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