MATERNITY HESI PREPARED BY ME
FROM EVOLVE EXAM QUESTIONS
WITH COMPLETE ANSWERS
A client at term presents to the labor and delivery in spontaneous labor; contractions
are occurring every 3 to 4 minutes and they are 60 seconds in durations. The client
states to the nurse, "I think I am having a breakout of my genital herpes." What
actions will the nurse take next? (Select all that apply.)
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
d. Open a vaginal delivery pack.
e. Assess her partner's penis for lesions - ANSWER-Correct Answer:
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
Rationale:
The nurse needs to assess the client's perineum, and the health care provider will
determine the status of the lesions. If active lesions are present, the
recommendation is for a Cesarean section; therefore, opening a vaginal delivery
pack may be unnecessary. It would not be appropriate for the nurse to assess the
partner's penis.
Which parental behavior is a warning to the practical nurse that there may be
negative bonding between parents and a newborn infant?
a. Parents frequently touch the infant and call the infant by name.
b. Parents hold the infant away from the body to show the infant's face.
c. Parents frequently leave the newborn infant wrapped in blankets.
d. Parents give immediate attention to infant's hunger and wet diapers. - ANSWER-c.
Parents frequently leave the newborn infant wrapped in blankets.
Rationale:
Attachment/bonding theory indicates that parents have an extreme interest in
visualizing every part of the newborn in a head to toe examination and exploration
process.
The practical nurse (PN) is assessing a client at 20 weeks' gestation. Which
measurement should be compared with the client's current weight to obtain data
about her weight gain during the entire pregnancy?
a. Usual pre-pregnancy weight
b. Weight at the first prenatal visit
c. Previous pregnancy weight gain
d. Daily weight gains or losses - ANSWER-a. Usual pre-pregnancy weight
Rationale:
Comparing the client's current weight with her pre-pregnancy weight allows for a
calculation of total weight gain.
,The nurse is assisting with data collection on a client who is in her last trimester of
pregnancy. Which findings should the nurse report urgently to the health care
provider? (Select all that apply.)
a. Increased heartburn that is not relieved with doses of antacids
b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
c. Shoes and rings which are too tight because of peripheral edema in extremities
d. Decrease in ability for the client to sleep for more than 2 hours at a time
e. Headaches that have been lingering for a week behind the client's eyes -
ANSWER-a. Increased heartburn that is not relieved with doses of antacids
e. Headaches that have been lingering for a week behind the client's eyes
Rationale:
Intractable indigestion and lingering headaches are not unusual during pregnancy,
but can be symptoms of preeclampsia and should be reported to the health care
provider. The fetal heart rate normally ranges between 120 and 160. Peripheral
edema and difficulty sleeping are common during pregnancy and do not warrant
immediate notification of the health care provider.
Two hours following vaginal delivery in a birthing suite, the practical nurse (PN)
observes that a newborn has respirations that are 58 breaths/min and cyanotic
hands and feet. What action should the PN implement?
a. Continue to observe the infant.
b. Administer oxygen at 5 L/m.
c. Notify the pediatrician immediately.
d. Transfer the infant to the nursery. - ANSWER-a. Continue to observe the infant.
Rationale:
A newborn infant's respirations should range between 40 and 60 breaths/min.
Acrocyanosis (bluing of the hands and feet) is a normal occurrence at birth.
A new mother has delivered her first baby vaginally and says to the practical nurse
(PN), I saw the baby in the recovery room. The baby sure has a funny-looking head.
Which response by the PN is best?
a. This is not an unusual-shaped head, especially for a first baby.
b. It may look odd, but newborn babies are often born with heads like that.
c. That is normal. The head will return to a round shape within 7 to 10 days.
d. Your pelvis was too small, so the head had to adjust to the birth canal. -
ANSWER-c. That is normal. The head will return to a round shape within 7 to 10
days.
Rationale:
Reassure the mother that this shape is normal in the newborn and then provide
information regarding the return to a normal shape of the molded neonate's head
after a vaginal delivery.
An off-duty practical nurse (PN) finds a female in a supermarket parking lot who has
delivered an infant while her husband is screaming for someone to help his wife.
Which intervention has the highest priority?
a. Use thread to tie off the umbilical cord.
b. Provide as much privacy as possible for the female.
c. Reassure the husband and try to keep him calm.
d. Put the newborn to the breast.Correct Answer - ANSWER-d. Put the newborn to
the breast.
