Maternity HESI Case Study Exam with
, , , , ,
Questions and Correct Answers 2025-2026
, , , , ,
GRADED A+
, ,
What ,action ,should ,the ,nursery ,nurse ,take ,first ,in ,caring ,for ,the ,infant? ,- ,CORRECT
,ANSWER-Dry ,the ,infant ,quickly ,with ,warm ,blankets
After ,clearing ,the ,airway ,with ,a ,bulb ,syringe ,and ,drying ,the ,infant ,with ,warming
,blankets, ,the ,nurse ,assesses ,that ,the ,infant ,is ,breathing ,and ,has ,a ,HR ,of ,124, ,but
,remains ,cyanotic. ,What ,action ,should ,the ,nurse ,take? ,- ,CORRECT ,ANSWER-
Prepare ,to ,give ,oxygen
At ,1 ,minute ,the ,infant ,has ,a ,heart ,rate ,of ,130, ,has ,a ,slow ,weak ,cry, ,is ,grimacing,
,and ,has ,sluggish ,movements ,with ,acrocyanosis. ,What ,Apgar ,score ,should ,the ,nurse
,assign? ,- ,CORRECT ,ANSWER-6
After ,receiving ,the ,labor ,and ,delivery ,report, ,which ,information ,should ,direct ,the ,nurse
,to ,further ,assessment ,of ,the ,infant's ,head? ,- ,CORRECT ,ANSWER-Low ,forceps
,delivery
Which ,action ,should ,the ,nurse ,take ,prior ,to ,weighing ,the ,infant? ,- ,CORRECT
,ANSWER-Place ,a ,cover ,on ,the ,scale
Which ,part ,of ,infant ,care ,should ,the ,nurse ,delay? ,- ,CORRECT ,ANSWER-Giving ,eye
,prophylaxis
The ,infant's ,vitals ,include: ,T ,96.8; ,HR ,136 ,irregular ,w/ ,soft ,murmur; ,RR ,42. ,Which
,action ,should ,the ,nurse ,take? ,- ,CORRECT ,ANSWER-Document ,the ,finding ,in ,the
,electronic ,medical ,record ,(EMR)
What ,action ,should ,the ,nurse ,take ,when ,finding ,that ,the ,head ,measures ,36cm ,and
,the ,chest ,measures ,35? ,- ,CORRECT ,ANSWER-Document ,the ,findings ,in ,the ,EMR
,Upon ,examining ,the ,infant's ,extremities, ,which ,finding ,should ,the ,nurse ,report ,to ,the
,HCP? ,- ,CORRECT ,ANSWER-Diminished ,movement ,in ,one ,arm
The ,nurse ,performs ,a ,newborn ,assessment ,and ,evaluates ,the ,infant's ,reflexes. ,How
,does ,the ,nurse ,perform ,the ,Moro ,reflex? ,- ,CORRECT ,ANSWER-Slightly ,raise ,the
,infant's ,head ,and ,trunk ,and ,allow ,the ,infant ,to ,drop ,back ,30 ,degrees
When ,the ,nurse ,conducts ,a ,gestational ,age ,assessment, ,which ,findings ,may ,indicate
,post-maturity? ,- ,CORRECT ,ANSWER-- ,Peeling, ,parchment-like ,skin
- ,Thin ,with ,loose ,skin ,and ,little ,subcutaneous ,fat
- ,Deep ,creases ,at ,the ,base ,of ,the ,toes ,extending ,to ,the ,heels
While ,administering ,Vitamin ,K ,to ,infant, ,which ,action ,should ,the ,nurse ,take? ,-
,CORRECT ,ANSWER-Select ,the ,middle ,part ,of ,the ,vastus ,lateralis ,for ,use.
