Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
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 symptoms.
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. - (ANSWERS)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.
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) - (ANSWERS)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.
, Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
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 - (ANSWERS)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.
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. -
(ANSWERS)A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not
facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on
the affected side. Option D will not decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells
the nurse that her feet have begun to swell. Which instruction will aid in the prevention of
pooling of blood in the lower extremities?
A.Wear support stockings.
, Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - (ANSWERS)C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on
the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase
venous return. Option A would increase venous return from varicose veins in the lower
extremities but would be of little help with swelling. Option B might be helpful with generalized
edema but is not specific for edematous lower extremities. Option D does not address venous
return, and there is no indication in the question that constrictive clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of
this accumulation of blood between the periosteum and skull that does not cross the suture
line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage - (ANSWERS)A.Cephalhematoma,
which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within
the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on
the cranium during vaginal delivery, and is a common variation of the newborn. Options B and
D both involve intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
, Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath - (ANSWERS)C.Allow the cord to air-dry as much
as possible.
Rationale:Recent studies have indicated that air drying or plain water application may be equal
to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect
because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. -
(ANSWERS)C.Place petroleum ointment around the glans with each diaper change and
cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any
urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking
to the healing surface. Prepackaged wipes often contain other products that may irritate the
site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is
not an infective process and should not be removed. If bleeding occurs at home, the client
should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze
squares and call the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in
preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg
subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline
sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
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 symptoms.
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. - (ANSWERS)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.
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) - (ANSWERS)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.
, Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
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 - (ANSWERS)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.
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. -
(ANSWERS)A.Breastfeed the infant, ensuring that both breasts are completely emptied.
Rationale:Mastitis, caused by plugged milk ducts, is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts,
eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not
facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on
the affected side. Option D will not decrease antibiotic effects on the infant.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells
the nurse that her feet have begun to swell. Which instruction will aid in the prevention of
pooling of blood in the lower extremities?
A.Wear support stockings.
, Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - (ANSWERS)C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting pressure on
the pelvic veins. Moving about every hour will relieve pressure on the pelvic veins and increase
venous return. Option A would increase venous return from varicose veins in the lower
extremities but would be of little help with swelling. Option B might be helpful with generalized
edema but is not specific for edematous lower extremities. Option D does not address venous
return, and there is no indication in the question that constrictive clothing is a problem.
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops
localized swelling on the right side of his head. In a newborn, what is the most likely cause of
this accumulation of blood between the periosteum and skull that does not cross the suture
line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage - (ANSWERS)A.Cephalhematoma,
which is caused by forceps trauma
Rationale: Cephalhematoma, a slight abnormal variation of the newborn, usually arises within
the first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and skull. Option C is a cranial distortion lasting 5 to 7 days, caused by pressure on
the cranium during vaginal delivery, and is a common variation of the newborn. Options B and
D both involve intracranial bleeding and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding the newborn's
umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
, Maternity HESI Test bank (combined red hesi and other sources), RN
HESI Maternity, Maternity/OB HESI Practice Part #1, HESI:
Maternity & Women's Health, Maternal HESI study guide !@#$%@#$
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath - (ANSWERS)C.Allow the cord to air-dry as much
as possible.
Rationale:Recent studies have indicated that air drying or plain water application may be equal
to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect
because they promote moisture and increase the potential for infection.
A mother expresses fear about changing the infant's diaper after circumcision. What
information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding occurs. -
(ANSWERS)C.Place petroleum ointment around the glans with each diaper change and
cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to remove any
urine or feces, and petroleum ointment should be applied to prevent the diaper from sticking
to the healing surface. Prepackaged wipes often contain other products that may irritate the
site. The yellow exudate, which covers the glans penis as the area heals and epithelializes, is
not an infective process and should not be removed. If bleeding occurs at home, the client
should be instructed to apply gentle pressure to the site of the bleeding with sterile gauze
squares and call the health care provider.
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in
preterm labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg
subcutaneously, to stop her labor contractions. What are the primary side effects of terbutaline
sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
