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HESI RN Maternity Assessment 2024, Practice
Questions with 100% Verified Answers/ Rated A+
The nurse assesses a male newborn and determines that he has the following vital signs: axillary
temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on
these findings, which action should the nurse take first?
-check the infant's ABGs
-notify the pediatrician of the infants VS
-assess the infant's blood glucose level
-encourage the infant to take the breast or sugar water - ANSWER - C. Assess the infant's blood glucose
level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing
intervention?
-evaluate the blood pH
-begin humidified oxygen via hood
-stimulate infant crying
-place the infant under a radiant warmer - ANSWER - B. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?
-quiet the infant before counting the HR
-listen at the apex of the heart
-count the HR for at least one full minute
-palpate the umbilical cord - ANSWER - C. Count the heart rate for at least one full minute
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32 weeks’
gestation who has severe preeclampsia with pulmonary edema. What action should the nurse
implement?
, 2
-assess fetal response to procedure
-note any complaint of sudden chest pain
-monitor for premature ventricular contractions
-observe for maternal bp changes - ANSWER - C. Monitor for premature ventricular contractions
A client at 28 weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse
assess first for signs of internal hemorrhage?
-vaginal bleeding
-complaints of abdominal pain
-changes is FHR patterns
-alteration in maternal bp - ANSWER - C. Changes in fetal heart rate patterns
A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure
catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which
finding would require the nurse to take action?
-labor has progressed at 1 cm/hr. dilation
intensity of contractions is 130 mmHg contractions
are lasting 60-80 seconds
-oxytocin is infusing at a rate of 30 mud/min - ANSWER - B. Intensity of contractions is 130 mmHg
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. What action should
the nurse implement?
-administer 10 L of oxytocin via face mask
-give the HCP a status report
-place client in knee-chest position
-wrap the cord with glaze soaked in saline - ANSWER - C. Place the client in the knee-chest position
, 3
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the
nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to
make?
-inform the mother that the injection was prescribed by the HCP
-explore the mother's concerns about the infant receiving an injection of vitamin K
-explain that vitamin K is required by state law and compliance is mandatory
-remind the mother that all babies receive this shot and it is relatively painless - ANSWER - B. Explore the
mother's concerns about the infant receiving an injection of vitamin K
Which finding indicates to the nurse that a 4-day old infant is receiving adequate breast milk?
-gain 1-2 oz per week
-saturates 6-8 diapers per day
-rests for 6 hours b/w feedings
-defecates at least once per 24 hours - ANSWER - B. Saturates 6 to 8 diapers per day
The nurse is providing discharge teaching for a gravid client who is being released from the hospital after
placement of cerclage. Which instruction is the most important for the client to understand?
-plan for a possible cesarean birth
-arrange for home uterine monitoring
-make arrangements for care at home
-report uterine cramping or low backache - ANSWER - D. Report uterine cramping or low backache
A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red,
painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? -
contraction stress test
-internal fetal monitoring
-abdominal ultrasound
-lecithin-sphingomyelin ratio - ANSWER - C. Abdominal ultrasound
The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is
the most important factor affecting this client's pregnancy outcome?
, 4
-mothers age
amount of insulin required prenatally degree
of glycemic control during pregnancy
-number of years since diabetes was diagnosed - ANSWER - C. Degree of glycemic control during
pregnancy
A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which
prescription should the nurse administer?
-oxytocin
-ibuprofen
-fentanyl
-hem abate - ANSWER - A. Oxytocin (Pitocin)
At 10-weeks’ gestation, a high-risk multiparous client with a family history of Down syndrome is admitted
for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires
immediate intervention? -uterine cramping
-abdominal tenderness
-systolic bp <100 mmHg
-intermittent nausea - ANSWER - A. Uterine cramping
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?
-the client may have a bladder or kidney infection
-bladder capacity increases during pregnancy
-during pregnancy a woman is especially sensitive to body functions
-the growing uterus is putting pressure on the bladder - ANSWER - D. The growing uterus is putting
pressure on the bladder.
The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding
indicates that the nurse should discontinue the oxytocin infusion?
-client needs to void
HESI RN Maternity Assessment 2024, Practice
Questions with 100% Verified Answers/ Rated A+
The nurse assesses a male newborn and determines that he has the following vital signs: axillary
temperature 95.1 F, heart rate 136 beats/minute, and a respiratory rate 48 breaths/minute. Based on
these findings, which action should the nurse take first?
