MATERNITY HESI QUESTIONS &
CORRECT ANSWERS
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: - correct
answer ✔✔Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants
further evaluation? - correct answer ✔✔Too much weight gain, gestational weight gain should
only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"? -
correct answer ✔✔Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say... - correct
answer ✔✔If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate -
correct answer ✔✔Inspect perineal and rectal area.
Cesarean - hemorrhage risk assessment? - correct answer ✔✔Check for fundal firmness Q15
min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery.
Q15 min checks stimulate fundus to contract and prevents bleeding.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx? -
correct answer ✔✔Fluid volume excess.
RATIONALE: 3rd spacing.
, Water broke, umbilical cord is on perineum, what does nurse do? - correct answer ✔✔Place pt
in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up
the presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s? - correct answer ✔✔To
evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority? - correct
answer ✔✔Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia.
What would be a therapeutic response to the injection? - correct answer ✔✔Increased HR and
decrease in oral secretions.
Newborn assessment that indicates a cardiac problem? - correct answer ✔✔RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give? - correct
answer ✔✔Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding. - correct answer ✔✔Assess infants position while
feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery. - correct answer ✔✔Rhogam prevents maternal
antibody formation for future Rh positive babies.
CORRECT ANSWERS
Newborn respiratory rate of 40 breaths per minute and cyanotic hands and feet: - correct
answer ✔✔Continue to monitor (normal).
20 weeks gestation, gained 20 lbs, fundal height 20, clear liquid from breasts. What warrants
further evaluation? - correct answer ✔✔Too much weight gain, gestational weight gain should
only be approx 10.3 lbs.
. Neonate under radiant warmer, naso-oral suctioned. Which indicates infant is "vigorous"? -
correct answer ✔✔Active movement and lusty cry.
24 hour old baby, mom is scared she is not breastfeeding right, the nurse should say... - correct
answer ✔✔If your baby's urine is straw colored , then she is feeding well.
. 12 hours after birth, mother c/o vaginal pressure, fundus firm @ midline, with moderate -
correct answer ✔✔Inspect perineal and rectal area.
Cesarean - hemorrhage risk assessment? - correct answer ✔✔Check for fundal firmness Q15
min.
RATIONALE: Risk for postpartum hemorrhage is decreased when uterus is firm after delivery.
Q15 min checks stimulate fundus to contract and prevents bleeding.
Rheumatic fever hx as a child, resulted in heart damage, risk for CHF post delivery. Nursing Dx? -
correct answer ✔✔Fluid volume excess.
RATIONALE: 3rd spacing.
, Water broke, umbilical cord is on perineum, what does nurse do? - correct answer ✔✔Place pt
in trendelenburg.
RATIONALE: Take the pressure off the presenting part of cord by vaginal exam and holding up
the presenting part as much as possible.
Primipara 20 week, schedule u/s, what's the reason for the u/s? - correct answer ✔✔To
evaluate fetal growth and to determine gestational age.
Assessing a 3 day old with cephalohematoma. What intervention is highest priority? - correct
answer ✔✔Examine Q8 hrs for jaundice (look for hyperbilirubinemia).
RATIONALE: Bilirubin increases as RBCs in cephalohematoma breakdown.
40 wks, cesarean, receives anticholinergic, atropine 0.4 mg IM as adjunct to inhaled anesthesia.
What would be a therapeutic response to the injection? - correct answer ✔✔Increased HR and
decrease in oral secretions.
Newborn assessment that indicates a cardiac problem? - correct answer ✔✔RR 78/min.
RATIONALE: Normal respiratory rate for a newborn is 40 - 60.
Abacavir (ziagen) 450 mg po tid ordered for HIV positive. Stock is 300 mg tabs. Give? - correct
answer ✔✔Give 1.5 tabs.
Sore nipples on day 2 of breastfeeding. - correct answer ✔✔Assess infants position while
feeding.
RATIONALE: To make sure baby is latching properly.
Rh negative refuses Rhogam after delivery. - correct answer ✔✔Rhogam prevents maternal
antibody formation for future Rh positive babies.
