MATERNITY HESI CASE STUDY
QUESTIONS & CORRECT ANSWERS
ALREADY GRADED A+ LATEST
VERSION
The nurse performs the first assessment upon the client's arrival to the postpartum unit. Where
would the nurse expect to palpate the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - correct answer ✔✔b. 1 cm above the
umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
Fifteen minutes after the initial assessment, the nurse finds the client disoriented and lying on
her back in a pool of vaginal blood, with the sheets beneath her saturated with blood.
Which action is most important for the nurse to implement immediately?
a. Take vital signs
b. Massage the fundus
,c. Check the bladder
d. Increase the IV rate - correct answer ✔✔b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's hemorrhaging, massing the
fundus is the most important intervention. The nurse should also call for assistance due to the
amount of blood that has pooled under the client.
What should be assessed immediately after fundus is massaged and nurse has called for help? -
correct answer ✔✔Assess for bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can contribute
to diuresis. A distended bladder impedes uterine contraction and contributes to excessive
bleeding. After the fundus is massaged, the bladder should be checked for distention.
what is the most likely reason a postpartum patient would be hemorrhaging? - correct answer
✔✔uterine atony (a "boggy" fundus)
When the nurse conducts a gestational age assessment, which findings may indicate
postmaturity? (Select all that apply. One, some, or all options may be correct.)
a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
,d. Thin with loose skin and little subcutaneous fat.
e. Deep creases at the base of the toes extending to the heels. - correct answer ✔✔c. d. and e.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This results in
the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending from the base
The infant has a reddish papular rash across his face. How should the nurse respond when the
client asks about the rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
, d. Good question. Let me take the infant's vital signs and examine him - correct answer ✔✔c. A
newborn rash is very common, but it will disappear soon.
--> The infant rash, erythema toxicum, is very common and usually disappears by the third day
of life.
what is a normal bilirubin range for a newborn? - correct answer ✔✔5-6 mg/dL
Which factor should alert the nurse to assess for the risk of jaundice? - correct answer
✔✔trauma at birth
Which instructions should the nurse include in the discharge planning regarding the infant's
jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
b. Holding the infant does not interrupt the phototherapy process.
c. A phototherapy blanket is more effective than the overhead lights.
d. The length of time required for phototherapy intervention is decreased. - correct answer
✔✔b. Holding the infant does not interrupt the phototherapy process.
--> Although diapers can be worn, the blanket is placed next to the skin on the trunk of the body
to expose as much skin as possible to the light.
--> The phototherapy blanket allows the infant to be held while the process is continued.
QUESTIONS & CORRECT ANSWERS
ALREADY GRADED A+ LATEST
VERSION
The nurse performs the first assessment upon the client's arrival to the postpartum unit. Where
would the nurse expect to palpate the fundus?
a. 3 cm above the umbilicus.
b. 1 cm above the umbilicus.
c. To the right of the umbilicus.
d. Midway between the umbilicus and the pubic bone. - correct answer ✔✔b. 1 cm above the
umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus
Fifteen minutes after the initial assessment, the nurse finds the client disoriented and lying on
her back in a pool of vaginal blood, with the sheets beneath her saturated with blood.
Which action is most important for the nurse to implement immediately?
a. Take vital signs
b. Massage the fundus
,c. Check the bladder
d. Increase the IV rate - correct answer ✔✔b. Massage the fundus.
Since a boggy fundus is the most likely reason for this client's hemorrhaging, massing the
fundus is the most important intervention. The nurse should also call for assistance due to the
amount of blood that has pooled under the client.
What should be assessed immediately after fundus is massaged and nurse has called for help? -
correct answer ✔✔Assess for bladder distention
--> The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can contribute
to diuresis. A distended bladder impedes uterine contraction and contributes to excessive
bleeding. After the fundus is massaged, the bladder should be checked for distention.
what is the most likely reason a postpartum patient would be hemorrhaging? - correct answer
✔✔uterine atony (a "boggy" fundus)
When the nurse conducts a gestational age assessment, which findings may indicate
postmaturity? (Select all that apply. One, some, or all options may be correct.)
a. Testes descended, good rugae.
b. Formed ears with instant recall.
c. Peeling, parchment-like skin.
,d. Thin with loose skin and little subcutaneous fat.
e. Deep creases at the base of the toes extending to the heels. - correct answer ✔✔c. d. and e.
c. Peeling, parchment-like skin.
d. Thin with loose skin and little subcutaneous fat.
--> Subcutaneous fat, which had been used for nourishment, is lost prior to birth. This results in
the infant's low temperature.
e. Deep creases at the base of the toes extending to the heels.
--> Postterm infants develop deep creases on the feet, extending from the base
The infant has a reddish papular rash across his face. How should the nurse respond when the
client asks about the rash?
a. Don't worry about it. This rash will go away in a couple of days.
b. I see you are concerned, so I will call your pediatrician.
c. A newborn rash is very common, but it will disappear soon.
, d. Good question. Let me take the infant's vital signs and examine him - correct answer ✔✔c. A
newborn rash is very common, but it will disappear soon.
--> The infant rash, erythema toxicum, is very common and usually disappears by the third day
of life.
what is a normal bilirubin range for a newborn? - correct answer ✔✔5-6 mg/dL
Which factor should alert the nurse to assess for the risk of jaundice? - correct answer
✔✔trauma at birth
Which instructions should the nurse include in the discharge planning regarding the infant's
jaundice?
a. The phototherapy blanket is placed over the infant's clothing.
b. Holding the infant does not interrupt the phototherapy process.
c. A phototherapy blanket is more effective than the overhead lights.
d. The length of time required for phototherapy intervention is decreased. - correct answer
✔✔b. Holding the infant does not interrupt the phototherapy process.
--> Although diapers can be worn, the blanket is placed next to the skin on the trunk of the body
to expose as much skin as possible to the light.
--> The phototherapy blanket allows the infant to be held while the process is continued.
