Maternity HESI Test
bank (combined red
hesi and other
sources)
An vexpectant vfather vtells vthe vnurse vhe vfears vthat vhis vwife vis v"losing vher vmind." vHe vstates vthat
vshe vis vconstantly vrubbing vher vabdomen vand vtalking vto vthe vbaby vand vthat vshe vactually
vreprimands vthe vbaby vwhen vit vmoves vtoo vmuch. vWhich vrecommendation vshould vthe vnurse
vmake vto vthis vexpectant vfather? v
A.Suggest vthat vhis vwife vseek vprofessional vcounseling vto vdeal vwith vher vsymptoms. v
,B.Explain vthat vhis vwife vis vexhibiting vambivalence vabout vthe vpregnancy. v
C. vAsk vhim vto vreport vsimilar vabnormal vbehaviors vat vthe vnext vprenatal vvisit. v
D.Reassure vhim vthat vnormal vmaternal-fetal vbonding vis voccurring. vCORRECT vANSWERS vD)
vReassure vhim vthat vnormal vmaternal-fetal vbonding vis voccurring. v
Rationale: v
These vbehaviors vare vpositive vsigns vof vmaternal-fetal vbonding vand vdo vnot vreflect vambivalence.
vNo vintervention vis vneeded. vQuickening, vthe vfirst vperception vof vfetal vmovement, voccurs vat v17 vto
v20 vweeks vof vgestation vand vbegins va vnew vphase vof vprenatal vbonding vduring vthe vsecond
vtrimester. vOptions vA vand vC vare vnot vnecessary vbecause vthe vbehaviors vdisplayed vare vnormal.
The vnurse vis vpreparing va vlaboring vclient vfor van vamniotomy. vImmediately vafter vthe vprocedure vis
vcompleted, vit vis vmost vimportant vfor vthe vnurse vto vobtain vwhich vinformation?
v
v A.Maternal vblood vpressure
v B.Maternal vtemperature
v C.Fetal vheart vrate v(FHR)
v
v D.White vblood vcell vcount v(WBC) vCORRECT vANSWERS vC. vFetal vheart vrate v(FHR)
Rationale:
The vFHR vshould vbe vassessed vbefore vand vafter vthe vprocedure vto vdetect vchanges vthat vmay
vindicate vthe vpresence vof vcord vcompression vor vprolapse. vAn vamniotomy v(artificial vrupture vof
vmembranes v[AROM]) vis vused vto vstimulate vlabor vwhen vthe vcondition vof vthe vcervix vis vfavorable.
vThe vfluid vshould vbe vassessed vfor vcolor, vodor, vand vconsistency. vOption vA vshould vbe vassessed
vevery v15 vto v20 vminutes vduring vlabor vbut vis vnot vspecific vfor vAROM. vOption vB vis vmonitored
,vhourly vafter vthe vmembranes vare vruptured vto vdetect vthe vdevelopment vof vamnionitis. vOption vD
vshould vbe vdetermined vfor vall vclients vin vlabor.
A vnurse vreceives va vshift vchange vreport vfor va vnewborn vwho vis v12 vhours vpost-vaginal vdelivery. vIn
vdeveloping va vplan vof vcare, vthe vnurse vshould vgive vthe vhighest vpriority vto vwhich vfinding?
v A.Cyanosis vof vthe vhands vand vfeet
v B.Skin vcolor vthat vis vslightly vjaundiced
v C.Tiny vwhite vpapules von vthe vnose vor vchin
vD.Red vpatches von vthe vcheeks vand vtrunk vCORRECT vANSWERS vB. vSkin vcolor vthat vis vslightly
vjaundiced
Rationale: vJaundice, va vyellow vskin vcoloration, vis vcaused vby velevated vlevels vof vbilirubin, vwhich
vshould vbe vfurther vevaluated vin va vnewborn v<24 vhours vold. vAcrocyanosis v(blue vcolor vof vthe
vhands vand vfeet) vis va vcommon vfinding vin vnewborns; vit voccurs vbecause vthe vcapillary vsystem vis
vimmature. vMilia vare vsmall vwhite vpapules vpresent von vthe vnose vand vchin vthat vare vcaused vby
vsebaceous vgland vblockage vand vdisappear vin va vfew vweeks. vSmall vred vpatches von vthe vcheeks vand
vtrunk vare vcalled verythema vtoxicum vneonatorum, va vcommon vfinding vin vnewborns.
A vbreastfeeding vpostpartum vclient vis vdiagnosed vwith vmastitis, vand vantibiotic vtherapy vis
vprescribed. vWhich vinstruction vshould vthe vnurse vprovide vto vthis vclient?
A.Breastfeed vthe vinfant, vensuring vthat vboth vbreasts vare vcompletely vemptied.
v B.Feed vexpressed vbreast vmilk vto vavoid vthe vpain vof vthe vinfant vlatching vonto vthe vinfected vbreast.
