HESI OB/Maternity Exam | Updated Study
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A multiparous client has been in active labor for 8 hours when her amniotic membranes
spontaneously rupture. Which nursing action should the nurse implement first?
a. Prepare the client for imminent birth
b. Assess the fetal heart rate and pattern
c. Document the characteristics of the amniotic fluid
d. Notify the client's primary healthcare provider
✔️ Correct Answer: B
Rationale:
Assessing the fetal heart rate and pattern (Option B) is the priority nursing action
following spontaneous rupture of membranes. Rupture of membranes can cause
umbilical cord prolapse, particularly if the presenting part is not well engaged. Cord
,compression can lead to fetal hypoxia and bradycardia. The fetal heart rate should be
assessed immediately to detect any signs of fetal distress, such as variable decelerations
or bradycardia, which would indicate cord compression. This assessment guides
subsequent interventions and ensures fetal well-being.
Option A is incorrect because imminent birth is not expected at 8 hours of labor without
additional signs of advanced labor. Option C is incorrect while documenting fluid
characteristics is important, it is not the first priority. Option D is incorrect because the
healthcare provider should be notified after the initial assessment if there are concerns.
A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has broken.
While inspecting the client's perineum, the nurse notes the umbilical cord protruding
from the vagina. Which action should the nurse implement first?
a. Administer 10 L of oxygen via face mask
b. Give the healthcare provider a status report
c. Place the client in the knee-chest position
d. Wrap the cord with gauze soaked in saline
✔️ Correct Answer: C
Rationale:
Placing the client in the knee-chest position (Option C) is the priority nursing action for
a prolapsed umbilical cord. This position uses gravity to reduce pressure on the cord
and decrease cord compression, improving fetal perfusion. The nurse should also use a
sterile gloved hand to gently elevate the presenting part off the cord while maintaining
the position. This is an obstetric emergency requiring immediate intervention to prevent
fetal hypoxia.
Option A is incorrect while oxygen administration is important, positioning is the priority
to relieve cord compression. Option B is incorrect because the healthcare provider
should be notified, but immediate positioning takes precedence. Option D is incorrect
while keeping the cord moist is important, it is not the first action; positioning to relieve
compression is the priority.
,The nurse observes a new mother avoiding eye contact with her newborn. Which action
should the nurse take?
a. Ask the mother why she won't look at the infant
b. Observe the mother for other bonding behaviors
c. Examine the newborn's eyes for the ability to focus
d. Recognize this as a common reaction in new mothers
✔️ Correct Answer: B
Rationale:
Observing the mother for other bonding behaviors (Option B) is the most appropriate
nursing action. Avoiding eye contact may be a temporary response to exhaustion, pain,
or anxiety. The nurse should assess for other signs of attachment, such as holding the
infant closely, talking to the infant, and expressing positive statements. This
nonjudgmental observation allows the nurse to gather more information before
intervening.
Option A is incorrect because asking "why" may be perceived as confrontational and
could increase the mother's anxiety. Option C is incorrect because the newborn's visual
acuity is limited and not relevant to the mother's bonding behavior. Option D is
incorrect because while this may occur, it is not a universal reaction and should not be
dismissed without further assessment.
A client states, "During the three months I've been pregnant, it seems like I have had to
go to the bathroom every five minutes." Which explanation should the nurse provide to
this client?
a. The client may have a bladder or kidney infection
b. Bladder capacity increases during pregnancy
c. During pregnancy, a woman is especially sensitive to body functions
d. The growing uterus is putting pressure on the bladder
✔️ Correct Answer: D
Rationale:
The growing uterus is putting pressure on the bladder (Option D) is the correct
explanation for increased urinary frequency in the first trimester of pregnancy. As the
uterus enlarges, it descends into the pelvic cavity and exerts pressure on the urinary
, bladder, reducing its capacity and causing the sensation of needing to void more
frequently. This is a normal physiological change of pregnancy.
Option A is incorrect because urinary frequency alone does not indicate infection; signs
of infection include dysuria, fever, and cloudy urine. Option B is incorrect because
bladder capacity actually decreases during pregnancy due to uterine pressure. Option C
is incorrect while hormonal changes affect the urinary system, the primary cause is
mechanical pressure from the growing uterus.
Which nursing action should be implemented when intermittently gavage feeding a
preterm infant?
a. Allow the formula to flow by gravity
b. Avoid letting the infant suck on the tube
c. Insert feeding tube through the nares
d. Apply steady pressure to the syringe
✔️ Correct Answer: A
Rationale:
Allowing the formula to flow by gravity (Option A) is the correct method for gavage
feeding. The formula should be placed in a syringe and allowed to flow gently by
gravity, which mimics the natural flow of feeding and reduces the risk of overdistention
or aspiration. The height of the syringe should be adjusted to control the flow rate.
Option B is incorrect because allowing the infant to suck on a pacifier during gavage
feeding can promote oral motor development and provide comfort. Option C is
incorrect because the feeding tube is typically inserted through the mouth (orogastric)
rather than the nares in preterm infants to avoid nasal trauma and airway obstruction.
Option D is incorrect because applying steady pressure can cause rapid infusion and
increase the risk of aspiration or gastric distention.
A client in her second trimester of pregnancy asks if it is safe for her to have a drink with
dinner. How should the nurse respond to the client?
Guide | Newly Revised Update | 100%
Accurate| Approved by Verified Tutors.
Brand new!!
