Maternity HESI Test bank QUESTIONS AND
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
1. An expectant father tells the nurse he fears that his wife is "losing her mind." He
states that she is constantly rubbing her abdomen and talking to the baby and
that she actually reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with her symp-
toms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring.
,Answer> D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
2. The nurse is preparing a laboring client for an amniotomy. Immediately after
the procedure is completed, it is most important for the nurse to obtain which
information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)
Answer> C. Fetal heart rate (FHR)
,Rationale
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the
cervix is favorable. The fluid should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is not specific
for AROM. Option B is monitored hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be determined for all clients in labor.
3. A nurse receives a shift change report for a newborn who is 12 hours post-
vaginal delivery. In developing a plan of care, the nurse should give the highest
priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced C.Tiny
white papules on the nose or chin
D.Red patches on the cheeks and trunk
Answer> B. Skin color that is slightly jaundiced
, Rationale Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue
color of the hands and feet) is a common finding in newborns; it occurs because the
capillary system is immature. Milia are small white papules present on the nose and
chin that are caused by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called erythema toxicum neonatorum,
a common finding in newborns.
4. 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.
CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
1. An expectant father tells the nurse he fears that his wife is "losing her mind." He
states that she is constantly rubbing her abdomen and talking to the baby and
that she actually reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with her symp-
toms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring.
,Answer> D) Reassure him that normal maternal-fetal bonding is occurring.
Rationale
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
2. The nurse is preparing a laboring client for an amniotomy. Immediately after
the procedure is completed, it is most important for the nurse to obtain which
information?
A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC)
Answer> C. Fetal heart rate (FHR)
,Rationale
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the
cervix is favorable. The fluid should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is not specific
for AROM. Option B is monitored hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be determined for all clients in labor.
3. A nurse receives a shift change report for a newborn who is 12 hours post-
vaginal delivery. In developing a plan of care, the nurse should give the highest
priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced C.Tiny
white papules on the nose or chin
D.Red patches on the cheeks and trunk
Answer> B. Skin color that is slightly jaundiced
, Rationale Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue
color of the hands and feet) is a common finding in newborns; it occurs because the
capillary system is immature. Milia are small white papules present on the nose and
chin that are caused by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called erythema toxicum neonatorum,
a common finding in newborns.
4. 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.
