HESI RN Maternity Exam 2025 –
Verified Questions and Correct
Answers with Expert Rationales
Question 1
A nurse is assessing a client at 36 weeks gestation who reports decreased fetal movement. What
is the priority action?
A. Encourage the client to drink orange juice
B. Perform a nonstress test
C. Prepare for an immediate cesarean section
D. Instruct the client to rest in a supine position
Correct Answer: B. Perform a nonstress test
Rationale: Decreased fetal movement may indicate fetal distress, and a nonstress test assesses
fetal heart rate and movement to evaluate well-being. Orange juice may stimulate movement but
is not diagnostic, cesarean section is premature, and supine positioning risks vena cava
compression.
Question 2
A client at 38 weeks gestation is in active labor and reports a sudden gush of fluid. The nurse
notes clear amniotic fluid. What is the next action?
A. Administer oxygen
B. Assess fetal heart rate
C. Prepare for an emergency delivery
D. Change the client’s position
Correct Answer: B. Assess fetal heart rate
Rationale: Rupture of membranes requires immediate assessment of fetal heart rate to detect
cord compression or distress. Oxygen, emergency delivery, or position changes are not indicated
without further assessment.
Question 3
,A nurse is teaching a client about postpartum self-care. Which statement indicates a need for
further teaching?
A. “I should report a fever over 100.4°F.”
B. “I can use a heating pad for afterpains.”
C. “I should expect heavy bleeding for 2 weeks.”
D. “I need to rest during the early postpartum period.”
Correct Answer: C. I should expect heavy bleeding for 2 weeks.
Rationale: Heavy bleeding beyond 3–4 days postpartum may indicate complications like
hemorrhage. Fever reporting, heating pad use, and rest are appropriate postpartum practices.
Question 4
A nurse is caring for a newborn with a respiratory rate of 50 breaths per minute at rest. What
should the nurse do?
A. Document the finding as normal
B. Notify the pediatrician immediately
C. Administer oxygen via nasal cannula
D. Stimulate the newborn to increase respirations
Correct Answer: A. Document the finding as normal
Rationale: A newborn’s normal respiratory rate is 30–60 breaths per minute at rest. This finding
is normal and requires no intervention beyond documentation.
Question 5
A client at 28 weeks gestation reports shortness of breath. Which action should the nurse take
first?
A. Administer oxygen at 2 L/min
B. Assess lung sounds and oxygen saturation
C. Place the client in a supine position
D. Prepare for an immediate ultrasound
Correct Answer: B. Assess lung sounds and oxygen saturation
Rationale: Shortness of breath requires assessment of lung sounds and oxygen saturation to
identify causes like pulmonary edema or anemia. Oxygen administration, supine positioning, or
ultrasound is premature without assessment.
Question 6
, A nurse is assessing a postpartum client who reports painful urination and frequency. Which
condition should the nurse suspect?
A. Urinary tract infection
B. Postpartum hemorrhage
C. Endometritis
D. Bladder distention
Correct Answer: A. Urinary tract infection
Rationale: Painful urination and frequency are classic signs of a urinary tract infection, common
postpartum due to catheterization or urinary stasis. Other conditions have different symptoms
(e.g., heavy bleeding for hemorrhage, fever for endometritis).
Question 7
A nurse is teaching a client about breastfeeding. Which position promotes effective latch?
A. Supine position
B. Side-lying position
C. Prone position
D. Standing position
Correct Answer: B. Side-lying position
Rationale: The side-lying position supports effective latch by allowing comfortable alignment of
the newborn’s mouth with the nipple. Supine and prone positions are unsafe, and standing is
impractical.
Question 8
A nurse is caring for a client in the second stage of labor. The fetal heart rate is 90 bpm with
minimal variability. What is the priority action?
A. Administer oxygen at 10 L/min via face mask
B. Prepare for a cesarean section
C. Change the client’s position to left lateral
D. Increase the IV fluid rate
Correct Answer: C. Change the client’s position to left lateral
Rationale: A fetal heart rate of 90 bpm with minimal variability indicates fetal distress, possibly
from cord compression. Changing to the left lateral position may relieve pressure and improve
fetal oxygenation. Other actions may follow if needed.
