HESI MATERNITY EXAM ( 4 VERSIONS) 2025
QUESTIONS AND CORRECT ANSWERS, WITH
COMPLETE VERIFIED SOLUTION
A nurse is performing an assessment of a pregnant woman to determine whether labor
has begun. For which sign of true labor does the nurse assess the client? - ANSWERS-
Contractions that begin in the lower abdomen and back and radiate over the entire
abdomen
Placental abruption is suspected in a client who is experiencing vaginal bleeding. On
assessment, which of the following findings would the nurse expect to note? -
ANSWERS-Uterine tender to palpation
A clinic nurse is performing an assessment of an HIV-positive pregnant woman during
the 32nd week of gestation. Which finding requires further follow-up? - ANSWERS-
Increased shortness of breath and bilateral crackles in the lungs
A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes
that the labia are edematous and darker than the surrounding skin and that a white
mucous vaginal discharge is present. On the basis of these findings, the nurse
determines that the appropriate action is: - ANSWERS-Documenting the findings
(normal findings)
A nurse assessing a pregnant woman in labor notes the presence of early decelerations
on the fetal monitor tracing. Which of the following situations would the nurse suspect in
light of this observation? - ANSWERS-Pressure on the fetal head during a contraction
A rubella antibody screen is performed in a pregnant client, and the results indicate that
the client is not immune to rubella. The nurse tells the client that: - ANSWERS-A rubella
vaccine must be administered after childbirth
Which piece of equipment does the nurse use to assess the fetal heartbeat? -
ANSWERS-Electronic Doppler
A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and
fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium
tuberculosis. The nurse, providing instructions to the mother regarding therapeutic
management of the disease, tells the mother that: - ANSWERS-The mother may need
to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months
A nurse assists a pregnant client who is in the second trimester into lithotomy position
on the examining table in the obstetrician's office. The client suddenly becomes dizzy,
,lightheaded, nauseated, and pale. The nurse immediately: - ANSWERS-Positions the
client on her side
A nurse is monitoring a client who was given an epidural opioid for a cesarean birth.
The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse
first: - ANSWERS-Instructs the client to take several deep breaths
A nurse is told that a newborn with myelomeningocele will be admitted to the newborn
nursery. In which position does the nurse plan to place the infant? - ANSWERS-Prone
(to prevent pressure on the sac until surgical repair can be performed)
Normal respiratory rate for a newborn infant - ANSWERS-30 to 60 breaths/min
A nurse is caring for a client experiencing a partial placental abruption. The client is
uncooperative, refusing any interventions until her husband arrives at the hospital. The
nurse analyzes the client's behavior as most likely the result of: - ANSWERS-Anxiety
and the need for support
A client in the third trimester of pregnancy is complaining of urinary frequency, and the
nurse instructs the client in measures to alleviate the discomfort. Which statement by
the client indicates an understanding of these self-care measures? - ANSWERS-"I need
to drink at least 2000 mL of fluid a day."
A pregnant woman at 38 weeks' gestation arrives at the emergency department,
reporting bright-red vaginal bleeding but denying pain. On the basis of this information,
the nurse determines that the client may be experiencing: - ANSWERS-Placenta previa
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse
takes the client's temperature and notes that it is 38° C (100.4° F). The most
appropriate nursing action would be to: - ANSWERS-Encourage the intake of oral fluids
A nurse is assessing the uterine fundus of a client who has just delivered a baby and
notes that the fundus is boggy. The nurse massages the fundus, and then presses to
expel clots from the uterus. To prevent uterine inversion during this procedure, the
nurse: - ANSWERS-Simultaneously provides pressure over the lower uterine segment
A nurse assists the primary healthcare provider in performing an amniotomy on a client
in labor. In which order should the nurse perform the following actions after the
amniotomy? - ANSWERS-1. Determining the fetal heart rate
2. Noting the quantity, color, and odor of the amniotic fluid
3. Taking the client's temperature, pulse, and blood pressure
4. Replacing soiled underpads from beneath the client's buttocks
,5. Planning evaluation of the client for signs and symptoms of infection
A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia
(CDH). Which assessment finding would the nurse specifically expect to note in the
newborn? - ANSWERS-Bowel sounds heard over the chest
A nurse is assessing a woman in labor and notes the presence of accelerations on the
fetal monitor tracing. Which of the following actions should the nurse perform in
response to this observation? - ANSWERS-Documenting the finding
A nurse teaching a pregnant client about the expectations and complications of
pregnancy is describing Braxton Hicks contractions. The nurse tells the client these
contractions: - ANSWERS-Are a common occurrence of pregnancy
Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before
administering the medication, the nurse reviews the client's history. Which of the
following findings is a contraindication to administration of the medication? -
ANSWERS-A previous hypersensitivity reaction to immune globulin
-Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-
positive fetal blood cells in any way
A pregnant woman reports that she has just finished taking the prescribed antibiotics to
treat her urinary tract infection but expresses concern that her baby will be born with an
infection. Which response should the nurse make to help ease these fears? -
ANSWERS-"Now that you have taken the medication as prescribed, we'll keep
monitoring you closely and repeat the urine culture before you leave today."
