HESI RN Maternity Exam 2025/2026 –
Verified Questions with Correct Answers
and Rationales
1. A pregnant client at 36 weeks gestation reports decreased
fetal movement. What is the nurse’s priority action?
A. Instruct the client to drink orange juice and rest.
B. Perform a nonstress test (NST).
C. Teach the client to perform daily kick counts.
D. Reassure the client that this is normal in late pregnancy.
Correct Answer: B. Perform a nonstress test (NST).
Rationale: Decreased fetal movement at 36 weeks may indicate fetal distress, requiring
immediate assessment with a nonstress test to evaluate fetal heart rate and movement. Drinking
juice (A) may stimulate movement but delays critical evaluation. Teaching kick counts (C) is
preventive, not diagnostic. Reassuring the client (D) is inappropriate without assessment.
2. A client in labor is receiving oxytocin for augmentation.
Which finding indicates the need to stop the infusion?
A. Contractions every 2–3 minutes, lasting 60 seconds.
B. Fetal heart rate of 90 beats per minute.
C. Maternal blood pressure of 130/80 mmHg.
D. Cervical dilation of 6 cm.
Correct Answer: B. Fetal heart rate of 90 beats per minute.
Rationale: A fetal heart rate of 90 beats per minute indicates bradycardia, a sign of fetal distress
that may be caused by uterine hyperstimulation from oxytocin. The infusion should be stopped
immediately, and the provider notified. Normal contractions (A), blood pressure (C), and dilation
(D) do not warrant stopping the infusion.
3. A postpartum client reports heavy vaginal bleeding with
large clots. What is the nurse’s first action?
A. Massage the fundus.
B. Administer oxytocin as prescribed.
,C. Insert a urinary catheter.
D. Notify the healthcare provider.
Correct Answer: A. Massage the fundus.
Rationale: Heavy bleeding with clots suggests postpartum hemorrhage, often due to uterine
atony. Fundal massage stimulates uterine contractions to control bleeding and is the first action.
Administering oxytocin (B) or inserting a catheter (C) may follow but are not the priority.
Notifying the provider (D) is secondary to immediate intervention.
4. A newborn is assessed using the Apgar score at 1 minute.
The heart rate is 120 beats per minute, respiratory effort is
good, muscle tone is active, reflex irritability is present, and
the skin is pink. What is the Apgar score?
A. 6
B. 8
C. 9
D. 10
Correct Answer: D. 10
Rationale: The Apgar score evaluates heart rate, respiratory effort, muscle tone, reflex
irritability, and color, with 0–2 points per category. Heart rate >100 (2 points), good respiratory
effort (2 points), active muscle tone (2 points), reflex irritability (2 points), and pink color (2
points) total 10, indicating a healthy newborn.
5. A client at 28 weeks gestation is diagnosed with gestational
diabetes. Which dietary instruction should the nurse
provide?
A. Increase intake of simple carbohydrates.
B. Consume small, frequent meals with protein and fiber.
C. Avoid all fruits to control blood sugar.
D. Eat a high-calorie diet to support fetal growth.
Correct Answer: B. Consume small, frequent meals with protein and fiber.
Rationale: Small, frequent meals with protein and fiber help stabilize blood glucose levels in
gestational diabetes. Simple carbohydrates (A) cause glucose spikes. Fruits (C) can be included
in moderation. A high-calorie diet (D) is unnecessary unless weight gain is inadequate.
, 6. A client in active labor reports a sudden gush of fluid. The
nurse notes clear amniotic Хер fluid and a fetal heart rate of
140 beats per minute. What is the nurse’s next action?
A. Prepare for immediate delivery.
B. Monitor the fetal heart rate and contraction pattern.
C. Administer oxygen to the client.
D. Notify the healthcare provider of rupture of membranes.
Correct Answer: B. Monitor the fetal heart rate and contraction pattern.
Rationale: Spontaneous rupture of membranes with clear fluid and a normal fetal heart rate is
expected in labor. The nurse should monitor fetal heart rate and contractions to assess for
complications like cord prolapse. Immediate delivery (A) or oxygen (C) is unnecessary without
distress. Notifying the provider (D) is not the priority unless abnormalities occur.
7. A postpartum client is breastfeeding and reports nipple
soreness. Which intervention should the nurse recommend?
A. Apply petroleum jelly to the nipples.
B. Ensure proper latch and positioning.
C. Stop breastfeeding for 24 hours.
D. Use a nipple shield for all feedings.
Correct Answer: B. Ensure proper latch and positioning.
Rationale: Proper latch and positioning prevent and alleviate nipple soreness by reducing
trauma. Petroleum jelly (A) can trap bacteria. Stopping breastfeeding (C) is unnecessary and may
reduce milk supply. Nipple shields (D) are a last resort and require guidance.
8. A newborn is receiving phototherapy for
hyperbilirubinemia. Which action is most important for the
nurse to implement?
A. Cover the newborn’s eyes during treatment.
B. Keep the newborn swaddled to maintain warmth.
C. Limit feedings to prevent vomiting.
D. Apply lotion to prevent skin drying.
Correct Answer: A. Cover the newborn’s eyes during treatment.
Rationale: Eye protection during phototherapy prevents retinal damage from light exposure.
Swaddling (B) interferes with light penetration. Feedings (C) should be encouraged to promote
bilirubin excretion. Lotion (D) is not used, as bare skin enhances treatment efficacy.
