Maternity HESI Test bank Latest Update
2024/2025
A 23 year old client who is receiving Medicaid is pregnant with her first child. Based on knowledge of the
statistics related to infant mortality, which plan should the nurse implement with this client?
A. refer the client to a social worker to arrange for home care
B. recommend prenatal care from an obstetrician, not a nurse midwife
C. teach the client why keeping prenatal care appointments is important
D. Advise the client that neonatal intensive care may be needed - ANSWER-C. teach the client why
keeping prenatal care appointments is important
A 24-hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back and
abdomen. What action should the nurse implement?
A. notify the healthcare provider
B. move the newborn to an isolation nursery
C. document the finding in the infant's record
D. obtain a culture of the vesicles - ANSWER-C. document the finding in the infant's record. Erythema
Toxicum (or erythema neonatorium) is a newborn rash that is commonly referred to as "flea bites." but
is a normal finding that is documented in the infant's record and requires no further action.
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. Which is the correct description of this client that should be documented in the
medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1 - ANSWER-C.Gravida 2, para 0
,Maternity HESI Test bank Latest Update
2024/2025
Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0.
Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not
take into account the current pregnancy, nor does option B, which also counts the miscarriage as a
"para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
A 26-year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor.
She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg SQ to stop her labor contractions. The
nurse plans to monitor for which primary side effect of terbutaline sulfate?
A. drowsiness and bradycardia
B. depressed reflexes and increased respirations
C. tachycardia and a feeling of nervousness
D. a flushed, warm feeling and a dry mouth - ANSWER-C. tachycardia and a feeling of nervousness
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth - ANSWER-C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug
may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness.
Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
,Maternity HESI Test bank Latest Update
2024/2025
A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor.
She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority
for the nurse to monitor during the adminstration of this drug?
A. maternal blood pressure and respirations
B. maternal and fetal heart rates
C. hourly urinary output
D. deep tendon reflexes - ANSWER-B. maternal and fetal heart rates
A 30 year old gravida, 2 para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor.
She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the
nurse to monitor during the administration of this drug?
A. maternal blood pressure and respirations
B. maternal and fetal heart rates
C. hourly urinary output
D. deep tendon reflexes - ANSWER-B. maternal and fetal heart rates
A 30-year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son
is so jealous of my daughter. I don't know who I'll ever manage both children when I get home." How
should the nurse respond?
A. "Tell the older child that he is a big boy now and should love his new sister."
B. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him."
C. "Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the
newborn."
D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time." -
ANSWER-D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this
time." Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep
habits, as a method of seeking attention so the parents should distribute their attention between the
children and include the preschooler during infant care.
, Maternity HESI Test bank Latest Update
2024/2025
A 35-year old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data would indicate to the nurse that the client is
experiencing magnesium sulfate toxicity?
A. deep tendon reflexes 2+
B. blood pressure 140/90
C. respiratory rate 18/min
D. urine output 90 mL/4 hours - ANSWER-A. deep tendon reflexes 2+
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing
magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
b. Blood pressure 140/90
c. Respiratory rate 18/minute
d. Urine output 90 ml/4 hours - ANSWER-d. Urine output 90 ml/4 hours
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12
breaths/minute are cardinal signs of magnesium sulfate toxicity
A 38-week primagravida who works as a secretary and sits at a computer 8 hours each day tells the
nurse that her feet have begun to swell. Which instruction would be most effective in preventing
pooling of blood in the lower extremities?
A. Wear support stockings
B. Reduce salt in her diet
C. Move about every hour
D. Avoid constrictive clothing - ANSWER-C. Move about every hour
2024/2025
A 23 year old client who is receiving Medicaid is pregnant with her first child. Based on knowledge of the
statistics related to infant mortality, which plan should the nurse implement with this client?
A. refer the client to a social worker to arrange for home care
B. recommend prenatal care from an obstetrician, not a nurse midwife
C. teach the client why keeping prenatal care appointments is important
D. Advise the client that neonatal intensive care may be needed - ANSWER-C. teach the client why
keeping prenatal care appointments is important
A 24-hour old newborn has a pink papular rash with vesicles superimposed on the thorax, back and
abdomen. What action should the nurse implement?
A. notify the healthcare provider
B. move the newborn to an isolation nursery
C. document the finding in the infant's record
D. obtain a culture of the vesicles - ANSWER-C. document the finding in the infant's record. Erythema
Toxicum (or erythema neonatorium) is a newborn rash that is commonly referred to as "flea bites." but
is a normal finding that is documented in the infant's record and requires no further action.
