedings
-defecates at least once per 24 hours - ANSWER-B. Saturates 6 to 8 diapers per day
The nurse is providing discharge teaching for a gravid client who is being released
from the hospital after placement of cerclage. Which instruction is the most important
for the client to understand?
-plan for a possible cesarean birth
-arrange for home uterine monitoring
-make arrangements for care at home
-report uterine cramping or low backache - ANSWER-D. Report uterine cramping or
low backache
A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint
of bright red, painless vaginal bleeding. For which diagnostic procedure should the
nurse prepare the client?
-contraction stress test
-internal fetal monitoring
-abdominal ultrasound
-lecithin-sphingmyelin ratio - ANSWER-C. Abdominal ultrasound
The nurse is planning for the care of a 30 year old primigravida with pre-gestational
diabetes. What is the most important factor affecting this client's pregnancy
outcome?
-mothers age
-amount of insulin required prenatally
-degree of glycemic control during pregnancy
,-number of years since diabetes was diagnosed - ANSWER-C. Degree of glycemic
control during pregnancy
A client with asthma who is 8 hours post delivery is experiencing postpartum
hemorrhage. Which prescription should the nurse administer?
-oxytocin
-ibuprofen
-fentanyl
-hemabate - ANSWER-A. Oxytocin (Pitocin)
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a
client at 32 weeks gestation who has severe preeclampsia with pulmonary edema.
What action should the nurse implement?
-assess fetal response to procedure
-note any complaint of sudden chest pain
-monitor for premature ventricular contractions
-observe for maternal bp changes - ANSWER-C. Monitor for premature ventricular
contractions
A client at 28 weeks gestation experiences blunt abdominal trauma. Which
parameter should the nurse assess first for signs of internal hemorrhage?
-vaginal bleeding
-complaints of abdominal pain
-changes is FHR patterns
-alteration in maternal bp - ANSWER-C. Changes in fetal heart rate patterns
A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An
intrauterine pressure catheter (IUPC) is in place when the client's membranes
rupture after 5 hours of active labor. Which finding would require the nurse to take
action?
-labor has progressed at 1 cm/hr dilation
-intensity of contractions is 130 mmHg
-contractions are lasting 60-80 seconds
-oxytocin is infusing at a rate of 30 mU/min - ANSWER-B. Intensity of contractions is
130 mmHg
A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has
broken. While inspecting the client's perineum, the nurse notes the umbilical cord
protruding from the vagina. What action should the nurse implement?
-administer 10 L of oxytocin via face mask
-give the HCP a status report
-place client in knee-chest position
-wrap the cord with glaze soaked in saline - ANSWER-C. Place the client in the
knee-chest position
The nurse is caring for a client whose labor is being augmented with oxytocin
(Pitocin). Which finding indicates that the nurse should discontinue the oxytocin
infusion?
-client needs to void
-amniotic membranes rupture
, -uterine contractions occur every 8-10 min
-FHR is 180 bpm w/o variability - ANSWER-D. The fetal heart rate is 180 bpm
without variability
The nurse on the postpartum unit receives report for 4 clients during change of shift.
Which client should the nurse assess for risk of postpartum hemorrhage?
-primigravida who had spontaneous birth of preterm twins
-multigravida who delivered an 8 lb 2 oz infant after 8 hour labor
-multiparous client receiving magnesium sulfate during induction for severe
preeclampsia
-primiparous client who had an emergency cesarean birth due to fetal distress -
ANSWER-C. A multiparous client receiving magnesium sulfate during induction for
severe preeclampsia
What nursing action should be included in the plan of care for a newborn
experiencing symptoms of drug withdrawal?
-play soft music and talk to soothe the infant
-administer chloral hydrate for sedation
-feed every 4-6 hours to allow extra rest
-swaddle the infant snugly and hold tight - ANSWER-D. Swaddle the infant snugly
and hold tightly
The father of a newborn tells the nurse, "My son just died." how should the nurse
respond?
-I am sorry for your loss
-there is an angel in heaven
-I understand how you feel
-you can have other children - ANSWER-A. "I am sorry for your loss."
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery.
After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the
priority nursing action?
-assess newborn reflexes for signs of neuro impairment
-leave infant in the room with the mother to foster attachment
-obtain serum glucose levels frequently while observing closely for signs of
hypoglycemia
-perform a gestational age assessment to determine if the infant is large for
gestational age - ANSWER-C. Obtain serum glucose levels frequently while
observing closely for signs of hypoglycemia
An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a
nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the
face and upper back of the newborn. What information should the nurse provide?
-further assessment is indicated
-petechiae occurs with forceps delivery
-an increased blood volume causes broken blood vessels
-pinpoint spots are benign and disappear within 48 hours - ANSWER-D. The pinpoint
spots are benign and disappear within 48 hours
EXAM QUESTIONS WITH CORRECT
ANSWERS
The nurse is assessing a full-term newborn's breathing pattern. Which findings
should the nurse assess further? (Select all that apply) - ANSWER-B. Chest
breathing with nasal flaring
C. Diaphragmatic with chest retraction
F. Grunting heard with a stethoscope
What action should the nurse implement when caring for a newborn receiving
phototherapy?