Verified Questions and Correct
Answers with Expert Rationales
Question 1
A nurse is assessing a client at 36 weeks gestation who reports decreased fetal movement. What
is the priority action?
A. Encourage the client to drink orange juice
B. Perform a nonstress test
C. Prepare for an immediate cesarean section
D. Instruct the client to rest in a supine position
Correct Answer: B. Perform a nonstress test
Rationale: Decreased fetal movement may indicate fetal distress, and a nonstress test assesses
fetal heart rate and movement to evaluate well-being. Orange juice may stimulate movement but
is not diagnostic, cesarean section is premature, and supine positioning risks vena cava
compression.
Question 2
A client at 38 weeks gestation is in active labor and reports a sudden gush of fluid. The nurse
notes clear amniotic fluid. What is the next action?
A. Administer oxygen
B. Assess fetal heart rate
C. Prepare for an emergency delivery
D. Change the client’s position
Correct Answer: B. Assess fetal heart rate
Rationale: Rupture of membranes requires immediate assessment of fetal heart rate to detect
cord compression or distress. Oxygen, emergency delivery, or position changes are not indicated
without further assessment.
Question 3
,A nurse is teaching a client about postpartum self-care. Which statement indicates a need for
further teaching?
A. “I should report a fever over 100.4°F.”
B. “I can use a heating pad for afterpains.”
C. “I should expect heavy bleeding for 2 weeks.”
D. “I need to rest during the early postpartum period.”
Correct Answer: C. I should expect heavy bleeding for 2 weeks.
Rationale: Heavy bleeding beyond 3–4 days postpartum may indicate complications like
hemorrhage. Fever reporting, heating pad use, and rest are appropriate postpartum practices.
Question 4
A nurse is caring for a newborn with a respiratory rate of 50 breaths per minute at rest. What
should the nurse do?
A. Document the finding as normal
B. Notify the pediatrician immediately
C. Administer oxygen via nasal cannula
D. Stimulate the newborn to increase respirations
Correct Answer: A. Document the finding as normal
Rationale: A newborn’s normal respiratory rate is 30–60 breaths per minute at rest. This finding
is normal and requires no intervention beyond documentation.
Question 5
A client at 28 weeks gestation reports shortness of breath. Which action should the nurse take
first?
A. Administer oxygen at 2 L/min
B. Assess lung sounds and oxygen saturation
C. Place the client in a supine position
D. Prepare for an immediate ultrasound
Correct Answer: B. Assess lung sounds and oxygen saturation
Rationale: Shortness of breath requires assessment of lung sounds and oxygen saturation to
identify causes like pulmonary edema or anemia. Oxygen administration, supine positioning, or
ultrasound is premature without assessment.
Question 6
, A nurse is assessing a postpartum client who reports painful urination and frequency. Which
condition should the nurse suspect?
A. Urinary tract infection
B. Postpartum hemorrhage
C. Endometritis
D. Bladder distention
Correct Answer: A. Urinary tract infection
Rationale: Painful urination and frequency are classic signs of a urinary tract infection, common
postpartum due to catheterization or urinary stasis. Other conditions have different symptoms
(e.g., heavy bleeding for hemorrhage, fever for endometritis).
Question 7
A nurse is teaching a client about breastfeeding. Which position promotes effective latch?
A. Supine position
B. Side-lying position
C. Prone position
D. Standing position
Correct Answer: B. Side-lying position
Rationale: The side-lying position supports effective latch by allowing comfortable alignment of
the newborn’s mouth with the nipple. Supine and prone positions are unsafe, and standing is
impractical.
Question 8
A nurse is caring for a client in the second stage of labor. The fetal heart rate is 90 bpm with
minimal variability. What is the priority action?
A. Administer oxygen at 10 L/min via face mask
B. Prepare for a cesarean section
C. Change the client’s position to left lateral
D. Increase the IV fluid rate
Correct Answer: C. Change the client’s position to left lateral
Rationale: A fetal heart rate of 90 bpm with minimal variability indicates fetal distress, possibly
from cord compression. Changing to the left lateral position may relieve pressure and improve
fetal oxygenation. Other actions may follow if needed.