, Rationale:
Putting the newborn to the breast will help contract the uterus and prevent a
postpartum hemorrhage. This intervention has the highest priority.
The practical nurse (PN) attempts to help a teenage client with her feelings following
a spontaneous abortion at 8 weeks' gestation. What type of emotional response
should the PN anticipate?
a. Grief related to her perceptions about the loss of this child.
b. Relief of ambivalent feelings experienced with this pregnancy.
c. Shock because she may not have realized that she was pregnant.
d. Guilt because she had not followed her health care provider's instructions. -
ANSWER-a. Grief related to her perceptions about the loss of this child.
Rationale:
A grief and loss response occurs at all stages of pregnancy loss.
Twenty-four hours after a full-term newborn is admitted to the newborn nursery, the
practical nurse (PN) observes a localized swelling on the right side of the head of the
newborn that does not cross the suture line. How does the nurse document this
finding?
a. A cephalohematomaCorrect Answer
b. A subarachnoid hematoma
c. Molding
d. A subdural hematoma - ANSWER-a. A cephalohematoma
Rationale:
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within
the first 24 hours after delivery.
The nurse educates the pregnant client about a new diagnosis of gestational
diabetes. Which statement made by the client indicates the need for further
education?
a. "I should watch for signs of infection and report them to my doctor."
b. "My doctor will prescribe oral medication to help keep my blood sugars normal."
c. "I should continue to exercise because it will help keep my blood glucose levels
down."
d. "If I cannot control my blood sugar with diet alone, my provider may prescribe
insulin." - ANSWER-b. "My doctor will prescribe oral medication to help keep my
blood sugars normal."
Rationale:
Oral hypoglycemics are not prescribed during pregnancy.
The practical nurse (PN) is teaching a couple about ovulation and conception. The
nurse realizes the teaching is effective if the couple states which time is most likely
for conception to occur?
a. 2 weeks before menstruation
b. Immediately after menstruation
c. Immediately before menstruation
d. 3 weeks before menstruation - ANSWER-a. 2 weeks before menstruation
Rationale:
Ovulation occurs 14 days before the first day of the menstrual period.
FROM EVOLVE EXAM QUESTIONS
WITH COMPLETE ANSWERS
A client at term presents to the labor and delivery in spontaneous labor; contractions
are occurring every 3 to 4 minutes and they are 60 seconds in durations. The client
states to the nurse, "I think I am having a breakout of my genital herpes." What
actions will the nurse take next? (Select all that apply.)
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
d. Open a vaginal delivery pack.
e. Assess her partner's penis for lesions - ANSWER-Correct Answer:
a. Observe the client's perineum.
b. Contact the health care provider.
c. Ask the patient about her antiviral therapy.
Rationale:
The nurse needs to assess the client's perineum, and the health care provider will
determine the status of the lesions. If active lesions are present, the
recommendation is for a Cesarean section; therefore, opening a vaginal delivery
pack may be unnecessary. It would not be appropriate for the nurse to assess the
partner's penis.
Which parental behavior is a warning to the practical nurse that there may be
negative bonding between parents and a newborn infant?
a. Parents frequently touch the infant and call the infant by name.
b. Parents hold the infant away from the body to show the infant's face.
c. Parents frequently leave the newborn infant wrapped in blankets.
d. Parents give immediate attention to infant's hunger and wet diapers. - ANSWER-c.
Parents frequently leave the newborn infant wrapped in blankets.
Rationale:
Attachment/bonding theory indicates that parents have an extreme interest in
visualizing every part of the newborn in a head to toe examination and exploration
process.
The practical nurse (PN) is assessing a client at 20 weeks' gestation. Which
measurement should be compared with the client's current weight to obtain data
about her weight gain during the entire pregnancy?
a. Usual pre-pregnancy weight
b. Weight at the first prenatal visit
c. Previous pregnancy weight gain
d. Daily weight gains or losses - ANSWER-a. Usual pre-pregnancy weight
Rationale:
Comparing the client's current weight with her pre-pregnancy weight allows for a
calculation of total weight gain.
