RN HESI Maternity Exam (Test Bank) by Linda Anne
Silvestri, RN, MSN, EdD, CNE, ANEF, and Judith
Wilkinson, RN, MSN, EdD, CNE, - Guaranteed A+
Actual Questions and Answers, Complete 100%
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a
diagnosis of eclampsia. She is not presently convulsing. Which intervention should the
nurse plan to include in this client's nursing care plan? - Answer--Monitor Blood
pressure, pulse, and respirations q4h.
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours
to prevent urinary retention. The home health nurse notes that the child has developed
episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action
is most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change - Answer--C. Change to
latex-free gloves when handling infant
A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving
Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour.
How many ml/hour should the nurse program the infusion pump? (Enter numeric value
only)
A. 120
B. 70
C. 65
D. 75 - Answer--D. 75
,A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - Answer--B. Notify the
healthcare provider from the client's bedside
A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a
non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin (
Pitocin ) infusion. Which finding is most important for the nurse to report to the health
care provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - Answer--D. A pattern of late fetal decelerations
A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test
(NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin)
infusion. Which finding is most important for the nurse to report to the healthcare
provider?
A. Spontaneous rupture of membranes.
B. Fetal heart rate accelerations with fetal movement.
C. Absences of uterine contraction of 20 minutes.
D. A pattern of fetal late decelerations. - Answer--D. A pattern of fetal late decelerations.
A 4-day postpartum client calls the clinic and reports that her nipples are so sore that
she does not know if she can continue to breastfeed her infant. What instruction is best
for the nurse to provide? - Answer--Apply hot packs just before each feeding.
A 6-month old child who had a cleft-lip repair has elbow restraints in place. What
nursing intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all
times
C. obtain the HCP advice as to when the restraints should be removed
, D. remove restraints one at a time to provide ROM exercises - Answer--D. remove
restraints one at a time to provide ROM exercises
A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile
vomiting. Which assessment finding indicates to the nurse that the infant is becoming
dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant - Answer--A. Weak cry without any tears
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low
levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the
best explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
D. The TSH is high because of the low production of T4 by the thyroid. - Answer--D.
The TSH is high because of the low production of T4 by the thyroid.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the
infant. - Answer--A. Breastfeed the infant, ensuring that both breasts are completely
emptied.
A client at 28 weeks gestation is admitted to the obstetrical unit following her
involvement in a motor vehicle collision. While stabilizing the patient , the nurse obtains
fetal monitor reading. Which action should the nurse take if the fetus is tachycardic is on
the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - Answer--D.
Contact the healthcare provider after initiating oxygen per face mask
Silvestri, RN, MSN, EdD, CNE, ANEF, and Judith
Wilkinson, RN, MSN, EdD, CNE, - Guaranteed A+
Actual Questions and Answers, Complete 100%
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a
diagnosis of eclampsia. She is not presently convulsing. Which intervention should the
nurse plan to include in this client's nursing care plan? - Answer--Monitor Blood
pressure, pulse, and respirations q4h.
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours
to prevent urinary retention. The home health nurse notes that the child has developed
episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action
is most important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
D. Apply zinc oxide to perineum with each diaper change - Answer--C. Change to
latex-free gloves when handling infant
A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving
Ringer's Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour.
How many ml/hour should the nurse program the infusion pump? (Enter numeric value
only)
A. 120
B. 70
C. 65
D. 75 - Answer--D. 75
,A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - Answer--B. Notify the
healthcare provider from the client's bedside
A 38 week primigravida is admitted to labor and delivery after a non-reactive result on a
non-stress test (NST) .The nurse begins contraction stress test (CST) with an oxytocin (
Pitocin ) infusion. Which finding is most important for the nurse to report to the health
care provider ?
A. Spontaneous rupture of membrane
B. Fetal heart rate accelerations with fetal movement
C. Absence of uterine contractions within 20 mins
D. A pattern of late fetal decelerations - Answer--D. A pattern of late fetal decelerations
A 38-week primigravida is admitted to labor and delivery after a non-reactive stress test
(NST). The nurse begins a contraction stress test (CST) with an oxytocin (Pitocin)
infusion. Which finding is most important for the nurse to report to the healthcare
provider?
A. Spontaneous rupture of membranes.
B. Fetal heart rate accelerations with fetal movement.
C. Absences of uterine contraction of 20 minutes.
D. A pattern of fetal late decelerations. - Answer--D. A pattern of fetal late decelerations.
A 4-day postpartum client calls the clinic and reports that her nipples are so sore that
she does not know if she can continue to breastfeed her infant. What instruction is best
for the nurse to provide? - Answer--Apply hot packs just before each feeding.
A 6-month old child who had a cleft-lip repair has elbow restraints in place. What
nursing intervention should the nurse plan to implement?
A. remove restraints q4h for 30 minutes and place gloves on the child's hands
B. record observations of the restraints q2h and ensure that they are in place at all
times
C. obtain the HCP advice as to when the restraints should be removed
, D. remove restraints one at a time to provide ROM exercises - Answer--D. remove
restraints one at a time to provide ROM exercises
A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile
vomiting. Which assessment finding indicates to the nurse that the infant is becoming
dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant - Answer--A. Weak cry without any tears
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low
levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH)/ What is the
best explanation for this finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for several weeks after
birth
D. The TSH is high because of the low production of T4 by the thyroid. - Answer--D.
The TSH is high because of the low production of T4 by the thyroid.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A. Breastfeed the infant, ensuring that both breasts are completely emptied.
B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the
infant. - Answer--A. Breastfeed the infant, ensuring that both breasts are completely
emptied.
A client at 28 weeks gestation is admitted to the obstetrical unit following her
involvement in a motor vehicle collision. While stabilizing the patient , the nurse obtains
fetal monitor reading. Which action should the nurse take if the fetus is tachycardic is on
the monitor?
A. Recount the heart rate manually to confirm a monitor malfunction
B. Explain that there is no indication the fetal heart rate is due to trauma
C. Evaluate the presence of preterm labor by performing a vaginal
D. Contact the healthcare provider after initiating oxygen per face mask - Answer--D.
Contact the healthcare provider after initiating oxygen per face mask