A delivery room nurse performing an initial assessment on a newborn notes that the
ears are low set. In light of this finding, which nursing action is appropriate initially? -
ANSWERS-Notifying the physician
A nurse is monitoring a pregnant client with placental abruption. Which pattern on the
fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? - ANSWERS-
Normal FHR
A nurse is performing an assessment of a female client with suspected mittelschmerz.
Which question does the nurse ask the client to elicit data specific to this disorder? -
ANSWERS-"Do you have sharp pain on the right or left side of your pelvis?"
-Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between
menstrual periods or at the time of ovulation. The pain, which is fairly sharp, is felt on
the right or left side of the pelvis.
, A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the
following, if noted in the infant, would indicate that the criteria for early discharge have
been met? - ANSWERS-The infant has urinated.
The infant has passed 1 stool.
Vital signs are documented as normal.
The infant has completed one successful feeding.
A nurse is monitoring a pregnant client with sepsis for signs of disseminated
intravascular coagulopathy (DIC). Which of the following laboratory findings causes the
nurse to suspect DIC? - ANSWERS-Increased fibrin degradation products
-DIC is a state of diffuse clotting in which clotting factors are consumed, leading to
widespread bleeding. Petechiae, oozing from injection sites, and hematuria are
indicative of DIC. Platelets are decreased because they are consumed by the process;
coagulation studies show no clot formation (and therefore prolonged times); and fibrin
plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen
and platelets are decreased, prothrombin and activated partial thromboplastin times are
prolonged, and fibrin degradation products are increased.
A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to
stimulate labor. Which of the following findings would prompt the nurse to stop the
infusion? - ANSWERS-Nonreassuring fetal heart rate pattern
A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at
risk for acquired neonatal congenital syphilis. Which finding specific to this disease does
the nurse look for while assessing the infant? - ANSWERS-A copper-colored rash
A client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the
administration of: - ANSWERS-Calcium gluconate
A nurse provides instructions to a breastfeeding mother who is experiencing breast
engorgement about measures for treating the problem. The nurse tells the mother to: -
ANSWERS-Gently massage the breasts during breastfeeding to help empty the breasts
A woman being seen in the prenatal clinic and complains of morning sickness that
continues throughout the day. What does the nurse tell the client to do to overcome this
discomfort? - ANSWERS-Eat dry crackers every 2 hours to prevent an empty stomach
A nurse performing an assessment of a pregnant client is preparing to take the client's
blood pressure. The nurse positions the client: - ANSWERS-In a sitting position with the
arm in a horizontal position at heart level
QUESTIONS AND CORRECT ANSWERS, WITH
COMPLETE VERIFIED SOLUTION
A nurse is performing an assessment of a pregnant woman to determine whether labor
has begun. For which sign of true labor does the nurse assess the client? - ANSWERS-
Contractions that begin in the lower abdomen and back and radiate over the entire
abdomen
Placental abruption is suspected in a client who is experiencing vaginal bleeding. On
assessment, which of the following findings would the nurse expect to note? -
ANSWERS-Uterine tender to palpation
A clinic nurse is performing an assessment of an HIV-positive pregnant woman during
the 32nd week of gestation. Which finding requires further follow-up? - ANSWERS-
Increased shortness of breath and bilateral crackles in the lungs
A nurse is changing the diaper of a 1-day-old full-term female newborn. The nurse notes
that the labia are edematous and darker than the surrounding skin and that a white
mucous vaginal discharge is present. On the basis of these findings, the nurse
determines that the appropriate action is: - ANSWERS-Documenting the findings
(normal findings)
A nurse assessing a pregnant woman in labor notes the presence of early decelerations
on the fetal monitor tracing. Which of the following situations would the nurse suspect in
light of this observation? - ANSWERS-Pressure on the fetal head during a contraction
A rubella antibody screen is performed in a pregnant client, and the results indicate that
the client is not immune to rubella. The nurse tells the client that: - ANSWERS-A rubella