The ,nurse ,next ,prepares ,to ,administer ,the ,erythromycin ,ointment ,(Ilotycin ,ophthalmic
,ointment). ,Which ,approach ,should ,the ,nurse ,use ,to ,administer ,the ,ointment? ,-
,CORRECT ,ANSWER-Cover ,entire ,lower ,conjunctiva ,with ,the ,ointment ,after ,gently
,retracting ,the ,lid
Five ,hours ,after ,delivery, ,the ,infant's ,vital ,signs ,are ,stable ,and ,he ,is ,taken ,to ,his
,family. ,While ,the ,nurse ,discusses ,care ,with ,Mrs. ,Ivy, ,the ,infant ,starts ,gagging. ,Which
,action ,should ,the ,nurse ,implement ,first? ,- ,CORRECT ,ANSWER-Use ,bulb ,syringe ,to
,clear ,the ,mouth ,and ,nose
The ,nurse ,instructs ,the ,family ,about ,feeding ,the ,infant. ,The ,mother ,asks ,how ,often
,the ,infant ,should ,be ,burped.Which ,is ,the ,best ,response ,by ,the ,nurse ,for ,how ,often
,the ,infant ,should ,be ,burped? ,- ,CORRECT ,ANSWER-He ,needs ,burping ,at ,the ,start ,of
,the ,feeding ,and ,after ,each ,ounce ,(30 ,mL) ,of ,formula
When ,Mrs. ,Ivy ,finishes ,feeding ,the ,infant, ,she ,checks ,the ,diaper ,and ,it ,is ,dry. ,Mr. ,Ivy
,expresses ,concern ,that ,he ,thinks ,the ,infant ,is ,becoming ,dehydrated. ,- ,CORRECT
,ANSWER-The ,infant ,should ,have ,1 ,or ,2 ,voids ,per ,day
After ,receiving ,report ,from ,the ,day ,shift, ,the ,night ,nurse ,begins ,making ,rounds. ,Upon
,entering ,the ,Ivy's ,room, ,the ,nurse ,finds ,Mrs. ,Ivy ,in ,the ,bathroom ,and ,the ,infant ,in ,the
,crib ,with ,a ,bottle ,propped ,on ,a ,towel. ,What ,action ,should ,the ,nurse ,take? ,-
,CORRECT ,ANSWER-Remove ,the ,bottle ,from ,the ,infant's ,mouth
The ,nurse ,conduct ,the ,change ,of ,shift ,assessment ,of ,the ,infant. ,Which ,finding ,by ,the
,nurse ,is ,consistent ,with ,a ,cephalhematoma? ,- ,CORRECT ,ANSWER-Well-outlined
,swelling ,that ,does ,not ,cross ,suture ,lines
, The ,infant ,has ,a ,reddish ,papular ,rash ,across ,his ,face. ,How ,should ,the ,nurse ,respond
,when ,Mrs. ,Ivy ,asks ,about ,the ,rash? ,- ,CORRECT ,ANSWER-A ,newborn ,rash ,is ,very
,common, ,but ,it ,will ,disappear ,soon
One ,the ,second ,day, ,the ,nurse ,assesses ,the ,infant ,for ,jaundice.Which ,factor ,should
,alert ,the ,nurse ,to ,assess ,for ,the ,risk ,of ,jaundice? ,- ,CORRECT ,ANSWER-Trauma ,at
,birth
The ,nurse ,observes ,that ,the ,infant ,is ,jaundiced ,on ,his ,face, ,head, ,and ,chest. ,What
,action ,should ,the ,nurse ,take ,next? ,- ,CORRECT ,ANSWER-Obtain ,blood ,for
,laboratory ,analysis
The ,nurse ,prepares ,infant ,for ,placement ,under ,a ,bilirubin ,light. ,Which ,actions ,should
,the ,nurse ,implement? ,- ,CORRECT ,ANSWER--Remove ,the ,infant's ,clothing
-Turn ,off ,the ,lights ,and ,allow ,parents ,to ,hold ,infant ,for ,feedings
-Place ,eye ,patches ,on ,the ,infant
While ,infant ,receives ,phototherapy, ,his ,stools ,become ,loose ,and ,green. ,What ,action
,should ,the ,nurse ,take? ,- ,CORRECT ,ANSWER-Document ,the ,findings ,in ,the ,EMR
Phototherapy ,blanket. ,Which ,instructions ,should ,the ,nurse ,include ,in ,the ,discharge
,planning? ,- ,CORRECT ,ANSWER-Holding ,the ,infant ,does ,not ,interrupt ,the
,phototherapy ,process
Mrs. ,Ivy ,asks ,how ,she ,will ,know ,the ,phototherapy ,is ,working. ,How ,should ,the ,nurse
,respond? ,- ,CORRECT ,ANSWER-Serum ,bilirubin ,level ,decreases
The ,nurse ,places ,the ,infant ,under ,a ,radiant ,warmer ,and ,starts ,to ,dry ,him ,quickly.
