HESI MATERNAL QUESTIONS
ANSWERS 2025/2026
During stage two of labor, what assessments must the labor nurse perform? (Select
all that apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - ANSWER-A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions
to determine the fetal response to the contractions. Frequency may slow during the
second stage. Duration will help facilitate decent of the presenting part. The uterine
tone between contractions should be soft to facilitate placental filling after the
contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are
firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal
heart rate increases with each contraction and returns to baseline after the
contraction. What is the next nursing action?
,A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin infusion. - ANSWER-D. Increase the rate of
the oxytocin infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2
to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal
stress. FHR accelerations are a normal response to contractions, so the oxytocin
(Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed
when the client exhibits signs of progressing labor, which is not indicated at this
time.
The nurse is teaching a prenatal class about the structure of the pelvis and is using
a model of a pelvis in the presentation. Which statements will the nurse include in
the teaching plan? (Select all that apply.)
A. "The baby has to pass through the true pelvis."
B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - ANSWER-A, B,
C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining
statements are true.
,A 38-week primigravida works as an office assistant and sits at a computer 8 hours
each day. She 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. - ANSWER-C. Move about every hour.
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 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.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close.
Which statement is accurate regarding the timing of closure of an infant's fontanels
that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the
end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the
end of the second week.
, C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the
end of the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the
end of the second month. - ANSWER-D. The anterior fontanel closes at 12 to 18
months and the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and
development milestones are frequently included in questions on the licensure
examination. Options A, B, and C are incorrect.
The laboring client at term states to the nurse, "I think my water just broke." The
nurse observes a shiny, gelatinous, rope-like structure protruding from the client's
vaginal area. What is the next nursing action?
A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - ANSWER-B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical
cord. Compression of the cord can lead to fetal anoxia. Placing the client in knee-
chest position reduces the weight of the presenting part off of the cord. The nurse
will need to complete the remaining options, but oxygenation of the fetus takes
priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a
full-term infant who has developed localized swelling on the right side of the head.
ANSWERS 2025/2026
During stage two of labor, what assessments must the labor nurse perform? (Select
all that apply.)
A. Fetal heart rate before the contraction
B. Fetal heart rate during the contraction
C. Fetal heart rate after the contraction
D. Frequency of contractions
E. Duration of contractions
F. Uterine tone between contractions - ANSWER-A, B, C, D, E, F
The nurse must assess the fetal heart rate before, during and after the contractions
to determine the fetal response to the contractions. Frequency may slow during the
second stage. Duration will help facilitate decent of the presenting part. The uterine
tone between contractions should be soft to facilitate placental filling after the
contraction.
A 41-week multigravida is receiving oxytocin to augment labor. Contractions are
firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal
heart rate increases with each contraction and returns to baseline after the
contraction. What is the next nursing action?
,A. Place a wedge under the client's left side.
B. Determine cervical dilation and effacement.
C. Administer 10 L of oxygen via facemask.
D. Increase the rate of the oxytocin infusion. - ANSWER-D. Increase the rate of
the oxytocin infusion.
The goal of labor augmentation is to produce firm contractions that occur every 2
to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal
stress. FHR accelerations are a normal response to contractions, so the oxytocin
(Pitocin) infusion should be increased per protocol to stimulate the frequency and
intensity of contractions. Options A and C are indicated for fetal stress. A sterile
vaginal examination places the client at risk for infection and should be performed
when the client exhibits signs of progressing labor, which is not indicated at this
time.
The nurse is teaching a prenatal class about the structure of the pelvis and is using
a model of a pelvis in the presentation. Which statements will the nurse include in
the teaching plan? (Select all that apply.)
A. "The baby has to pass through the true pelvis."
B. "The pelvis consists of three distinct features."
C. "The true pelvis is below the pelvic brim."
D. "The ischial spines determine how low the baby is located."
E. "The shape of the pelvis does not impact the labor process." - ANSWER-A, B,
C, D
A gynecoid shape pelvis is the most favorable for birthing. The remaining
statements are true.
,A 38-week primigravida works as an office assistant and sits at a computer 8 hours
each day. She 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. - ANSWER-C. Move about every hour.
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 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.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close.
Which statement is accurate regarding the timing of closure of an infant's fontanels
that should be included in this teaching plan?
A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the
end of the first week.
B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the
end of the second week.
, C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the
end of the first month.
D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the
end of the second month. - ANSWER-D. The anterior fontanel closes at 12 to 18
months and the posterior fontanel by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel closes by the end of the second month. These growth and
development milestones are frequently included in questions on the licensure
examination. Options A, B, and C are incorrect.
The laboring client at term states to the nurse, "I think my water just broke." The
nurse observes a shiny, gelatinous, rope-like structure protruding from the client's
vaginal area. What is the next nursing action?
A. Call for help.
B. Place the client in knee-chest position.
C. Increase the mainline IV fluids.
D. Reassure the client. - ANSWER-B. Place the client in knee-chest position.
This client is showing signs of an obstetric emergency of a prolapsed umbilical
cord. Compression of the cord can lead to fetal anoxia. Placing the client in knee-
chest position reduces the weight of the presenting part off of the cord. The nurse
will need to complete the remaining options, but oxygenation of the fetus takes
priority.
Twenty-four hours after admission to the newborn nursery, the nurse assesses a
full-term infant who has developed localized swelling on the right side of the head.
