Page 1 of 54
Exit HESI Practice Exam – Verified Questions and
Answers | Complete Nursing Prep 2025
Which action should the nurse implement when preparing to
measure the fundal height of a pregnant client?
......ANSWER........To accurately measure the fundal height, the
bladder must be empty to avoid elevation of the uterus.
The nurse identifies crepitus when examining the chest of a
newborn who was delivered vaginally. Which further assessment
should the nurse perform? ......ANSWER........The most common
neonatal birth trauma due to a vaginal delivery is fracture of
the clavicle. Although an infant may be asymptomatic, a
fractured clavicle should be suspected if an infant has limited
use of the affected arm, malposition of the arm, an asymmetric
Moro reflex, crepitus over the clavicle, focal swelling or
tenderness, or cries when the arm is moved.
,Page 2 of 54
One hour after giving birth to an 8-pound infant, a client's lochia
rubra has increased from small to large and her fundus is boggy
despite massage. The client's pulse is 84 beats/minute and
blood pressure is 156/96. The healthcare provider prescribes
Methergine 0.2 mg IM × 1. What action should the nurse take
immediately? ......ANSWER........Methergine is contraindicated for
clients with elevated blood pressure, so the nurse should contact
the healthcare provider and question the prescription
The nurse is preparing to give an enema to a laboring client.
Which client requires the most caution when carrying out this
procedure? ......ANSWER........A 40-week primigravida who is at
6 cm cervical dilatation and the presenting part is not engaged.
When the presenting part is ballottable, it is floating out of the
pelvis. In such a situation, the cord can descend before the fetus
causing a prolapsed cord, which is an emergency situation.
,Page 3 of 54
the Silverman-Anderson Index ......ANSWER........A Silverman-
Anderson Index has five categories with scores of 0, 1, or 2. The
total score ranges from 0 to 10. A total score of 0 means the
infant has no dyspnea, a total score of 10 indicates maximum
respiratory distress.
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? ......ANSWER........Do you have a history of rheumatic
fever?
Clients with a history of rheumatic fever may develop mitral
valve prolapse, which increases the risk for cardiac
decompensation due to the increased blood volume that occurs
during pregnancy, so obtaining information about this client's
health history is a priority.
, Page 4 of 54
The nurse is assessing a client who is having a non-stress test
(NST) at 41-weeks gestation. The nurse determines that the client
is not having contractions, the fetal heart rate (FHR) baseline is
144 bpm, and no FHR accelerations are occurring. What action
should the nurse take? ......ANSWER........The client should be
asked if she has felt the fetus move.
An NST is used to determine fetal well-being, and is often
implemented when postmaturity is suspected. A "reactive" NST
occurs if the FHR accelerates 15 bpm for 15 seconds in response
to the fetus' own movement, and is "nonreactive" if no FHR
acceleration occurs in response to fetal movement.
A client in active labor is admitted with preeclampsia. Which
assessment finding is most significant in planning this client's
care? ......ANSWER........A 4+ reflex in a client with pregnancy-
induced hypertension indicates hyperreflexia, which is an
indication of an impending seizure.
Exit HESI Practice Exam – Verified Questions and
Answers | Complete Nursing Prep 2025
Which action should the nurse implement when preparing to
measure the fundal height of a pregnant client?
......ANSWER........To accurately measure the fundal height, the
bladder must be empty to avoid elevation of the uterus.
The nurse identifies crepitus when examining the chest of a
newborn who was delivered vaginally. Which further assessment
should the nurse perform? ......ANSWER........The most common
neonatal birth trauma due to a vaginal delivery is fracture of
the clavicle. Although an infant may be asymptomatic, a
fractured clavicle should be suspected if an infant has limited
use of the affected arm, malposition of the arm, an asymmetric
Moro reflex, crepitus over the clavicle, focal swelling or
tenderness, or cries when the arm is moved.
,Page 2 of 54
One hour after giving birth to an 8-pound infant, a client's lochia
rubra has increased from small to large and her fundus is boggy
despite massage. The client's pulse is 84 beats/minute and
blood pressure is 156/96. The healthcare provider prescribes
Methergine 0.2 mg IM × 1. What action should the nurse take
immediately? ......ANSWER........Methergine is contraindicated for
clients with elevated blood pressure, so the nurse should contact
the healthcare provider and question the prescription
The nurse is preparing to give an enema to a laboring client.
Which client requires the most caution when carrying out this
procedure? ......ANSWER........A 40-week primigravida who is at
6 cm cervical dilatation and the presenting part is not engaged.
When the presenting part is ballottable, it is floating out of the
pelvis. In such a situation, the cord can descend before the fetus
causing a prolapsed cord, which is an emergency situation.
,Page 3 of 54
the Silverman-Anderson Index ......ANSWER........A Silverman-
Anderson Index has five categories with scores of 0, 1, or 2. The
total score ranges from 0 to 10. A total score of 0 means the
infant has no dyspnea, a total score of 10 indicates maximum
respiratory distress.
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? ......ANSWER........Do you have a history of rheumatic
fever?
Clients with a history of rheumatic fever may develop mitral
valve prolapse, which increases the risk for cardiac
decompensation due to the increased blood volume that occurs
during pregnancy, so obtaining information about this client's
health history is a priority.
, Page 4 of 54
The nurse is assessing a client who is having a non-stress test
(NST) at 41-weeks gestation. The nurse determines that the client
is not having contractions, the fetal heart rate (FHR) baseline is
144 bpm, and no FHR accelerations are occurring. What action
should the nurse take? ......ANSWER........The client should be
asked if she has felt the fetus move.
An NST is used to determine fetal well-being, and is often
implemented when postmaturity is suspected. A "reactive" NST
occurs if the FHR accelerates 15 bpm for 15 seconds in response
to the fetus' own movement, and is "nonreactive" if no FHR
acceleration occurs in response to fetal movement.
A client in active labor is admitted with preeclampsia. Which
assessment finding is most significant in planning this client's
care? ......ANSWER........A 4+ reflex in a client with pregnancy-
induced hypertension indicates hyperreflexia, which is an
indication of an impending seizure.