Verified Questions with Correct Answers
and Rationales
1. A pregnant client at 36 weeks gestation reports decreased
fetal movement. What is the nurse’s priority action?
A. Instruct the client to drink orange juice and rest.
B. Perform a nonstress test (NST).
C. Teach the client to perform daily kick counts.
D. Reassure the client that this is normal in late pregnancy.
Correct Answer: B. Perform a nonstress test (NST).
Rationale: Decreased fetal movement at 36 weeks may indicate fetal distress, requiring
immediate assessment with a nonstress test to evaluate fetal heart rate and movement. Drinking
juice (A) may stimulate movement but delays critical evaluation. Teaching kick counts (C) is
preventive, not diagnostic. Reassuring the client (D) is inappropriate without assessment.
2. A client in labor is receiving oxytocin for augmentation.
Which finding indicates the need to stop the infusion?
A. Contractions every 2–3 minutes, lasting 60 seconds.
B. Fetal heart rate of 90 beats per minute.
C. Maternal blood pressure of 130/80 mmHg.
D. Cervical dilation of 6 cm.
Correct Answer: B. Fetal heart rate of 90 beats per minute.
Rationale: A fetal heart rate of 90 beats per minute indicates bradycardia, a sign of fetal distress
that may be caused by uterine hyperstimulation from oxytocin. The infusion should be stopped
immediately, and the provider notified. Normal contractions (A), blood pressure (C), and dilation
(D) do not warrant stopping the infusion.
3. A postpartum client reports heavy vaginal bleeding with
large clots. What is the nurse’s first action?
A. Massage the fundus.
B. Administer oxytocin as prescribed.
,C. Insert a urinary catheter.
D. Notify the healthcare provider.
Correct Answer: A. Massage the fundus.
Rationale: Heavy bleeding with clots suggests postpartum hemorrhage, often due to uterine
atony. Fundal massage stimulates uterine contractions to control bleeding and is the first action.
Administering oxytocin (B) or inserting a catheter (C) may follow but are not the priority.
Notifying the provider (D) is secondary to immediate intervention.
4. A newborn is assessed using the Apgar score at 1 minute.
The heart rate is 120 beats per minute, respiratory effort is
good, muscle tone is active, reflex irritability is present, and
the skin is pink. What is the Apgar score?
A. 6
B. 8
C. 9
D. 10
Correct Answer: D. 10
Rationale: The Apgar score evaluates heart rate, respiratory effort, muscle tone, reflex
irritability, and color, with 0–2 points per category. Heart rate >100 (2 points), good respiratory
effort (2 points), active muscle tone (2 points), reflex irritability (2 points), and pink color (2
points) total 10, indicating a healthy newborn.
5. A client at 28 weeks gestation is diagnosed with gestational
diabetes. Which dietary instruction should the nurse
provide?
A. Increase intake of simple carbohydrates.
B. Consume small, frequent meals with protein and fiber.
C. Avoid all fruits to control blood sugar.
D. Eat a high-calorie diet to support fetal growth.
Correct Answer: B. Consume small, frequent meals with protein and fiber.
Rationale: Small, frequent meals with protein and fiber help stabilize blood glucose levels in
gestational diabetes. Simple carbohydrates (A) cause glucose spikes. Fruits (C) can be included
in moderation. A high-calorie diet (D) is unnecessary unless weight gain is inadequate.
, 6. A client in active labor reports a sudden gush of fluid. The
nurse notes clear amniotic Хер fluid and a fetal heart rate of
140 beats per minute. What is the nurse’s next action?
A. Prepare for immediate delivery.
B. Monitor the fetal heart rate and contraction pattern.
C. Administer oxygen to the client.
D. Notify the healthcare provider of rupture of membranes.
Correct Answer: B. Monitor the fetal heart rate and contraction pattern.
Rationale: Spontaneous rupture of membranes with clear fluid and a normal fetal heart rate is
expected in labor. The nurse should monitor fetal heart rate and contractions to assess for
complications like cord prolapse. Immediate delivery (A) or oxygen (C) is unnecessary without
distress. Notifying the provider (D) is not the priority unless abnormalities occur.
7. A postpartum client is breastfeeding and reports nipple
soreness. Which intervention should the nurse recommend?
A. Apply petroleum jelly to the nipples.
B. Ensure proper latch and positioning.
C. Stop breastfeeding for 24 hours.
D. Use a nipple shield for all feedings.
Correct Answer: B. Ensure proper latch and positioning.
Rationale: Proper latch and positioning prevent and alleviate nipple soreness by reducing
trauma. Petroleum jelly (A) can trap bacteria. Stopping breastfeeding (C) is unnecessary and may
reduce milk supply. Nipple shields (D) are a last resort and require guidance.
8. A newborn is receiving phototherapy for
hyperbilirubinemia. Which action is most important for the
nurse to implement?
A. Cover the newborn’s eyes during treatment.
B. Keep the newborn swaddled to maintain warmth.
C. Limit feedings to prevent vomiting.
D. Apply lotion to prevent skin drying.
Correct Answer: A. Cover the newborn’s eyes during treatment.
Rationale: Eye protection during phototherapy prevents retinal damage from light exposure.
Swaddling (B) interferes with light penetration. Feedings (C) should be encouraged to promote
bilirubin excretion. Lotion (D) is not used, as bare skin enhances treatment efficacy.