vaccine must be administered after childbirth
Which piece of equipment does the nurse use to assess the fetal heartbeat? -
ANSWERS-Electronic Doppler
A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and
fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium
tuberculosis. The nurse, providing instructions to the mother regarding therapeutic
management of the disease, tells the mother that: - ANSWERS-The mother may need
to take isoniazid (INH), pyrazinamide, and rifampin (Rifadin) for a total of 9 months
A nurse assists a pregnant client who is in the second trimester into lithotomy position
on the examining table in the obstetrician's office. The client suddenly becomes dizzy,
,lightheaded, nauseated, and pale. The nurse immediately: - ANSWERS-Positions the
client on her side
A nurse is monitoring a client who was given an epidural opioid for a cesarean birth.
The nurse notes that the client's oxygen saturation on pulse oximetry is 92%. The nurse
first: - ANSWERS-Instructs the client to take several deep breaths
A nurse is told that a newborn with myelomeningocele will be admitted to the newborn
nursery. In which position does the nurse plan to place the infant? - ANSWERS-Prone
(to prevent pressure on the sac until surgical repair can be performed)
Normal respiratory rate for a newborn infant - ANSWERS-30 to 60 breaths/min
A nurse is caring for a client experiencing a partial placental abruption. The client is
uncooperative, refusing any interventions until her husband arrives at the hospital. The
nurse analyzes the client's behavior as most likely the result of: - ANSWERS-Anxiety
and the need for support
A client in the third trimester of pregnancy is complaining of urinary frequency, and the
nurse instructs the client in measures to alleviate the discomfort. Which statement by
the client indicates an understanding of these self-care measures? - ANSWERS-"I need
to drink at least 2000 mL of fluid a day."
A pregnant woman at 38 weeks' gestation arrives at the emergency department,
reporting bright-red vaginal bleeding but denying pain. On the basis of this information,
the nurse determines that the client may be experiencing: - ANSWERS-Placenta previa
A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse
takes the client's temperature and notes that it is 38° C (100.4° F). The most
appropriate nursing action would be to: - ANSWERS-Encourage the intake of oral fluids
A nurse is assessing the uterine fundus of a client who has just delivered a baby and
notes that the fundus is boggy. The nurse massages the fundus, and then presses to
expel clots from the uterus. To prevent uterine inversion during this procedure, the
nurse: - ANSWERS-Simultaneously provides pressure over the lower uterine segment
A nurse assists the primary healthcare provider in performing an amniotomy on a client
in labor. In which order should the nurse perform the following actions after the
amniotomy? - ANSWERS-1. Determining the fetal heart rate
2. Noting the quantity, color, and odor of the amniotic fluid
3. Taking the client's temperature, pulse, and blood pressure
4. Replacing soiled underpads from beneath the client's buttocks
,5. Planning evaluation of the client for signs and symptoms of infection
A nurse is assessing a newborn with a diagnosis of congenital diaphragmatic hernia
(CDH). Which assessment finding would the nurse specifically expect to note in the
newborn? - ANSWERS-Bowel sounds heard over the chest
A nurse is assessing a woman in labor and notes the presence of accelerations on the
fetal monitor tracing. Which of the following actions should the nurse perform in
response to this observation? - ANSWERS-Documenting the finding
A nurse teaching a pregnant client about the expectations and complications of
pregnancy is describing Braxton Hicks contractions. The nurse tells the client these
contractions: - ANSWERS-Are a common occurrence of pregnancy
Rho(D) immune globulin (RhoGam) is prescribed for a client after delivery. Before
administering the medication, the nurse reviews the client's history. Which of the
following findings is a contraindication to administration of the medication? -
ANSWERS-A previous hypersensitivity reaction to immune globulin
-Rho(D) immune globulin is indicated when an Rh-negative client is exposed to Rh-
positive fetal blood cells in any way
A pregnant woman reports that she has just finished taking the prescribed antibiotics to
treat her urinary tract infection but expresses concern that her baby will be born with an
infection. Which response should the nurse make to help ease these fears? -
ANSWERS-"Now that you have taken the medication as prescribed, we'll keep
monitoring you closely and repeat the urine culture before you leave today."
