HESI RN MATERNITY ASSIGNMENT
EXAM QUESTIONS WITH CORRECT
ANSWERS
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 mU/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
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
-amniotic membranes rupture
-uterine contractions occur every 8-10 min
-FHR is 180 bpm w/o variability - ANSWER-D. The fetal heart rate is 180 bpm
without variability
The nurse on the postpartum unit receives report for 4 clients during change of shift.
Which client should the nurse assess for risk of postpartum hemorrhage?
-primigravida who had spontaneous birth of preterm twins
-multigravida who delivered an 8 lb 2 oz infant after 8 hour labor
-multiparous client receiving magnesium sulfate during induction for severe
preeclampsia
,-primiparous client who had an emergency cesarean birth due to fetal distress -
ANSWER-C. A multiparous client receiving magnesium sulfate during induction for
severe preeclampsia
What nursing action should be included in the plan of care for a newborn
experiencing symptoms of drug withdrawal?
-play soft music and talk to soothe the infant
-administer chloral hydrate for sedation
-feed every 4-6 hours to allow extra rest
-swaddle the infant snugly and hold tight - ANSWER-D. Swaddle the infant snugly
and hold tightly
The father of a newborn tells the nurse, "My son just died." how should the nurse
respond?
-I am sorry for your loss
-there is an angel in heaven
-I understand how you feel
-you can have other children - ANSWER-A. "I am sorry for your loss."
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery.
After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the
priority nursing action?
-assess newborn reflexes for signs of neuro impairment
-leave infant in the room with the mother to foster attachment
-obtain serum glucose levels frequently while observing closely for signs of
hypoglycemia
-perform a gestational age assessment to determine if the infant is large for
gestational age - ANSWER-C. Obtain serum glucose levels frequently while
observing closely for signs of hypoglycemia
An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a
nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the
face and upper back of the newborn. What information should the nurse provide?
-further assessment is indicated
-petechiae occurs with forceps delivery
-an increased blood volume causes broken blood vessels
-pinpoint spots are benign and disappear within 48 hours - ANSWER-D. The pinpoint
spots are benign and disappear within 48 hours
Which finding for a client in labor at 41 weeks gestation requires additional
assessment by the nurse?
-cervix dilated 2 cm and 50% effaced
-score of 8 on the biophysical profile
-fetal heart rate of 116 bpm
-one fetal movement noted in an hour - ANSWER-D. One fetal movement noted in
an hour
A primigravida at 12 weeks gestation who just moved to the United States indicates
she has not received any immunizations. Which Immunizations should the nurse
administer at this time? (Select all that apply) - ANSWER-A. Tetanus
, C. Diphtheria
E. Hepatitis B
A gravid client develops maternal hypotension following regional anesthesia. What
interventions should the nurse implement? (Select all that apply) - ANSWER-A.
Administer oxygen
B. Increase IV fluids
E. Place the client in a lateral position
F. Monitor fetal status
A client at 29 weeks gestation with possible placental insufficiency is being prepared
for prenatal testing. Information about which diagnostic study should the nurse
provide information to the client?
-amniocentesis
-ultrasonography
-chorionic villus sampling
-maternal serum alpha-fetoprotein - ANSWER-B. Ultrasonography
The mother of a neonate asks the nurse why it is so important to keep the infant
warm. What information should the nurse provide?
-kidneys and renal function are not fully developed
-warmth promotes sleep so the infant will grow quickly
-a large body surface area favors heat loss to the environment
-thick layer of subcut fat is inadequate for insulation - ANSWER-C. A large body
surface area favors heat loss to the environment
The nurse observes a new mother avoiding eye contact with her newborn. Which
action should the nurse take?
-ask mother why she won't look at infant
-observe the mother for other attachment behaviors
-examine the newborns eyes for ability to focus
-recognize this as a common reaction in new mothers - ANSWER-B. Observe the
mother for other attachment behaviors
The nurse notes an irregular bluish hue on the sacral area of a 1 day old Hispanic
infant. How should the nurse document this finding?
-acrocyanosis
-mongolian spots
-erythema toxicum
-harlequin sign - ANSWER-B. Mongolian spots
An infant with hyperbilirubinaemia is receiving phototherapy. What intervention
should the nurse implement?
-maintain NPO
-monitor temp
-apply skin lotion as prescribed
-change t-shirt every 3 hours - ANSWER-B. Monitor temperature
EXAM QUESTIONS WITH CORRECT
ANSWERS
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 mU/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
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
-amniotic membranes rupture
-uterine contractions occur every 8-10 min
-FHR is 180 bpm w/o variability - ANSWER-D. The fetal heart rate is 180 bpm
without variability
The nurse on the postpartum unit receives report for 4 clients during change of shift.
