MATERNITY HESI 1
TEST BANK
2025
Question 1.
A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would be
most effective in preventing pooling of blood in the lower extremities?
Ans: 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 straighten out the pelvic
veins and increase venous return.
Question 2.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
Ans: Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
Question 3.
When do the anterior and posterior fontanels close?
Ans: anterior fontanel closes at 12 to 18 months and the posterior by the end of the
second month.
Question 4.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she
and her husband consider attending childbirth preparation classes. When is the best time
for the couple to attend these classes?
Ans: 30 weeks gestation
1
,at 30 weeks gestation is closest (of the options) to the time parents would be ready for
such classes. Learning is facilitated by an interested pupil! The couple is most
interested in childbirth toward the end of the pregnancy when they are psychologically
ready for the termination of the pregnancy, and the birth of their child is an immediate
concern.
Question 5.
The nurse should encourage the laboring client to begin pushing when..
Ans: the cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix
can become edematous and may never completely dilate, necessitating an operative
delivery. Many primigravida's begin active labor 100% effaced and then proceed to
dilate.
Question 6.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins
to complain of tingling fingers and dizziness. What action should the nurse take?
Ans: Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
facilitated by breathing into a paper bag or cupped hands.
Question 7.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized edema on the right side of his head. The nurse knows that, in the
newborn, an accumulation of blood between the periosteum and skull which does not
cross the suture line is a newborn variation known as...
Ans: a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and the skull.
Question 8.
When does the head return to its normal shape?
Ans: 7-10 days
Question 9.
What did Nurse theorist Reva Rubin describe?
2
,Ans: The initial postpartum period as the "taking-in phase," which is characterized by
maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and
closeness to families and the newborn.
Question 10.
A couple, concerned because the woman has not been able to conceive, is referred to a
healthcare provider for a fertility workup and a hysterosalpingography is scheduled.
Which post procedure complaint indicates that the fallopian tubes are patent?
Ans: Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
collection of peritoneal dye/gas.
Question 11.
Which nursing intervention is most helpful in relieving postpartum uterine contractions
or "afterpains?"
Ans: Lying prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful with multiparas, who
commonly experience afterpains due to lack of uterine tone.
Question 12.
Which maternal behavior is the nurse most likely to see when a new mother receives her
infant for the first time?
Ans: Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
described in during the first visit with the newborn, which may be at delivery or later.
Question 13.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved?
Ans; A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory
rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic
effects.)
Question 14.
Urinary output must be monitored when administering magnesium sulfate and should be
at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client is
4.8 to 9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
3
, Ans: The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
What does it help prevent? helps prevent seizures What
indicates toxic levels? 3
Respiratory rate below 12 indicates toxic effects.
Urine output of less than 100 ml/4 hours
Absent DTRs
Question 15.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's
blood pressure drops from 120/80 to 90/60. What action should the nurse take?
Ans: Place woman in a lateral position
The nurse should immediately turn the woman to a lateral position, place a pillow or
wedge under the right hip to deflect the uterus, increase the rate of the main line IV
infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure
remains low, especially if it further decreases, the anesthesiologist/healthcare provider
should be notified immediately.
Question 16.
A client at 28-weeks gestation calls the antepartum clinic and states that she is
experiencing a small amount of vaginal bleeding which she describes as bright red. She
further states that she is not experiencing any uterine contractions or abdominal pain.
What instruction should the nurse provide?
Ans: Come to the clinic today for an ultrasound
Third trimester painless bleeding is characteristic of a placenta previa. Bright red
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound.
Question 17.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority?
Ans: Put the newborn to breast
Putting the newborn to breast will help contract the uterus and prevent a postpartum
hemorrhage--this intervention has the highest priority.
Question 18.
A pregnant client with mitral stenosis Class Ill is prescribed complete bedrest. The client
asks the nurse, "Why must I stay in bed all the time?" Which response is best for the
nurse to provide this client?
4
TEST BANK
2025
Question 1.
A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would be
most effective in preventing pooling of blood in the lower extremities?
Ans: 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 straighten out the pelvic
veins and increase venous return.
Question 2.
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
Ans: Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
headache, and a feeling of "nervousness".
Question 3.
When do the anterior and posterior fontanels close?
Ans: anterior fontanel closes at 12 to 18 months and the posterior by the end of the
second month.
Question 4.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she
and her husband consider attending childbirth preparation classes. When is the best time
for the couple to attend these classes?