-reposition every 6 hr
-place eye shield over eyes
-limit intake of formula
-apply oil based lotion to skin - ANSWER-B. Place an eyeshield over the eyes
Which finding indicates to the nurse that a 4 day old infant is receiving adequate
breast milk?
-gain 1-2 oz per week
-saturates 6-8 diapers per day
-rests for 6 hours b/w feedings
-defecates at least once per 24 hours - ANSWER-B. Saturates 6 to 8 diapers per day
The nurse is providing discharge teaching for a gravid client who is being released
from the hospital after placement of cerclage. Which instruction is the most important
for the client to understand?
-plan for a possible cesarean birth
-arrange for home uterine monitoring
-make arrangements for care at home
-report uterine cramping or low backache - ANSWER-D. Report uterine cramping or
low backache
A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint
of bright red, painless vaginal bleeding. For which diagnostic procedure should the
nurse prepare the client?
-contraction stress test
-internal fetal monitoring
-abdominal ultrasound
-lecithin-sphingmyelin ratio - ANSWER-C. Abdominal ultrasound
The nurse is planning for the care of a 30 year old primigravida with pre-gestational
diabetes. What is the most important factor affecting this client's pregnancy
outcome?
-mothers age
-amount of insulin required prenatally
-degree of glycemic control during pregnancy
,-number of years since diabetes was diagnosed - ANSWER-C. Degree of glycemic
control during pregnancy
A client with asthma who is 8 hours post delivery is experiencing postpartum
hemorrhage. Which prescription should the nurse administer?
-oxytocin
-ibuprofen
-fentanyl
-hemabate - ANSWER-A. Oxytocin (Pitocin)
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a
client at 32 weeks gestation who has severe preeclampsia with pulmonary edema.
What action should the nurse implement?
-assess fetal response to procedure
-note any complaint of sudden chest pain
-monitor for premature ventricular contractions
-observe for maternal bp changes - ANSWER-C. Monitor for premature ventricular
contractions
A client at 28 weeks gestation experiences blunt abdominal trauma. Which
parameter should the nurse assess first for signs of internal hemorrhage?
-vaginal bleeding
-complaints of abdominal pain
-changes is FHR patterns
-alteration in maternal bp - ANSWER-C. Changes in fetal heart rate patterns
A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An
intrauterine pressure catheter (IUPC) is in place when the client's membranes
rupture after 5 hours of active labor. Which finding would require the nurse to take
action?
-labor has progressed at 1 cm/hr dilation
-intensity of contractions is 130 mmHg
-contractions are lasting 60-80 seconds
-oxytocin is infusing at a rate of 30 mU/min - ANSWER-B. Intensity of contractions is
130 mmHg
A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has
broken. While inspecting the client's perineum, the nurse notes the umbilical cord
protruding from the vagina. What action should the nurse implement?
-administer 10 L of oxytocin via face mask
-give the HCP a status report
-place client in knee-chest position
-wrap the cord with glaze soaked in saline - ANSWER-C. Place the client in the
knee-chest position
The nurse is caring for a client whose labor is being augmented with oxytocin
(Pitocin). Which finding indicates that the nurse should discontinue the oxytocin
infusion?
-client needs to void
-amniotic membranes rupture
, -uterine contractions occur every 8-10 min
-FHR is 180 bpm w/o variability - ANSWER-D. The fetal heart rate is 180 bpm
without variability
The nurse on the postpartum unit receives report for 4 clients during change of shift.
Which client should the nurse assess for risk of postpartum hemorrhage?
-primigravida who had spontaneous birth of preterm twins
-multigravida who delivered an 8 lb 2 oz infant after 8 hour labor
-multiparous client receiving magnesium sulfate during induction for severe
preeclampsia
-primiparous client who had an emergency cesarean birth due to fetal distress -
ANSWER-C. A multiparous client receiving magnesium sulfate during induction for
severe preeclampsia
What nursing action should be included in the plan of care for a newborn
experiencing symptoms of drug withdrawal?
-play soft music and talk to soothe the infant
-administer chloral hydrate for sedation
-feed every 4-6 hours to allow extra rest
-swaddle the infant snugly and hold tight - ANSWER-D. Swaddle the infant snugly
and hold tightly
The father of a newborn tells the nurse, "My son just died." how should the nurse
respond?
-I am sorry for your loss
-there is an angel in heaven
-I understand how you feel
-you can have other children - ANSWER-A. "I am sorry for your loss."
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery.
After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the
priority nursing action?
-assess newborn reflexes for signs of neuro impairment
-leave infant in the room with the mother to foster attachment
-obtain serum glucose levels frequently while observing closely for signs of
hypoglycemia
-perform a gestational age assessment to determine if the infant is large for
gestational age - ANSWER-C. Obtain serum glucose levels frequently while
observing closely for signs of hypoglycemia
An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a
nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the
face and upper back of the newborn. What information should the nurse provide?
-further assessment is indicated
-petechiae occurs with forceps delivery
-an increased blood volume causes broken blood vessels
-pinpoint spots are benign and disappear within 48 hours - ANSWER-D. The pinpoint
spots are benign and disappear within 48 hours