Which client should the nurse assess for risk of postpartum hemorrhage?
-primigravida who had spontaneous birth of preterm twins
-multigravida who delivered an 8 lb 2 oz infant after 8 hour labor
-multiparous client receiving magnesium sulfate during induction for severe
preeclampsia
,-primiparous client who had an emergency cesarean birth due to fetal distress -
ANSWER-C. A multiparous client receiving magnesium sulfate during induction for
severe preeclampsia
What nursing action should be included in the plan of care for a newborn
experiencing symptoms of drug withdrawal?
-play soft music and talk to soothe the infant
-administer chloral hydrate for sedation
-feed every 4-6 hours to allow extra rest
-swaddle the infant snugly and hold tight - ANSWER-D. Swaddle the infant snugly
and hold tightly
The father of a newborn tells the nurse, "My son just died." how should the nurse
respond?
-I am sorry for your loss
-there is an angel in heaven
-I understand how you feel
-you can have other children - ANSWER-A. "I am sorry for your loss."
A macrosomic infant is in stable condition after a difficult forceps-assisted delivery.
After obtaining the infant's weight at 4550 grams (9 pounds, 6 ounces), what is the
priority nursing action?
-assess newborn reflexes for signs of neuro impairment
-leave infant in the room with the mother to foster attachment
-obtain serum glucose levels frequently while observing closely for signs of
hypoglycemia
-perform a gestational age assessment to determine if the infant is large for
gestational age - ANSWER-C. Obtain serum glucose levels frequently while
observing closely for signs of hypoglycemia
An infant who weighs 3.8 kg is delivered vaginally at 39 weeks gestation with a
nuchal cord after a 30 minute second stage. The nurse identifies petechiae over the
face and upper back of the newborn. What information should the nurse provide?
-further assessment is indicated
-petechiae occurs with forceps delivery
-an increased blood volume causes broken blood vessels
-pinpoint spots are benign and disappear within 48 hours - ANSWER-D. The pinpoint
spots are benign and disappear within 48 hours
Which finding for a client in labor at 41 weeks gestation requires additional
assessment by the nurse?
-cervix dilated 2 cm and 50% effaced
-score of 8 on the biophysical profile
-fetal heart rate of 116 bpm
-one fetal movement noted in an hour - ANSWER-D. One fetal movement noted in
an hour
A primigravida at 12 weeks gestation who just moved to the United States indicates
she has not received any immunizations. Which Immunizations should the nurse
administer at this time? (Select all that apply) - ANSWER-A. Tetanus
, C. Diphtheria
E. Hepatitis B
A gravid client develops maternal hypotension following regional anesthesia. What
interventions should the nurse implement? (Select all that apply) - ANSWER-A.
Administer oxygen
B. Increase IV fluids
E. Place the client in a lateral position
F. Monitor fetal status
A client at 29 weeks gestation with possible placental insufficiency is being prepared
for prenatal testing. Information about which diagnostic study should the nurse
provide information to the client?
-amniocentesis
-ultrasonography
-chorionic villus sampling
-maternal serum alpha-fetoprotein - ANSWER-B. Ultrasonography
The mother of a neonate asks the nurse why it is so important to keep the infant
warm. What information should the nurse provide?
-kidneys and renal function are not fully developed
-warmth promotes sleep so the infant will grow quickly
-a large body surface area favors heat loss to the environment
-thick layer of subcut fat is inadequate for insulation - ANSWER-C. A large body
surface area favors heat loss to the environment
The nurse observes a new mother avoiding eye contact with her newborn. Which
action should the nurse take?
-ask mother why she won't look at infant
-observe the mother for other attachment behaviors
-examine the newborns eyes for ability to focus
-recognize this as a common reaction in new mothers - ANSWER-B. Observe the
mother for other attachment behaviors
The nurse notes an irregular bluish hue on the sacral area of a 1 day old Hispanic
infant. How should the nurse document this finding?
-acrocyanosis
-mongolian spots
-erythema toxicum
-harlequin sign - ANSWER-B. Mongolian spots
An infant with hyperbilirubinaemia is receiving phototherapy. What intervention
should the nurse implement?
-maintain NPO
-monitor temp
-apply skin lotion as prescribed
-change t-shirt every 3 hours - ANSWER-B. Monitor temperature