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. Which is the correct description of this client that should be documented in the
medical record?
A.Gravida 1, para 0
B.Gravida 1, para 1
C.Gravida 2, para 0
D.Gravida 2, para 1 - ANSWER-C.Gravida 2, para 0
,Maternity HESI Test bank Latest Update
2024/2025
Rationale: This is the client's second pregnancy or second gravid event, so option C is correct. The
spontaneous abortion (miscarriage) occurred at 3 months of gestation (12 weeks), so she is a para 0.
Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond. Option A does not
take into account the current pregnancy, nor does option B, which also counts the miscarriage as a
"para," an incorrect recording. Although option D is correct concerning gravidity, para 1 is incorrect.
A 26-year old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor.
She is given 3 doses of terbutaline sulfate (Brethine) 0.25mg SQ to stop her labor contractions. The
nurse plans to monitor for which primary side effect of terbutaline sulfate?
A. drowsiness and bradycardia
B. depressed reflexes and increased respirations
C. tachycardia and a feeling of nervousness
D. a flushed, warm feeling and a dry mouth - ANSWER-C. tachycardia and a feeling of nervousness
A 26-year-old gravida 2, para 1, client is admitted to the hospital at 28 weeks of gestation in preterm
labor. She is given three doses of terbutaline sulfate (Brethine), 0.25 mg subcutaneously, to stop her
labor contractions. What are the primary side effects of terbutaline sulfate?
A.Drowsiness and paroxysmal bradycardia
B.Depressed reflexes and increased respirations
C.Tachycardia and a feeling of nervousness
D.A flushed warm feeling and dry mouth - ANSWER-C.Tachycardia and a feeling of nervousness
Rationale: Terbutaline sulfate (Brethine), a beta-sympathomimetic drug, stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist properties of the drug
may cause tachycardia, increased cardiac output, restlessness, headache, and a feeling of nervousness.
Option A is not a side effect. Options B and D are side effects of magnesium sulfate.
,Maternity HESI Test bank Latest Update
2024/2025
A 30 year old gravida 2, para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor.
She is given a dose of terbutaline sulfate (Brethine) 0.25 mg SQ. Which assessment is the highest priority
for the nurse to monitor during the adminstration of this drug?
A. maternal blood pressure and respirations
B. maternal and fetal heart rates
C. hourly urinary output
D. deep tendon reflexes - ANSWER-B. maternal and fetal heart rates
A 30 year old gravida, 2 para 1 client is admitted to the hospital at 26 weeks gestation in preterm labor.
She is started on an IV solution of terbutaline (Brethine). Which assessment is the highest priority for the
nurse to monitor during the administration of this drug?
A. maternal blood pressure and respirations
B. maternal and fetal heart rates
C. hourly urinary output
D. deep tendon reflexes - ANSWER-B. maternal and fetal heart rates
A 30-year old multiparous woman who has a 3 year old boy and a newborn girl tells the nurse, "My son
is so jealous of my daughter. I don't know who I'll ever manage both children when I get home." How
should the nurse respond?
A. "Tell the older child that he is a big boy now and should love his new sister."
B. "Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him."
C. "Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the
newborn."
D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this time." -
ANSWER-D. "Regression in behaviors in the older child is a typical reaction so he needs attention at this
time." Preschool-aged children frequently regress in habits or behaviors, such as toileting and sleep
habits, as a method of seeking attention so the parents should distribute their attention between the
children and include the preschooler during infant care.
, Maternity HESI Test bank Latest Update
2024/2025
A 35-year old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data would indicate to the nurse that the client is
experiencing magnesium sulfate toxicity?
A. deep tendon reflexes 2+
B. blood pressure 140/90
C. respiratory rate 18/min
D. urine output 90 mL/4 hours - ANSWER-A. deep tendon reflexes 2+
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is experiencing
magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
b. Blood pressure 140/90
c. Respiratory rate 18/minute
d. Urine output 90 ml/4 hours - ANSWER-d. Urine output 90 ml/4 hours
Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a respiratory rate of less than 12
breaths/minute are cardinal signs of magnesium sulfate toxicity
A 38-week primagravida who works as a secretary and sits at a computer 8 hours each day tells the
nurse that her feet have begun to swell. Which instruction would be most effective in preventing
pooling of blood in the lower extremities?
A. Wear support stockings
B. Reduce salt in her diet
C. Move about every hour
D. Avoid constrictive clothing - ANSWER-C. Move about every hour