,Why? ,- ,CORRECT ,ANSWER-Convective ,heat ,loss ,from ,evaporation ,is ,reduced. ,
Rationale: ,Drying ,the ,infant ,quickly ,and ,placing ,him ,under ,a ,radiant ,warmer ,reduces
,heat ,loss ,through ,evaporation ,and ,radiation.
At ,1 ,minute ,of ,age, ,the ,infant ,is ,alert ,and ,active, ,and ,has ,a ,strong ,cry. ,He ,has ,a
,heart ,rate ,of ,172 ,and ,a ,respiratory ,rate ,of ,50. ,The ,infant's ,arms ,and ,legs ,are ,flexed,
,the ,color ,of ,his ,body ,is ,pink, ,and ,the ,color ,of ,both ,feet ,is ,blue. ,The ,nurse ,continues
,a ,physical ,assessment ,of ,the ,infant ,looking ,for ,normal ,and ,abnormal ,findings. ,Which
,APGAR ,score ,should ,the ,nurse ,assign? ,- ,CORRECT ,ANSWER-One ,point ,is
,deducted ,for ,acrocyanosis.
,The ,correct ,score ,is ,9
Upon ,inspection ,of ,the ,umbilical ,cord, ,which ,finding ,should ,the ,nurse ,report ,to ,the
,healthcare ,provider ,(HCP)? ,- ,CORRECT ,ANSWER-One ,artery ,and ,one ,vein ,are
,present
, , , , ,
Questions and Correct Answers 2025-2026
, , , , ,
GRADED A+
, ,
What ,action ,should ,the ,nursery ,nurse ,take ,first ,in ,caring ,for ,the ,infant? ,- ,CORRECT
,ANSWER-Dry ,the ,infant ,quickly ,with ,warm ,blankets
After ,clearing ,the ,airway ,with ,a ,bulb ,syringe ,and ,drying ,the ,infant ,with ,warming
,blankets, ,the ,nurse ,assesses ,that ,the ,infant ,is ,breathing ,and ,has ,a ,HR ,of ,124, ,but
,remains ,cyanotic. ,What ,action ,should ,the ,nurse ,take? ,- ,CORRECT ,ANSWER-
Prepare ,to ,give ,oxygen
At ,1 ,minute ,the ,infant ,has ,a ,heart ,rate ,of ,130, ,has ,a ,slow ,weak ,cry, ,is ,grimacing,
,and ,has ,sluggish ,movements ,with ,acrocyanosis. ,What ,Apgar ,score ,should ,the ,nurse
,assign? ,- ,CORRECT ,ANSWER-6
After ,receiving ,the ,labor ,and ,delivery ,report, ,which ,information ,should ,direct ,the ,nurse
,to ,further ,assessment ,of ,the ,infant's ,head? ,- ,CORRECT ,ANSWER-Low ,forceps
,delivery
Which ,action ,should ,the ,nurse ,take ,prior ,to ,weighing ,the ,infant? ,- ,CORRECT
,ANSWER-Place ,a ,cover ,on ,the ,scale
Which ,part ,of ,infant ,care ,should ,the ,nurse ,delay? ,- ,CORRECT ,ANSWER-Giving ,eye
,prophylaxis
The ,infant's ,vitals ,include: ,T ,96.8; ,HR ,136 ,irregular ,w/ ,soft ,murmur; ,RR ,42. ,Which
,action ,should ,the ,nurse ,take? ,- ,CORRECT ,ANSWER-Document ,the ,finding ,in ,the
,electronic ,medical ,record ,(EMR)
What ,action ,should ,the ,nurse ,take ,when ,finding ,that ,the ,head ,measures ,36cm ,and
,the ,chest ,measures ,35? ,- ,CORRECT ,ANSWER-Document ,the ,findings ,in ,the ,EMR