, v C.Breastfeed von vthe vunaffected vbreast vonly vuntil vthe vmastitis vsubsides.
vD.Dilute vexpressed vbreast vmilk vwith vsterile vwater vto vreduce vthe vantibiotic veffect von vthe vinfant.
vCORRECT vANSWERS vA.Breastfeed vthe vinfant, vensuring vthat vboth vbreasts vare vcompletely
vemptied.
Rationale:Mastitis, vcaused vby vplugged vmilk vducts, vis vrelated vto vbreast vengorgement, vand
vbreastfeeding vduring vmastitis vfacilitates vthe vcomplete vemptying vof vengorged vbreasts,
veliminating vthe vpressure von vthe vinflamed vbreast vtissue. vOption vB vis vless vpainful vbut vdoes vnot
vfacilitate vcomplete vemptying vof vthe vbreast vtissue. vOption vC vwill vnot vrelieve vthe vengorgement
von vthe vaffected vside. vOption vD vwill vnot vdecrease vantibiotic veffects von vthe vinfant.
A v38-week vprimigravida vwho vworks vas va vsecretary vand vsits vat va vcomputer v8 vhours veach vday
vtells vthe vnurse vthat vher vfeet vhave vbegun vto vswell. vWhich vinstruction vwill vaid vin vthe vprevention
vof vpooling vof vblood vin vthe vlower vextremities?
v A.Wear vsupport vstockings.
v B.Reduce vsalt vin vthe vdiet.
v C.Move vabout vevery vhour.
v D.Avoid vconstrictive vclothing. vCORRECT vANSWERS vC.Move vabout vevery vhour.
Rationale:
Pooling vof vblood vin vthe vlower vextremities vresults vfrom vthe venlarged vuterus vexerting vpressure
von vthe vpelvic vveins. vMoving vabout vevery vhour vwill vrelieve vpressure von vthe vpelvic vveins vand
vincrease vvenous vreturn. vOption vA vwould vincrease vvenous vreturn vfrom vvaricose vveins vin vthe
vlower vextremities vbut vwould vbe vof vlittle vhelp vwith vswelling. vOption vB vmight vbe vhelpful vwith
vgeneralized vedema vbut vis vnot vspecific vfor vedematous vlower vextremities. vOption vD vdoes vnot
bank (combined red
hesi and other
sources)
An vexpectant vfather vtells vthe vnurse vhe vfears vthat vhis vwife vis v"losing vher vmind." vHe vstates vthat
vshe vis vconstantly vrubbing vher vabdomen vand vtalking vto vthe vbaby vand vthat vshe vactually
vreprimands vthe vbaby vwhen vit vmoves vtoo vmuch. vWhich vrecommendation vshould vthe vnurse
vmake vto vthis vexpectant vfather? v
A.Suggest vthat vhis vwife vseek vprofessional vcounseling vto vdeal vwith vher vsymptoms. v
,B.Explain vthat vhis vwife vis vexhibiting vambivalence vabout vthe vpregnancy. v
C. vAsk vhim vto vreport vsimilar vabnormal vbehaviors vat vthe vnext vprenatal vvisit. v
D.Reassure vhim vthat vnormal vmaternal-fetal vbonding vis voccurring. vCORRECT vANSWERS vD)
vReassure vhim vthat vnormal vmaternal-fetal vbonding vis voccurring. v
Rationale: v
These vbehaviors vare vpositive vsigns vof vmaternal-fetal vbonding vand vdo vnot vreflect vambivalence.
vNo vintervention vis vneeded. vQuickening, vthe vfirst vperception vof vfetal vmovement, voccurs vat v17 vto
v20 vweeks vof vgestation vand vbegins va vnew vphase vof vprenatal vbonding vduring vthe vsecond
vtrimester. vOptions vA vand vC vare vnot vnecessary vbecause vthe vbehaviors vdisplayed vare vnormal.
The vnurse vis vpreparing va vlaboring vclient vfor van vamniotomy. vImmediately vafter vthe vprocedure vis
vcompleted, vit vis vmost vimportant vfor vthe vnurse vto vobtain vwhich vinformation?
v
v A.Maternal vblood vpressure
v B.Maternal vtemperature
v C.Fetal vheart vrate v(FHR)
v
v D.White vblood vcell vcount v(WBC) vCORRECT vANSWERS vC. vFetal vheart vrate v(FHR)
Rationale:
The vFHR vshould vbe vassessed vbefore vand vafter vthe vprocedure vto vdetect vchanges vthat vmay
vindicate vthe vpresence vof vcord vcompression vor vprolapse. vAn vamniotomy v(artificial vrupture vof
vmembranes v[AROM]) vis vused vto vstimulate vlabor vwhen vthe vcondition vof vthe vcervix vis vfavorable.
vThe vfluid vshould vbe vassessed vfor vcolor, vodor, vand vconsistency. vOption vA vshould vbe vassessed
vevery v15 vto v20 vminutes vduring vlabor vbut vis vnot vspecific vfor vAROM. vOption vB vis vmonitored
,vhourly vafter vthe vmembranes vare vruptured vto vdetect vthe vdevelopment vof vamnionitis. vOption vD
vshould vbe vdetermined vfor vall vclients vin vlabor.
