REVISED MATERNITY HESI QUESTIONS AND VERIFIED ANSWERS

REVISED MATERNITY HESI ef ef




QUESTIONS AND VERIFIED ANSW ef ef ef




ERS
The nurse observes a new mother avoiding eye contact with her newborn. Which action should the n
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


urse take? - CORRECT ANSWER -Observe the mother for other attachment behaviors.
ef ef ef ef ef ef ef ef ef ef ef




The nurse should explain to a 30-year-
ef ef ef ef ef ef


old gravid client that alpha fetoprotein testing is recommended for which purpose? -
ef ef ef ef ef ef ef ef ef ef ef ef


CORRECT ANSWER -Screen for neural tube defects.
ef ef ef ef ef ef ef




What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean secti
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


on? - CORRECT ANSWER -Check the firmness of the uterus every 15 minutes.
ef ef ef ef ef ef ef ef ef ef ef ef




The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous abo
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


rtion at 8-weeks gestation. What type of emotional response should the nurse anticipate? -
ef ef ef ef ef ef ef ef ef ef ef ef ef


CORRECT ANSWER -Grief related to her perceptions about the loss of this child.
ef ef ef ef ef ef ef ef ef ef ef ef ef




The nurse is assessing a 3-
ef ef ef ef ef


day old infant with a cephalohematoma in the newborn nursery. Which assessment finding should th
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


e nurse report to the healthcare provider? - CORRECT ANSWER -Yellowish tinge to the skin.
ef ef ef ef ef ef ef ef ef ef ef ef ef ef




When assessing a client who is at 12-
ef ef ef ef ef ef ef


weeks gestation, the nurse recommends that she and her husband consider attending childbirth prep
ef ef ef ef ef ef ef ef ef ef ef ef ef


aration classes. When is the best time for the couple to attend these classes? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


At 30- ef


weeks gestation is closest to the time parents would be ready for such classes. Learning is facilitated
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


by an interested pupil! The couple is most interested in childbirth toward the end of the pregnancy w
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


hen they are psychologically ready for the termination of the pregnancy, and the birth of their child i
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


s an immediate concern.
ef ef ef

,A client at 32-
ef ef ef


weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an i
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


mpending convulsion? - CORRECT ANSWER - ef ef ef ef ef


Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign of an
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


impending convulsion (eclampsia) and requires immediate attention.
ef ef ef ef ef ef




A client is admitted with the diagnosis of total placenta previa. Which finding is most important for th
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


e nurse to report to the healthcare provider immediately? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef


Onset of uterine contractions. ef ef ef




A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal thera
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


py. Which response is best for the nurse to provide? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef


It is important that you want to take part in your care.
ef ef ef ef ef ef ef ef ef ef ef




A couple, concerned because the woman has not been able to conceive, is referred to a healthcare p
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


rovider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure compla
ef ef ef ef ef ef ef ef ef ef ef ef


int indicates that the fallopian tubes are patent? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef


If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic collection
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


of peritoneal dye/gas.
ef ef




A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


inch diameter pool of blood. Which action should the nurse implement next? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


Palpate the firmness of the fundus. ef ef ef ef ef




One hour after giving birth to an 8-
ef ef ef ef ef ef ef


pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provide
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


r prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately? -
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


CORRECT ANSWER -
ef ef ef


Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact t
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


he healthcare provider and question the prescription (D).
ef ef ef ef ef ef ef




A client at 32-
ef ef ef


weeks gestation comes to the prenatal clinic with complaints of pedal edema, dyspnea, fatigue, and a
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


moist cough. Which question is most important for the nurse to ask this client? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may develop
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


mitral valve prolapse, which increases the risk for cardiac decompensation due to the increased
ef ef ef ef ef ef ef ef ef ef ef ef ef

,blood volume that occurs during pregnancy, so obtaining information about this client's health history i
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


s a priority.
ef ef




A primigravida at 40-
ef ef ef


weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which adverse effect should the nur
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


se monitor for during the infusion of Pitocin? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef


Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the client
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef e


is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture, and fetal di
f ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


stress or demise. ef ef




A 35-year-
ef


old primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infu
ef ef ef ef ef ef ef ef ef ef ef ef ef


sion. Which assessment data indicates to the nurse that the client is experiencing magnesium sulfate t
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


oxicity? - CORRECT ANSWER - ef ef ef ef


Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respirat
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


ory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
ef ef ef ef ef ef ef ef ef ef ef ef ef




The nurse is planning preconception care for a new female client. Which information should the nurse prov
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


ide the client? - CORRECT ANSWER -
ef ef ef ef ef ef


Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with healthy lif
ef ef ef ef ef ef ef ef ef ef ef ef ef


estyles in the family (D) which is an intervention in preconception care that targets an overall goal for a cl
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


ient preparing for pregnancy.
ef ef ef




A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a non-
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


stress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test should t
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


he nurse prepare the client for additional information about fetal status? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining 5 areas: fetal
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


breathing movements, fetal movements, amniotic fluid volume, and fetal tone and heart rate.
ef ef ef ef ef ef ef ef ef ef ef ef ef




A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse pe
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


rforms a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What a
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


dditional information is most important for the nurse to obtain? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef


Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes priority. If t
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


he fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider may attempt to
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


prolong the pregnancy and administer corticosteroids to mature the lungs of the fetus.
ef ef ef ef ef ef ef ef ef ef ef ef

, A client at 28-
ef ef ef


weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vagin
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


al bleeding which she describes as bright red. She further states that she is not experiencing any uteri
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


ne contractions or abdominal pain. What instruction should the nurse provide? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a plac
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


enta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


first incidence life-
ef ef


threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by transabdominal ultrasound (
ef ef ef ef ef ef ef ef ef ef ef ef


A).



A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which expl
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


anation should the nurse give to this anxious client? - CORRECT ANSWER -
ef ef ef ef ef ef ef ef ef ef ef ef


There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or co
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


mb his/her hair.ef ef




During labor, the nurse determines that a full-
ef ef ef ef ef ef ef


term client is demonstrating late decelerations. In which sequence should the nurse implement thes
ef ef ef ef ef ef ef ef ef ef ef ef ef


e nursing actions? (Arrange in order.) - CORRECT ANSWER - Reposition the client.
ef ef ef ef ef ef ef ef ef ef ef ef




Provide oxygen via face mask. ef ef ef ef




ef Increase IV fluid. ef ef




Call the healthcare provider.
ef ef ef




An off- ef


duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screa
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


ming for someone to help his wife. Which intervention has the highest priority? -
ef ef ef ef ef ef ef ef ef ef ef ef ef


CORRECT ANSWER -
ef ef ef


Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and preve
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


nt a postpartum hemorrhage--this intervention has the highest priority.
ef ef ef ef ef ef ef ef




A 40-ef


week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and c
ef ef ef ef ef ef ef ef ef ef ef ef ef ef


omplains of pain in her lower back. Which intervention should the nurse implement? -
ef ef ef ef ef ef ef ef ef ef ef ef ef


CORRECT ANSWER -
ef ef ef


Apply firm pressure to sacral area. The discomfort of back labor can be minimized by the application
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef


of firm pressure to the sacral area
ef ef ef ef ef ef




A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water
ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef ef