HESI RN Maternity – Test Bank for
LPN to RN Transitions: Achieving
Success in Your New Role, 5th
Edition by Lora Claywell
(2025/2026 Edition)
A client who gave birth to a healthy 8-pound infant 3 hours ago is
admitted to the postpartum unit. Which nursing plan is best in assisting
this mother to bond with her newborn infant?
a. Encourage the mother to provide total care for her infant
b. Provide privacy, so the mother can develop a relationship with the
infant
c. Encourage the father to provide most of the infant's care during
hospitalization
d. Meet the mother's physical needs and demonstrate warmth toward
the infant - ANSWER -d. Meet the mother's physical needs and
demonstrate warmth toward the infant
It is most important to meet the mother's requirement for attention to
her needs so that she can begin infant care-taking (D). Nurse theorist
Reva Rubin describes the initial postpartum period as the "taking-in
phase," which is characterized by maternal reliance on others to satisfy
the needs for comfort, rest, nourishment, and closeness to families and
the newborn.
pg. 1
,A client receiving epidural anesthesia begins to experience nausea and
becomes pale and clammy. What intervention should the nurse
implement first?
a. Raise the foot of the bed
b. Assess for vaginal bleeding
c. Evaluate the fetal heart rate
d. Take the client's blood pressure - ANSWER -a. Raise the foot of the
bed
These symptoms are suggestive of hypotension which is a side effect of
epidural anesthesia. Raising the foot of the bed (A) will increase venous
return and provide blood to the vital areas. Increasing the IV fluid rate
using a balanced non-dextrose solution and ensuring that the silent is in
a lateral position are also appropriate interventions.
The nurse is providing discharge teaching for a client who is 24 hours
postpartum. The nurse explains to the client that her vaginal discharge
will change from red to pink and then to white. The client asks, "What if
I start having red bleeding after it changes?" What should the nurse
instruct the client to do?
a. Reduce activity level and notify the healthcare provider
b. Go to bed and assume a knee-chest position
c. Massage the uterus and go to the emergency room
pg. 2
,d. Do not worry as this is a normal occurrence - ANSWER -a. Reduce
activity level and notify the healthcare provider
Lochia should progress in stages from rubra (red) to serosa (pinkish) to
alba (whitish), and not return to red. The return to rubra usually
indicates subinvolution of infection.
A pregnant client with mitral stenosis Class III is prescribed complete
bedrest. The client asks the nurse, "Why must I stay in bed all the
time?" Which response is best for the nurse to provide this client?
a. Complete bedrest decreases oxygen needs and demands on the heart
muscle
b. We want your baby to be healthy, and this is the only way we can
make sure that will happen again
c. I know you're upset. Would you like to talk about somethings you
could so while in bed?
d. Labor is difficult, and you need to use this time to rest before you
have to assume all child-caring duties - ANSWER -a. Complete bedrest
decreases oxygen needs and demands on the heart muscle
To help preserve cardiac reserves, the woman may need to restrict her
activities and complete bedrest is often prescribes (A).
A pregnant woman comes to the prenatal clinic for an initial visit. In
reviewing her childbearing history, the client indicated that she has
delivered premature twins, one full- term baby, and has had no
pg. 3
, abortions. Which GTPAL should the nurse document in this client's
record?
a. 3-1-2-0-3
b. 4-1-2-0-3
c. 2-1-2-1-2
d. 3-1-1-0-3 - ANSWER -d. 3-1-1-0-3
(D) describes the correct GTPAL. The client has been pregnant 3 times
including the current pregnancy (G-3). She had one full-term infant (T-
1). She also had a preterm (P- 1) twin pregnancy (a multifetal gestation
is considered one birth when calculating parity). There were no
abortions (A-0), so this client has a total of 3 living children.
A client at 32-weeks gestation comes to the prenatal clinic with
complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which
question is most important for the nurse to ask this client?
a. Which symptom did you experience first?
b. Are you eating large amounts of salty foods?
c. Have you visited a foreign country recently?
d. Do you have a history of rheumatic fever? - ANSWER -d. Do you have
a history of rheumatic fever?