2026/2027 Frequently Most Tested Questions and
100% Accurate From Past papers | Graded A+ ,
Reviewed and Updated | 100% Guarantee Pass |
Latest Exam and Newest Version!!!
A multiparous client has been in active labor for 8 hours when her amniotic membranes
spontaneously rupture. Which nursing action should the nurse implement first?
a. Prepare the client for imminent birth
b. Assess the fetal heart rate and pattern
c. Document the characteristics of the amniotic fluid
d. Notify the client's primary healthcare provider
✔️ Correct Answer: B
Rationale:
Assessing the fetal heart rate and pattern (Option B) is the priority nursing action
following spontaneous rupture of membranes. Rupture of membranes can cause
umbilical cord prolapse, particularly if the presenting part is not well engaged. Cord
,compression can lead to fetal hypoxia and bradycardia. The fetal heart rate should be
assessed immediately to detect any signs of fetal distress, such as variable decelerations
or bradycardia, which would indicate cord compression. This assessment guides
subsequent interventions and ensures fetal well-being.
Option A is incorrect because imminent birth is not expected at 8 hours of labor without
additional signs of advanced labor. Option C is incorrect while documenting fluid
characteristics is important, it is not the first priority. Option D is incorrect because the
healthcare provider should be notified after the initial assessment if there are concerns.
A primigravida at 37 weeks gestation tells the nurse that her "bag of water" has broken.
While inspecting the client's perineum, the nurse notes the umbilical cord protruding
from the vagina. Which action should the nurse implement first?
a. Administer 10 L of oxygen via face mask
b. Give the healthcare provider a status report
c. Place the client in the knee-chest position
d. Wrap the cord with gauze soaked in saline
✔️ Correct Answer: C
Rationale:
Placing the client in the knee-chest position (Option C) is the priority nursing action for
a prolapsed umbilical cord. This position uses gravity to reduce pressure on the cord
and decrease cord compression, improving fetal perfusion. The nurse should also use a
sterile gloved hand to gently elevate the presenting part off the cord while maintaining
the position. This is an obstetric emergency requiring immediate intervention to prevent
fetal hypoxia.
Option A is incorrect while oxygen administration is important, positioning is the priority
to relieve cord compression. Option B is incorrect because the healthcare provider
should be notified, but immediate positioning takes precedence. Option D is incorrect
while keeping the cord moist is important, it is not the first action; positioning to relieve
compression is the priority.
,The nurse observes a new mother avoiding eye contact with her newborn. Which action
should the nurse take?
a. Ask the mother why she won't look at the infant
b. Observe the mother for other bonding behaviors
c. Examine the newborn's eyes for the ability to focus
d. Recognize this as a common reaction in new mothers
✔️ Correct Answer: B
Rationale:
Observing the mother for other bonding behaviors (Option B) is the most appropriate
nursing action. Avoiding eye contact may be a temporary response to exhaustion, pain,
or anxiety. The nurse should assess for other signs of attachment, such as holding the
infant closely, talking to the infant, and expressing positive statements. This
nonjudgmental observation allows the nurse to gather more information before
intervening.
Option A is incorrect because asking "why" may be perceived as confrontational and
could increase the mother's anxiety. Option C is incorrect because the newborn's visual
acuity is limited and not relevant to the mother's bonding behavior. Option D is
incorrect because while this may occur, it is not a universal reaction and should not be
dismissed without further assessment.
A client states, "During the three months I've been pregnant, it seems like I have had to
go to the bathroom every five minutes." Which explanation should the nurse provide to
this client?
a. The client may have a bladder or kidney infection
b. Bladder capacity increases during pregnancy
c. During pregnancy, a woman is especially sensitive to body functions
d. The growing uterus is putting pressure on the bladder
✔️ Correct Answer: D
Rationale:
The growing uterus is putting pressure on the bladder (Option D) is the correct
explanation for increased urinary frequency in the first trimester of pregnancy. As the
uterus enlarges, it descends into the pelvic cavity and exerts pressure on the urinary
, bladder, reducing its capacity and causing the sensation of needing to void more
frequently. This is a normal physiological change of pregnancy.
Option A is incorrect because urinary frequency alone does not indicate infection; signs
of infection include dysuria, fever, and cloudy urine. Option B is incorrect because
bladder capacity actually decreases during pregnancy due to uterine pressure. Option C
is incorrect while hormonal changes affect the urinary system, the primary cause is
mechanical pressure from the growing uterus.
Which nursing action should be implemented when intermittently gavage feeding a
preterm infant?
a. Allow the formula to flow by gravity
b. Avoid letting the infant suck on the tube
c. Insert feeding tube through the nares
d. Apply steady pressure to the syringe
✔️ Correct Answer: A
Rationale:
Allowing the formula to flow by gravity (Option A) is the correct method for gavage
feeding. The formula should be placed in a syringe and allowed to flow gently by
gravity, which mimics the natural flow of feeding and reduces the risk of overdistention
or aspiration. The height of the syringe should be adjusted to control the flow rate.
Option B is incorrect because allowing the infant to suck on a pacifier during gavage
feeding can promote oral motor development and provide comfort. Option C is
incorrect because the feeding tube is typically inserted through the mouth (orogastric)
rather than the nares in preterm infants to avoid nasal trauma and airway obstruction.
Option D is incorrect because applying steady pressure can cause rapid infusion and
increase the risk of aspiration or gastric distention.
A client in her second trimester of pregnancy asks if it is safe for her to have a drink with
dinner. How should the nurse respond to the client?