,Upon ,examining ,the ,infant's ,extremities, ,which ,finding ,should ,the ,nurse ,report ,to ,the
,HCP? ,- ,CORRECT ,ANSWER-Diminished ,movement ,in ,one ,arm
The ,nurse ,performs ,a ,newborn ,assessment ,and ,evaluates ,the ,infant's ,reflexes. ,How
,does ,the ,nurse ,perform ,the ,Moro ,reflex? ,- ,CORRECT ,ANSWER-Slightly ,raise ,the
,infant's ,head ,and ,trunk ,and ,allow ,the ,infant ,to ,drop ,back ,30 ,degrees
When ,the ,nurse ,conducts ,a ,gestational ,age ,assessment, ,which ,findings ,may ,indicate
,post-maturity? ,- ,CORRECT ,ANSWER-- ,Peeling, ,parchment-like ,skin
- ,Thin ,with ,loose ,skin ,and ,little ,subcutaneous ,fat
- ,Deep ,creases ,at ,the ,base ,of ,the ,toes ,extending ,to ,the ,heels
While ,administering ,Vitamin ,K ,to ,infant, ,which ,action ,should ,the ,nurse ,take? ,-
,CORRECT ,ANSWER-Select ,the ,middle ,part ,of ,the ,vastus ,lateralis ,for ,use.
The ,nurse ,next ,prepares ,to ,administer ,the ,erythromycin ,ointment ,(Ilotycin ,ophthalmic
,ointment). ,Which ,approach ,should ,the ,nurse ,use ,to ,administer ,the ,ointment? ,-
,CORRECT ,ANSWER-Cover ,entire ,lower ,conjunctiva ,with ,the ,ointment ,after ,gently
,retracting ,the ,lid
Five ,hours ,after ,delivery, ,the ,infant's ,vital ,signs ,are ,stable ,and ,he ,is ,taken ,to ,his
,family. ,While ,the ,nurse ,discusses ,care ,with ,Mrs. ,Ivy, ,the ,infant ,starts ,gagging. ,Which
,action ,should ,the ,nurse ,implement ,first? ,- ,CORRECT ,ANSWER-Use ,bulb ,syringe ,to
,clear ,the ,mouth ,and ,nose
The ,nurse ,instructs ,the ,family ,about ,feeding ,the ,infant. ,The ,mother ,asks ,how ,often
,the ,infant ,should ,be ,burped.Which ,is ,the ,best ,response ,by ,the ,nurse ,for ,how ,often
,the ,infant ,should ,be ,burped? ,- ,CORRECT ,ANSWER-He ,needs ,burping ,at ,the ,start ,of
,the ,feeding ,and ,after ,each ,ounce ,(30 ,mL) ,of ,formula
When ,Mrs. ,Ivy ,finishes ,feeding ,the ,infant, ,she ,checks ,the ,diaper ,and ,it ,is ,dry. ,Mr. ,Ivy
,expresses ,concern ,that ,he ,thinks ,the ,infant ,is ,becoming ,dehydrated. ,- ,CORRECT
,ANSWER-The ,infant ,should ,have ,1 ,or ,2 ,voids ,per ,day
After ,receiving ,report ,from ,the ,day ,shift, ,the ,night ,nurse ,begins ,making ,rounds. ,Upon
,entering ,the ,Ivy's ,room, ,the ,nurse ,finds ,Mrs. ,Ivy ,in ,the ,bathroom ,and ,the ,infant ,in ,the
,crib ,with ,a ,bottle ,propped ,on ,a ,towel. ,What ,action ,should ,the ,nurse ,take? ,-
,CORRECT ,ANSWER-Remove ,the ,bottle ,from ,the ,infant's ,mouth
The ,nurse ,conduct ,the ,change ,of ,shift ,assessment ,of ,the ,infant. ,Which ,finding ,by ,the
,nurse ,is ,consistent ,with ,a ,cephalhematoma? ,- ,CORRECT ,ANSWER-Well-outlined