,The nurse is assisting with data collection on a client who is in her last trimester of
pregnancy. Which findings should the nurse report urgently to the health care
provider? (Select all that apply.)
a. Increased heartburn that is not relieved with doses of antacids
b. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit
c. Shoes and rings which are too tight because of peripheral edema in extremities
d. Decrease in ability for the client to sleep for more than 2 hours at a time
e. Headaches that have been lingering for a week behind the client's eyes -
ANSWER-a. Increased heartburn that is not relieved with doses of antacids
e. Headaches that have been lingering for a week behind the client's eyes
Rationale:
Intractable indigestion and lingering headaches are not unusual during pregnancy,
but can be symptoms of preeclampsia and should be reported to the health care
provider. The fetal heart rate normally ranges between 120 and 160. Peripheral
edema and difficulty sleeping are common during pregnancy and do not warrant
immediate notification of the health care provider.
Two hours following vaginal delivery in a birthing suite, the practical nurse (PN)
observes that a newborn has respirations that are 58 breaths/min and cyanotic
hands and feet. What action should the PN implement?
a. Continue to observe the infant.
b. Administer oxygen at 5 L/m.
c. Notify the pediatrician immediately.
d. Transfer the infant to the nursery. - ANSWER-a. Continue to observe the infant.
Rationale:
A newborn infant's respirations should range between 40 and 60 breaths/min.
Acrocyanosis (bluing of the hands and feet) is a normal occurrence at birth.
A new mother has delivered her first baby vaginally and says to the practical nurse
(PN), I saw the baby in the recovery room. The baby sure has a funny-looking head.
Which response by the PN is best?
a. This is not an unusual-shaped head, especially for a first baby.
b. It may look odd, but newborn babies are often born with heads like that.
c. That is normal. The head will return to a round shape within 7 to 10 days.
d. Your pelvis was too small, so the head had to adjust to the birth canal. -
ANSWER-c. That is normal. The head will return to a round shape within 7 to 10
days.
Rationale:
Reassure the mother that this shape is normal in the newborn and then provide
information regarding the return to a normal shape of the molded neonate's head
after a vaginal delivery.
An off-duty practical nurse (PN) finds a female in a supermarket parking lot who has
delivered an infant while her husband is screaming for someone to help his wife.
Which intervention has the highest priority?
a. Use thread to tie off the umbilical cord.
b. Provide as much privacy as possible for the female.
c. Reassure the husband and try to keep him calm.
d. Put the newborn to the breast.Correct Answer - ANSWER-d. Put the newborn to
the breast.
, Rationale:
Putting the newborn to the breast will help contract the uterus and prevent a
postpartum hemorrhage. This intervention has the highest priority.
The practical nurse (PN) attempts to help a teenage client with her feelings following
a spontaneous abortion at 8 weeks' gestation. What type of emotional response
should the PN anticipate?
a. Grief related to her perceptions about the loss of this child.
b. Relief of ambivalent feelings experienced with this pregnancy.
c. Shock because she may not have realized that she was pregnant.
d. Guilt because she had not followed her health care provider's instructions. -
ANSWER-a. Grief related to her perceptions about the loss of this child.
Rationale:
A grief and loss response occurs at all stages of pregnancy loss.
Twenty-four hours after a full-term newborn is admitted to the newborn nursery, the
practical nurse (PN) observes a localized swelling on the right side of the head of the
newborn that does not cross the suture line. How does the nurse document this
finding?
a. A cephalohematomaCorrect Answer
b. A subarachnoid hematoma
c. Molding
d. A subdural hematoma - ANSWER-a. A cephalohematoma
Rationale:
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within
the first 24 hours after delivery.
The nurse educates the pregnant client about a new diagnosis of gestational
diabetes. Which statement made by the client indicates the need for further
education?
a. "I should watch for signs of infection and report them to my doctor."
b. "My doctor will prescribe oral medication to help keep my blood sugars normal."
c. "I should continue to exercise because it will help keep my blood glucose levels
down."
d. "If I cannot control my blood sugar with diet alone, my provider may prescribe
insulin." - ANSWER-b. "My doctor will prescribe oral medication to help keep my
blood sugars normal."
Rationale:
Oral hypoglycemics are not prescribed during pregnancy.
The practical nurse (PN) is teaching a couple about ovulation and conception. The
nurse realizes the teaching is effective if the couple states which time is most likely
for conception to occur?
a. 2 weeks before menstruation
b. Immediately after menstruation
c. Immediately before menstruation
d. 3 weeks before menstruation - ANSWER-a. 2 weeks before menstruation
Rationale:
Ovulation occurs 14 days before the first day of the menstrual period.