-check the infant's ABGs
-notify the pediatrician of the infants VS
-assess the infant's blood glucose level
-encourage the infant to take the breast or sugar water - ANSWER - C. Assess the infant's blood glucose
level
An infant in respiratory distress is placed on pulse ox. The O2 sat is 85%. What is the priority nursing
intervention?
-evaluate the blood pH
-begin humidified oxygen via hood
-stimulate infant crying
-place the infant under a radiant warmer - ANSWER - B. Begin humidified oxygen via hood
When assessing a newborn infant's heart rate, which technique is most important for the nurse to use?
-quiet the infant before counting the HR
-listen at the apex of the heart
-count the HR for at least one full minute
-palpate the umbilical cord - ANSWER - C. Count the heart rate for at least one full minute
The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32 weeks’
gestation who has severe preeclampsia with pulmonary edema. What action should the nurse
implement?
, 2
-assess fetal response to procedure
-note any complaint of sudden chest pain
-monitor for premature ventricular contractions
-observe for maternal bp changes - ANSWER - C. Monitor for premature ventricular contractions
A client at 28 weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse
assess first for signs of internal hemorrhage?
-vaginal bleeding
-complaints of abdominal pain
-changes is FHR patterns
-alteration in maternal bp - ANSWER - C. Changes in fetal heart rate patterns
A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure
catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which
finding would require the nurse to take action?
-labor has progressed at 1 cm/hr. dilation
intensity of contractions is 130 mmHg contractions
are lasting 60-80 seconds
-oxytocin is infusing at a rate of 30 mud/min - ANSWER - B. Intensity of contractions is 130 mmHg
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. What action should
the nurse implement?
-administer 10 L of oxytocin via face mask
-give the HCP a status report
-place client in knee-chest position
-wrap the cord with glaze soaked in saline - ANSWER - C. Place the client in the knee-chest position
, 3
The nurse prepares to administer an injection of vitamin K to a newborn infant. The mother tells the
nurse, "Wait! I don't want my baby to have a shot." Which response would be best for the nurse to
make?
-inform the mother that the injection was prescribed by the HCP
-explore the mother's concerns about the infant receiving an injection of vitamin K
-explain that vitamin K is required by state law and compliance is mandatory
-remind the mother that all babies receive this shot and it is relatively painless - ANSWER - B. Explore the
mother's concerns about the infant receiving an injection of vitamin K
Which finding indicates to the nurse that a 4-day old infant is receiving adequate breast milk?
-gain 1-2 oz per week
-saturates 6-8 diapers per day
-rests for 6 hours b/w feedings
-defecates at least once per 24 hours - ANSWER - B. Saturates 6 to 8 diapers per day
The nurse is providing discharge teaching for a gravid client who is being released from the hospital after
placement of cerclage. Which instruction is the most important for the client to understand?
-plan for a possible cesarean birth
-arrange for home uterine monitoring
-make arrangements for care at home
-report uterine cramping or low backache - ANSWER - D. Report uterine cramping or low backache
A client at 28 weeks gestation arrives at the labor and delivery unit with a complaint of bright red,
painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? -
contraction stress test
-internal fetal monitoring
-abdominal ultrasound
-lecithin-sphingomyelin ratio - ANSWER - C. Abdominal ultrasound
The nurse is planning for the care of a 30-year-old primigravida with pre-gestational diabetes. What is
the most important factor affecting this client's pregnancy outcome?
, 4
-mothers age
amount of insulin required prenatally degree
of glycemic control during pregnancy
-number of years since diabetes was diagnosed - ANSWER - C. Degree of glycemic control during
pregnancy
A client with asthma who is 8 hours post-delivery is experiencing postpartum hemorrhage. Which
prescription should the nurse administer?
-oxytocin
-ibuprofen
-fentanyl
-hem abate - ANSWER - A. Oxytocin (Pitocin)
At 10-weeks’ gestation, a high-risk multiparous client with a family history of Down syndrome is admitted
for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires
immediate intervention? -uterine cramping
-abdominal tenderness
-systolic bp <100 mmHg
-intermittent nausea - ANSWER - A. Uterine cramping
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?
-the client may have a bladder or kidney infection
-bladder capacity increases during pregnancy
-during pregnancy a woman is especially sensitive to body functions
-the growing uterus is putting pressure on the bladder - ANSWER - D. The growing uterus is putting
pressure on the bladder.
The nurse is caring for a client whose labor is being augmented with oxytocin (Pitocin). Which finding
indicates that the nurse should discontinue the oxytocin infusion?
-client needs to void
