HESI CAT Test Bank | Questions and Answers
(Actual 2025/2026 Update) 100% Solved
Certified Quality Verified by Experts With
Rationales
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should
the nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - ANSWER -C.Place the client in a lateral
position.
Rationale: The nurse should immediately turn the client to a lateral position or
place a pillow or wedge under one hip to deflect the uterus. Other immediate
interventions include increasing the rate of the main line IV infusion and
administering oxygen by facemask. If the blood pressure remains low after these
interventions or decreases further, the anesthesiologist or health care provider
should be notified immediately. To continue to monitor blood pressure without
taking further action could constitute malpractice. Option D may also be
warranted, but such action is based on hospital protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
,C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - ANSWER -A.Avoid alcohol
because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and
cognitive impairment for the infant. Options B, C, and D should also be included in
diet teaching for a breastfeeding mother; however, because these do not involve
safety of the infant, they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright
red. The bleeding has subsided. She further states that she is not experiencing any
uterine contractions or abdominal pain. What instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract
infection (UTI). - ANSWER -A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa.
Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely
is the first incident life threatening or cause for hypovolemic shock. Diagnosis is
confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta, which is life
threatening to the mother and fetus. If those symptoms were described, option B
would be appropriate. Option C does not address the cause of the symptoms. The
client is not describing symptoms of a UTI.
,A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.
Contractions are firm and occurring every 5 minutes, with a 30- to 40-second
duration. The fetal heart rate increases with each contraction and returns to
baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER -B.Determine
cervical dilation and effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that
occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without
evidence of fetal stress. FHR accelerations are a normal response to contractions,
so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the
frequency and intensity of contractions. Options A and C are indicated for fetal
stress. A sterile vaginal examination places the client at risk for infection and
should be performed when the client exhibits signs of progressing labor, which is
not indicated at this time.
A client who delivered by cesarean section 24 hours ago is using a patient-
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice
chips only since surgery. She is now complaining of nausea and bloating and states
that because she has had nothing to eat, she is too weak to breastfeed her infant.
Which nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
, D.Fatigue related to cesarean delivery and physical care demands of infant -
ANSWER -C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication,
and immobility is the priority nursing diagnosis and addresses the potential
problem of a paralytic ileus. Options A and B are both caused by impaired bowel
motility. Option D is not as important as impaired motility.
The nurse is counseling a client who wants to become pregnant. She tells the nurse
that she has a 36-day menstrual cycle and the first day of her last menstrual period
was January 8. When will the client's next fertile period occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7 - ANSWER -C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first
day of her last menstrual period. Her next period would begin on February 12.
Ovulation occurs 14 days before the first day of the menstrual period. The client
can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close.
Which statement is accurate regarding the timing of closure of an infant's fontanels
that should be included in this teaching plan?
A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the
end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the
end of the second week.
(Actual 2025/2026 Update) 100% Solved
Certified Quality Verified by Experts With
Rationales
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60 mm Hg. Which action should
the nurse take immediately?
A.Notify the health care provider or anesthesiologist.
B.Continue to assess the blood pressure every 5 minutes.
C.Place the client in a lateral position.
D.Turn off the continuous epidural. - ANSWER -C.Place the client in a lateral
position.
Rationale: The nurse should immediately turn the client to a lateral position or
place a pillow or wedge under one hip to deflect the uterus. Other immediate
interventions include increasing the rate of the main line IV infusion and
administering oxygen by facemask. If the blood pressure remains low after these
interventions or decreases further, the anesthesiologist or health care provider
should be notified immediately. To continue to monitor blood pressure without
taking further action could constitute malpractice. Option D may also be
warranted, but such action is based on hospital protocol.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
,C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day. - ANSWER -A.Avoid alcohol
because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it is excreted in
breast milk and may cause a variety of problems, including slower growth and
cognitive impairment for the infant. Options B, C, and D should also be included in
diet teaching for a breastfeeding mother; however, because these do not involve
safety of the infant, they do not have the same degree of importance as option A.
A client at 28 weeks of gestation calls the antepartal clinic and states that she has
just experienced a small amount of vaginal bleeding, which she describes as bright
red. The bleeding has subsided. She further states that she is not experiencing any
uterine contractions or abdominal pain. What instruction should the nurse provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a urinary tract
infection (UTI). - ANSWER -A.Come to the clinic today for an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a placenta previa.
Bright red bleeding may be intermittent, occur in gushes, or be continuous. Rarely
is the first incident life threatening or cause for hypovolemic shock. Diagnosis is
confirmed by transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta, which is life
threatening to the mother and fetus. If those symptoms were described, option B
would be appropriate. Option C does not address the cause of the symptoms. The
client is not describing symptoms of a UTI.
,A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor.
Contractions are firm and occurring every 5 minutes, with a 30- to 40-second
duration. The fetal heart rate increases with each contraction and returns to
baseline after the contraction. Which action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion. - ANSWER -B.Determine
cervical dilation and effacement.
Rationale: The goal of labor augmentation is to produce firm contractions that
occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without
evidence of fetal stress. FHR accelerations are a normal response to contractions,
so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the
frequency and intensity of contractions. Options A and C are indicated for fetal
stress. A sterile vaginal examination places the client at risk for infection and
should be performed when the client exhibits signs of progressing labor, which is
not indicated at this time.
A client who delivered by cesarean section 24 hours ago is using a patient-
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice
chips only since surgery. She is now complaining of nausea and bloating and states
that because she has had nothing to eat, she is too weak to breastfeed her infant.
Which nursing diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and immobility
, D.Fatigue related to cesarean delivery and physical care demands of infant -
ANSWER -C.Impaired bowel motility related to pain medication and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication,
and immobility is the priority nursing diagnosis and addresses the potential
problem of a paralytic ileus. Options A and B are both caused by impaired bowel
motility. Option D is not as important as impaired motility.
The nurse is counseling a client who wants to become pregnant. She tells the nurse
that she has a 36-day menstrual cycle and the first day of her last menstrual period
was January 8. When will the client's next fertile period occur?
A.January 14 to 15
B.January 22 to 23
C.January 29 to 30
D.February 6 to 7 - ANSWER -C.January 29 to 30
Rationale: This client can expect her next period to begin 36 days from the first
day of her last menstrual period. Her next period would begin on February 12.
Ovulation occurs 14 days before the first day of the menstrual period. The client
can expect ovulation to occur January 29 to 30. Options A, B, and D are incorrect.
In developing a teaching plan for expectant parents, the nurse decides to include
information about when the parents can expect the infant's fontanels to close.
Which statement is accurate regarding the timing of closure of an infant's fontanels
that should be included in this teaching plan?
A.The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the
end of the first week.
B.The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the
end of the second week.