Ans: 30 weeks gestation
1
,at 30 weeks gestation is closest (of the options) to the time parents would be ready for
such classes. Learning is facilitated by an interested pupil! The couple is most
interested in childbirth toward the end of the pregnancy when they are psychologically
ready for the termination of the pregnancy, and the birth of their child is an immediate
concern.
Question 5.
The nurse should encourage the laboring client to begin pushing when..
Ans: the cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix
can become edematous and may never completely dilate, necessitating an operative
delivery. Many primigravida's begin active labor 100% effaced and then proceed to
dilate.
Question 6.
The nurse instructs a laboring client to use accelerated-blow breathing. The client begins
to complain of tingling fingers and dizziness. What action should the nurse take?
Ans: Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
facilitated by breathing into a paper bag or cupped hands.
Question 7.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized edema on the right side of his head. The nurse knows that, in the
newborn, an accumulation of blood between the periosteum and skull which does not
cross the suture line is a newborn variation known as...
Ans: a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and the skull.
Question 8.
When does the head return to its normal shape?
Ans: 7-10 days
Question 9.
What did Nurse theorist Reva Rubin describe?
2
,Ans: The initial postpartum period as the "taking-in phase," which is characterized by
maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and
closeness to families and the newborn.
Question 10.
A couple, concerned because the woman has not been able to conceive, is referred to a
healthcare provider for a fertility workup and a hysterosalpingography is scheduled.
Which post procedure complaint indicates that the fallopian tubes are patent?
Ans: Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
collection of peritoneal dye/gas.
Question 11.
Which nursing intervention is most helpful in relieving postpartum uterine contractions
or "afterpains?"
Ans: Lying prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful with multiparas, who
commonly experience afterpains due to lack of uterine tone.
Question 12.
Which maternal behavior is the nurse most likely to see when a new mother receives her
infant for the first time?
Ans: Her arms and hands receive the infant and she then traces the infant's profile with
her fingertips.
Attachment/bonding theory indicates that most mothers will demonstrate behaviors
described in during the first visit with the newborn, which may be at delivery or later.
Question 13.
A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms.
Which assessment finding indicates the therapeutic drug level has been achieved?
Ans; A decreased in respiratory rate from 24 to 16
Magnesium sulfate, a CNS depressant, helps prevent seizures. A decreased respiratory
rate indicates that the drug is effective. (Respiratory rate below 12 indicates toxic
effects.)
Question 14.
Urinary output must be monitored when administering magnesium sulfate and should be
at least 30 ml per hour. (The therapeutic level of magnesium sulfate for a PIH client is
4.8 to 9.6 mg/dl.) What is the therapeutic level of magnesium sulfate?
3
, Ans: The therapeutic level of magnesium sulfate for a PIH client is 4.8 to 9.6 mg/dl.
What does it help prevent? helps prevent seizures What
indicates toxic levels? 3
Respiratory rate below 12 indicates toxic effects.
Urine output of less than 100 ml/4 hours
Absent DTRs
Question 15.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's
blood pressure drops from 120/80 to 90/60. What action should the nurse take?
Ans: Place woman in a lateral position
The nurse should immediately turn the woman to a lateral position, place a pillow or
wedge under the right hip to deflect the uterus, increase the rate of the main line IV
infusion, and administer oxygen by face mask at 10-12 L/min. If the blood pressure
remains low, especially if it further decreases, the anesthesiologist/healthcare provider
should be notified immediately.
Question 16.
A client at 28-weeks gestation calls the antepartum clinic and states that she is
experiencing a small amount of vaginal bleeding which she describes as bright red. She
further states that she is not experiencing any uterine contractions or abdominal pain.
What instruction should the nurse provide?
Ans: Come to the clinic today for an ultrasound
Third trimester painless bleeding is characteristic of a placenta previa. Bright red
bleeding may be intermittent, occur in gushes, or be continuous. Rarely is the first
incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound.
Question 17.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
while her husband is screaming for someone to help his wife. Which intervention has
the highest priority?
Ans: Put the newborn to breast
Putting the newborn to breast will help contract the uterus and prevent a postpartum
hemorrhage--this intervention has the highest priority.
Question 18.
A pregnant client with mitral stenosis Class Ill is prescribed complete bedrest. The client
asks the nurse, "Why must I stay in bed all the time?" Which response is best for the
nurse to provide this client?
4