Clients with a history of rheumatic fever (D) may develop mitral valve
prolapse, which increases the risk for cardiac decompensation due to
pg. 4
LPN to RN Transitions: Achieving
Success in Your New Role, 5th
Edition by Lora Claywell
(2025/2026 Edition)
A client who gave birth to a healthy 8-pound infant 3 hours ago is
admitted to the postpartum unit. Which nursing plan is best in assisting
this mother to bond with her newborn infant?
a. Encourage the mother to provide total care for her infant
b. Provide privacy, so the mother can develop a relationship with the
infant
c. Encourage the father to provide most of the infant's care during
hospitalization
d. Meet the mother's physical needs and demonstrate warmth toward
the infant - ANSWER -d. Meet the mother's physical needs and
demonstrate warmth toward the infant
It is most important to meet the mother's requirement for attention to
her needs so that she can begin infant care-taking (D). Nurse theorist
Reva Rubin describes the initial postpartum period as the "taking-in
phase," which is characterized by maternal reliance on others to satisfy
the needs for comfort, rest, nourishment, and closeness to families and
the newborn.
pg. 1
,A client receiving epidural anesthesia begins to experience nausea and
becomes pale and clammy. What intervention should the nurse
implement first?
a. Raise the foot of the bed
b. Assess for vaginal bleeding
c. Evaluate the fetal heart rate
d. Take the client's blood pressure - ANSWER -a. Raise the foot of the
bed
These symptoms are suggestive of hypotension which is a side effect of
epidural anesthesia. Raising the foot of the bed (A) will increase venous
return and provide blood to the vital areas. Increasing the IV fluid rate
using a balanced non-dextrose solution and ensuring that the silent is in
a lateral position are also appropriate interventions.
The nurse is providing discharge teaching for a client who is 24 hours
postpartum. The nurse explains to the client that her vaginal discharge
will change from red to pink and then to white. The client asks, "What if
I start having red bleeding after it changes?" What should the nurse
instruct the client to do?
a. Reduce activity level and notify the healthcare provider
b. Go to bed and assume a knee-chest position
c. Massage the uterus and go to the emergency room
pg. 2
,d. Do not worry as this is a normal occurrence - ANSWER -a. Reduce
activity level and notify the healthcare provider
Lochia should progress in stages from rubra (red) to serosa (pinkish) to
alba (whitish), and not return to red. The return to rubra usually
indicates subinvolution of infection.
A pregnant client with mitral stenosis Class III is prescribed complete
bedrest. The client asks the nurse, "Why must I stay in bed all the
time?" Which response is best for the nurse to provide this client?
a. Complete bedrest decreases oxygen needs and demands on the heart
muscle
b. We want your baby to be healthy, and this is the only way we can
make sure that will happen again
c. I know you're upset. Would you like to talk about somethings you
could so while in bed?
d. Labor is difficult, and you need to use this time to rest before you
have to assume all child-caring duties - ANSWER -a. Complete bedrest
decreases oxygen needs and demands on the heart muscle
To help preserve cardiac reserves, the woman may need to restrict her
activities and complete bedrest is often prescribes (A).
A pregnant woman comes to the prenatal clinic for an initial visit. In
reviewing her childbearing history, the client indicated that she has
delivered premature twins, one full- term baby, and has had no
pg. 3
, abortions. Which GTPAL should the nurse document in this client's
record?
a. 3-1-2-0-3
b. 4-1-2-0-3
c. 2-1-2-1-2
d. 3-1-1-0-3 - ANSWER -d. 3-1-1-0-3
(D) describes the correct GTPAL. The client has been pregnant 3 times
including the current pregnancy (G-3). She had one full-term infant (T-
1). She also had a preterm (P- 1) twin pregnancy (a multifetal gestation
is considered one birth when calculating parity). There were no
abortions (A-0), so this client has a total of 3 living children.
A client at 32-weeks gestation comes to the prenatal clinic with
complaints of pedal edema, dyspnea, fatigue, and a moist cough. Which
question is most important for the nurse to ask this client?
a. Which symptom did you experience first?
b. Are you eating large amounts of salty foods?
c. Have you visited a foreign country recently?
d. Do you have a history of rheumatic fever? - ANSWER -d. Do you have
a history of rheumatic fever?
Clients with a history of rheumatic fever (D) may develop mitral valve
prolapse, which increases the risk for cardiac decompensation due to
pg. 4