A delivery room nurse performing an initial assessment on a newborn notes that the
ears are low set. In light of this finding, which nursing action is appropriate initially? -
ANSWERS-Notifying the physician
A nurse is monitoring a pregnant client with placental abruption. Which pattern on the
fetal monitor indicates to the nurse that fetal tissue perfusion is adequate? - ANSWERS-
Normal FHR
A nurse is performing an assessment of a female client with suspected mittelschmerz.
Which question does the nurse ask the client to elicit data specific to this disorder? -
ANSWERS-"Do you have sharp pain on the right or left side of your pelvis?"
-Mittelschmerz ("middle pain") refers to pelvic pain that occurs midway between
menstrual periods or at the time of ovulation. The pain, which is fairly sharp, is felt on
the right or left side of the pelvis.
, A nurse is reviewing the criteria for early discharge of a newborn infant. Which of the
following, if noted in the infant, would indicate that the criteria for early discharge have
been met? - ANSWERS-The infant has urinated.
The infant has passed 1 stool.
Vital signs are documented as normal.
The infant has completed one successful feeding.
A nurse is monitoring a pregnant client with sepsis for signs of disseminated
intravascular coagulopathy (DIC). Which of the following laboratory findings causes the
nurse to suspect DIC? - ANSWERS-Increased fibrin degradation products
-DIC is a state of diffuse clotting in which clotting factors are consumed, leading to
widespread bleeding. Petechiae, oozing from injection sites, and hematuria are
indicative of DIC. Platelets are decreased because they are consumed by the process;
coagulation studies show no clot formation (and therefore prolonged times); and fibrin
plugs may clog the microvasculature diffusely rather than in an isolated area. Fibrinogen
and platelets are decreased, prothrombin and activated partial thromboplastin times are
prolonged, and fibrin degradation products are increased.
A nurse is caring for a client receiving an intravenous infusion of oxytocin (Pitocin) to
stimulate labor. Which of the following findings would prompt the nurse to stop the
infusion? - ANSWERS-Nonreassuring fetal heart rate pattern
A nurse is conducting a home visit with a mother and her 1-week-old infant, who is at
risk for acquired neonatal congenital syphilis. Which finding specific to this disease does
the nurse look for while assessing the infant? - ANSWERS-A copper-colored rash
A client with preeclampsia who is receiving magnesium sulfate in an intravenous
infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the
administration of: - ANSWERS-Calcium gluconate
A nurse provides instructions to a breastfeeding mother who is experiencing breast
engorgement about measures for treating the problem. The nurse tells the mother to: -
ANSWERS-Gently massage the breasts during breastfeeding to help empty the breasts
A woman being seen in the prenatal clinic and complains of morning sickness that
continues throughout the day. What does the nurse tell the client to do to overcome this
discomfort? - ANSWERS-Eat dry crackers every 2 hours to prevent an empty stomach
A nurse performing an assessment of a pregnant client is preparing to take the client's
blood pressure. The nurse positions the client: - ANSWERS-In a sitting position with the
arm in a horizontal position at heart level