A vnurse vreceives va vshift vchange vreport vfor va vnewborn vwho vis v12 vhours vpost-vaginal vdelivery. vIn
vdeveloping va vplan vof vcare, vthe vnurse vshould vgive vthe vhighest vpriority vto vwhich vfinding?
v A.Cyanosis vof vthe vhands vand vfeet
v B.Skin vcolor vthat vis vslightly vjaundiced
v C.Tiny vwhite vpapules von vthe vnose vor vchin
vD.Red vpatches von vthe vcheeks vand vtrunk vCORRECT vANSWERS vB. vSkin vcolor vthat vis vslightly
vjaundiced
Rationale: vJaundice, va vyellow vskin vcoloration, vis vcaused vby velevated vlevels vof vbilirubin, vwhich
vshould vbe vfurther vevaluated vin va vnewborn v<24 vhours vold. vAcrocyanosis v(blue vcolor vof vthe
vhands vand vfeet) vis va vcommon vfinding vin vnewborns; vit voccurs vbecause vthe vcapillary vsystem vis
vimmature. vMilia vare vsmall vwhite vpapules vpresent von vthe vnose vand vchin vthat vare vcaused vby
vsebaceous vgland vblockage vand vdisappear vin va vfew vweeks. vSmall vred vpatches von vthe vcheeks vand
vtrunk vare vcalled verythema vtoxicum vneonatorum, va vcommon vfinding vin vnewborns.
A vbreastfeeding vpostpartum vclient vis vdiagnosed vwith vmastitis, vand vantibiotic vtherapy vis
vprescribed. vWhich vinstruction vshould vthe vnurse vprovide vto vthis vclient?
A.Breastfeed vthe vinfant, vensuring vthat vboth vbreasts vare vcompletely vemptied.
v B.Feed vexpressed vbreast vmilk vto vavoid vthe vpain vof vthe vinfant vlatching vonto vthe vinfected vbreast.
, v C.Breastfeed von vthe vunaffected vbreast vonly vuntil vthe vmastitis vsubsides.
vD.Dilute vexpressed vbreast vmilk vwith vsterile vwater vto vreduce vthe vantibiotic veffect von vthe vinfant.
vCORRECT vANSWERS vA.Breastfeed vthe vinfant, vensuring vthat vboth vbreasts vare vcompletely
vemptied.
Rationale:Mastitis, vcaused vby vplugged vmilk vducts, vis vrelated vto vbreast vengorgement, vand
vbreastfeeding vduring vmastitis vfacilitates vthe vcomplete vemptying vof vengorged vbreasts,
veliminating vthe vpressure von vthe vinflamed vbreast vtissue. vOption vB vis vless vpainful vbut vdoes vnot
vfacilitate vcomplete vemptying vof vthe vbreast vtissue. vOption vC vwill vnot vrelieve vthe vengorgement
von vthe vaffected vside. vOption vD vwill vnot vdecrease vantibiotic veffects von vthe vinfant.
A v38-week vprimigravida vwho vworks vas va vsecretary vand vsits vat va vcomputer v8 vhours veach vday
vtells vthe vnurse vthat vher vfeet vhave vbegun vto vswell. vWhich vinstruction vwill vaid vin vthe vprevention
vof vpooling vof vblood vin vthe vlower vextremities?
v A.Wear vsupport vstockings.
v B.Reduce vsalt vin vthe vdiet.
v C.Move vabout vevery vhour.
v D.Avoid vconstrictive vclothing. vCORRECT vANSWERS vC.Move vabout vevery vhour.
Rationale:
Pooling vof vblood vin vthe vlower vextremities vresults vfrom vthe venlarged vuterus vexerting vpressure
von vthe vpelvic vveins. vMoving vabout vevery vhour vwill vrelieve vpressure von vthe vpelvic vveins vand
vincrease vvenous vreturn. vOption vA vwould vincrease vvenous vreturn vfrom vvaricose vveins vin vthe
vlower vextremities vbut vwould vbe vof vlittle vhelp vwith vswelling. vOption vB vmight vbe vhelpful vwith
vgeneralized vedema vbut vis vnot vspecific vfor vedematous vlower vextremities. vOption vD vdoes vnot
