Maternity HESI Test bank (combined red hesi
and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby
when it moves too much. Which recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. -
D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No
intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks
of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and
C are not necessary because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) -
C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may indicate the
presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes
[AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should
be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes
during labor but is not specific for AROM. Option B is monitored hourly after the membranes are
ruptured to detect the development of amnionitis. Option D should be determined for all clients in
labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
1
,B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk -
B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which
should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and
feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia
are small white papules present on the nose and chin that are caused by sebaceous gland blockage
and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema
toxicum neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed.
Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. -
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the
pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete
emptying of the breast tissue. Option C will not relieve the engorgement on the affected side.
Option D will not decrease antibiotic effects on the infant.
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 will aid in the prevention of pooling of
blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. -
C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous
return. Option A would increase venous return from varicose veins in the lower extremities but
2
,would be of little help with swelling. Option B might be helpful with generalized edema but is not
specific for edematous lower extremities. Option D does not address venous return, and there is no
indication in the question that constrictive clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of this
accumulation of blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage -
A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the
cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both
involve intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath -
C.Allow the cord to air-dry as much as possible.
Rationale:Recent studies have indicated that air drying or plain water application may be equal to or
more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because
they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What information
should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. -
C.Place petroleum ointment around the glans with each diaper change and cleansing.
3
, Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any urine or
feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing
surface. Prepackaged wipes often contain other products that may irritate the site. The yellow
exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process
and should not be removed. If bleeding occurs at home, the client should be instructed to apply
gentle pressure to the site of the bleeding with sterile gauze squares and call the health care
provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth -
C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the
drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of
nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is
most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing. -
C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the
breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a
straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing,
and nonbinding support aids in prevention of discomfort from the stretching of the Cooper
ligament. Option B is important but is not necessary for all women. Option D helps soften an
engorged breast and encourages correct infant latching on but is not the best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?"
Which explanation is appropriate?
4
and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that she is
constantly rubbing her abdomen and talking to the baby and that she actually reprimands the baby
when it moves too much. Which recommendation should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. -
D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect ambivalence. No
intervention is needed. Quickening, the first perception of fetal movement, occurs at 17 to 20 weeks
of gestation and begins a new phase of prenatal bonding during the second trimester. Options A and
C are not necessary because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure is
completed, it is most important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) -
C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may indicate the
presence of cord compression or prolapse. An amniotomy (artificial rupture of membranes
[AROM]) is used to stimulate labor when the condition of the cervix is favorable. The fluid should
be assessed for color, odor, and consistency. Option A should be assessed every 15 to 20 minutes
during labor but is not specific for AROM. Option B is monitored hourly after the membranes are
ruptured to detect the development of amnionitis. Option D should be determined for all clients in
labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In
developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
1
,B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk -
B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which
should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and
feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia
are small white papules present on the nose and chin that are caused by sebaceous gland blockage
and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema
toxicum neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed.
Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant. -
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the
pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete
emptying of the breast tissue. Option C will not relieve the engorgement on the affected side.
Option D will not decrease antibiotic effects on the infant.
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 will aid in the prevention of pooling of
blood in the lower extremities?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. -
C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on the
pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase venous
return. Option A would increase venous return from varicose veins in the lower extremities but
2
,would be of little help with swelling. Option B might be helpful with generalized edema but is not
specific for edematous lower extremities. Option D does not address venous return, and there is no
indication in the question that constrictive clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of this
accumulation of blood between the periosteum and skull that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage -
A.Cephalhematoma, which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on the
cranium during vaginal delivery, and is a common variation of the newborn. Options B and D both
involve intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath -
C.Allow the cord to air-dry as much as possible.
Rationale:Recent studies have indicated that air drying or plain water application may be equal to or
more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because
they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What information
should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. -
C.Place petroleum ointment around the glans with each diaper change and cleansing.
3
, Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any urine or
feces, and petroleum ointment should be applied to prevent the diaper from sticking to the healing
surface. Prepackaged wipes often contain other products that may irritate the site. The yellow
exudate, which covers the glans penis as the area heals and epithelializes, is not an infective process
and should not be removed. If bleeding occurs at home, the client should be instructed to apply
gentle pressure to the site of the bleeding with sterile gauze squares and call the health care
provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth -
C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the
drug may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of
nervousness. Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is
most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
B.Increase nursing time gradually over several days.
C.Ensure that the baby is positioned correctly for latching on.
D.Manually express a small amount of milk before nursing. -
C.Ensure that the baby is positioned correctly for latching on.
Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the
breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a
straight line, with the nose, cheeks, and chin touching the breast. Option A helps prevent chafing,
and nonbinding support aids in prevention of discomfort from the stretching of the Cooper
ligament. Option B is important but is not necessary for all women. Option D helps soften an
engorged breast and encourages correct infant latching on but is not the best answer.
A new mother asks the nurse, "How do I know that my daughter is getting enough breast milk?"
Which explanation is appropriate?
4