,swelling ,that ,does ,not ,cross ,suture ,lines
, The ,infant ,has ,a ,reddish ,papular ,rash ,across ,his ,face. ,How ,should ,the ,nurse ,respond
,when ,Mrs. ,Ivy ,asks ,about ,the ,rash? ,- ,CORRECT ,ANSWER-A ,newborn ,rash ,is ,very
,common, ,but ,it ,will ,disappear ,soon
One ,the ,second ,day, ,the ,nurse ,assesses ,the ,infant ,for ,jaundice.Which ,factor ,should
,alert ,the ,nurse ,to ,assess ,for ,the ,risk ,of ,jaundice? ,- ,CORRECT ,ANSWER-Trauma ,at
,birth
The ,nurse ,observes ,that ,the ,infant ,is ,jaundiced ,on ,his ,face, ,head, ,and ,chest. ,What
,action ,should ,the ,nurse ,take ,next? ,- ,CORRECT ,ANSWER-Obtain ,blood ,for
,laboratory ,analysis
The ,nurse ,prepares ,infant ,for ,placement ,under ,a ,bilirubin ,light. ,Which ,actions ,should
,the ,nurse ,implement? ,- ,CORRECT ,ANSWER--Remove ,the ,infant's ,clothing
-Turn ,off ,the ,lights ,and ,allow ,parents ,to ,hold ,infant ,for ,feedings
-Place ,eye ,patches ,on ,the ,infant
While ,infant ,receives ,phototherapy, ,his ,stools ,become ,loose ,and ,green. ,What ,action
,should ,the ,nurse ,take? ,- ,CORRECT ,ANSWER-Document ,the ,findings ,in ,the ,EMR
Phototherapy ,blanket. ,Which ,instructions ,should ,the ,nurse ,include ,in ,the ,discharge
,planning? ,- ,CORRECT ,ANSWER-Holding ,the ,infant ,does ,not ,interrupt ,the
,phototherapy ,process
Mrs. ,Ivy ,asks ,how ,she ,will ,know ,the ,phototherapy ,is ,working. ,How ,should ,the ,nurse
,respond? ,- ,CORRECT ,ANSWER-Serum ,bilirubin ,level ,decreases
The ,nurse ,places ,the ,infant ,under ,a ,radiant ,warmer ,and ,starts ,to ,dry ,him ,quickly.
,Why? ,- ,CORRECT ,ANSWER-Convective ,heat ,loss ,from ,evaporation ,is ,reduced. ,
Rationale: ,Drying ,the ,infant ,quickly ,and ,placing ,him ,under ,a ,radiant ,warmer ,reduces
,heat ,loss ,through ,evaporation ,and ,radiation.
At ,1 ,minute ,of ,age, ,the ,infant ,is ,alert ,and ,active, ,and ,has ,a ,strong ,cry. ,He ,has ,a
,heart ,rate ,of ,172 ,and ,a ,respiratory ,rate ,of ,50. ,The ,infant's ,arms ,and ,legs ,are ,flexed,
,the ,color ,of ,his ,body ,is ,pink, ,and ,the ,color ,of ,both ,feet ,is ,blue. ,The ,nurse ,continues
,a ,physical ,assessment ,of ,the ,infant ,looking ,for ,normal ,and ,abnormal ,findings. ,Which
,APGAR ,score ,should ,the ,nurse ,assign? ,- ,CORRECT ,ANSWER-One ,point ,is
,deducted ,for ,acrocyanosis.
,The ,correct ,score ,is ,9
Upon ,inspection ,of ,the ,umbilical ,cord, ,which ,finding ,should ,the ,nurse ,report ,to ,the
,healthcare ,provider ,(HCP)? ,- ,CORRECT ,ANSWER-One ,artery ,and ,one ,vein ,are
,present
