HESI Maternity OB Exam Version 5
Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A pregnant client at 34 weeks gestation reports sudden gush of clear fluid from the vagina. What
is the priority nursing assessment?
A. Assess blood pressure and heart rate
✔✔B. Check fetal heart rate and note time of rupture
C. Measure fundal height
D. Prepare for immediate delivery
A postpartum client reports severe perineal pain and observes swelling at the site. What is the
priority intervention?
A. Encourage ambulation
✔✔B. Apply cold compress and assess for hematoma
C. Provide warm sitz bath immediately
D. Document findings only
A client in active labor has a contraction every 2 minutes lasting 80 seconds with fetal heart rate
showing late decelerations. What should the nurse do first?
1
,A. Administer pain medication
✔✔B. Reposition the client, give oxygen, and notify provider
C. Encourage deep breathing
D. Continue monitoring
A client at 28 weeks gestation presents with swelling of the face and hands and reports
headaches. What is the priority nursing action?
A. Measure fundal height
✔✔B. Assess for preeclampsia and notify provider
C. Encourage rest and hydration
D. Teach fetal kick counts
A client with gestational diabetes is unsure about how to monitor blood sugar at home. What
teaching is essential?
A. Check blood sugar once a week
B. Skip insulin on low-glucose days
✔✔C. Teach fingerstick technique, target levels, and diet management
D. Monitor only if feeling symptoms
2
,A newborn at 2 hours of life has a heart rate of 80 bpm and weak cry. What is the immediate
nursing intervention?
A. Swaddle the newborn
✔✔B. Stimulate and provide supplemental oxygen
C. Administer vitamin K
D. Place under phototherapy
A client in labor reports severe back pain with contractions. What non-pharmacologic method
can the nurse suggest?
A. Apply cold packs to the abdomen
B. Administer IV opioids immediately
✔✔C. Encourage ambulation, position changes, and counter-pressure
D. Limit movement and keep supine
A client at 36 weeks gestation presents with sudden abdominal pain and no fetal movement.
What is the priority action?
A. Provide pain medication
✔✔B. Assess fetal heart rate and prepare for emergency evaluation
3
, C. Encourage rest
D. Perform fundal massage
A postpartum client on day 2 reports heavy vaginal bleeding with passage of clots. What is the
priority nursing assessment?
A. Encourage ambulation
✔✔B. Assess uterine tone and massage fundus
C. Document amount of bleeding
D. Apply a perineal pad only
A client at 40 weeks gestation reports regular contractions every 3 minutes. What is the next
nursing action?
A. Prepare for induction immediately
B. Encourage the client to walk
✔✔C. Assess cervical dilation and effacement
D. Assess vital signs only
A client receiving oxytocin develops contractions lasting 90 seconds every 1–2 minutes. What is
the priority nursing intervention?
4
Questions and Answers | Latest Version
| 2025/2026 | Correct & Verified
A pregnant client at 34 weeks gestation reports sudden gush of clear fluid from the vagina. What
is the priority nursing assessment?
A. Assess blood pressure and heart rate
✔✔B. Check fetal heart rate and note time of rupture
C. Measure fundal height
D. Prepare for immediate delivery
A postpartum client reports severe perineal pain and observes swelling at the site. What is the
priority intervention?
A. Encourage ambulation
✔✔B. Apply cold compress and assess for hematoma
C. Provide warm sitz bath immediately
D. Document findings only
A client in active labor has a contraction every 2 minutes lasting 80 seconds with fetal heart rate
showing late decelerations. What should the nurse do first?
1
,A. Administer pain medication
✔✔B. Reposition the client, give oxygen, and notify provider
C. Encourage deep breathing
D. Continue monitoring
A client at 28 weeks gestation presents with swelling of the face and hands and reports
headaches. What is the priority nursing action?
A. Measure fundal height
✔✔B. Assess for preeclampsia and notify provider
C. Encourage rest and hydration
D. Teach fetal kick counts
A client with gestational diabetes is unsure about how to monitor blood sugar at home. What
teaching is essential?
A. Check blood sugar once a week
B. Skip insulin on low-glucose days
✔✔C. Teach fingerstick technique, target levels, and diet management
D. Monitor only if feeling symptoms
2
,A newborn at 2 hours of life has a heart rate of 80 bpm and weak cry. What is the immediate
nursing intervention?
A. Swaddle the newborn
✔✔B. Stimulate and provide supplemental oxygen
C. Administer vitamin K
D. Place under phototherapy
A client in labor reports severe back pain with contractions. What non-pharmacologic method
can the nurse suggest?
A. Apply cold packs to the abdomen
B. Administer IV opioids immediately
✔✔C. Encourage ambulation, position changes, and counter-pressure
D. Limit movement and keep supine
A client at 36 weeks gestation presents with sudden abdominal pain and no fetal movement.
What is the priority action?
A. Provide pain medication
✔✔B. Assess fetal heart rate and prepare for emergency evaluation
3
, C. Encourage rest
D. Perform fundal massage
A postpartum client on day 2 reports heavy vaginal bleeding with passage of clots. What is the
priority nursing assessment?
A. Encourage ambulation
✔✔B. Assess uterine tone and massage fundus
C. Document amount of bleeding
D. Apply a perineal pad only
A client at 40 weeks gestation reports regular contractions every 3 minutes. What is the next
nursing action?
A. Prepare for induction immediately
B. Encourage the client to walk
✔✔C. Assess cervical dilation and effacement
D. Assess vital signs only
A client receiving oxytocin develops contractions lasting 90 seconds every 1–2 minutes. What is
the priority nursing intervention?
4
