RN HESI MATERNITY STANDARD EXAMS ANSWERS
AND QUESTIONS SET A+
✔✔The nurse is planning discharge teaching for a client who had an evacuation of
gestational
trophoblastic disease (GTD) two days ago. Which information is most important for the
nurse to
include in this client's teaching plan? - ✔✔Oral contraceptive use for at least one year.
✔✔A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl
and a hematocrit of 25.1%. What food should the nurse encourage this client to include
in her diet?
A. Carrots
B. Chicken
C. Yogurt
D. Cheese - ✔✔B. Chicken
✔✔The newborn nursery admission protocol includes a prescption for phytonadione
(Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule
provides 2 mg/ml. How
many ml should the nurse administer? - ✔✔0.3
✔✔The nurse places one hand above the symphysis while massaging the fundus of a
multiparous client
whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant.
Which information
should the nurse provide the client about this finding? - ✔✔Both the lower uterine
segment and the fundus must be massaged.
✔✔The nurse is preparing to administer methylergonovine maleate (Methergine)
to a postpartum client. Based on what assessment finding should the nurse
withhold the drug?
A. Respiratory rate of 22 breaths/min
,B. A large amount of lochia rubra
C. Blood pressure 149/90
D. Positive Homan's sign - ✔✔C. Blood pressure 149/90
✔✔At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When
is the best time
to administer a rubella vaccine to this client? - ✔✔Early postpartum, within 72 hours of
delivery.
✔✔A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern - ✔✔D. Contraction pattern.
✔✔A client delivers a viable infant , but begins to have excessive uncontrolled vaginal ..
notifying the healthcare provider of the clients condition ,What information is most
important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused - ✔✔A. Maternal blood pressure.
✔✔A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous
genitalia. What is the primary nursing consideration when
supporting the parents of a child with this anomaly?
A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
B. Support the parents in their decision to assign sex of their child according to their
preference
C. Offer information about ultrasonography and genotyping to determine sex
assignment
D. Explain that corrective surgical procedures consistent with sex
assignment can be delayed - ✔✔C. Offer information about ultrasonography and
genotyping to determine sex assignment
✔✔During a 26-week gestation prenatal exam, a client reports occasional dizziness and
lightheadness
when she is lying down. What intervention is best for the nurse to recommend to this
client. - ✔✔Elevate the head with two pillows while sleeping.
✔✔The current vital signs for a primipara who delivered vaginally during the previous
shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16
, breaths/minute, and blood pressure 130/74. What action should the nurse implement? -
✔✔Document the vital signs in the record.
✔✔A 4-day postpartum client calls the clinic and reports that her nipples are so sore
that she does not know if she can continue to breastfeed her infant. What instruction is
best for the nurse to provide? - ✔✔Apply hot packs just before each feeding.
✔✔A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in
preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution
should the nurse administer? (Enter numeric value only) - ✔✔13
✔✔A newborn with myelomeningocele is admitted to the neonatal intensive care unit.
Which preoperative nursing intervention should the nurse implement first? - ✔✔Place
the infant on the abdomen to protect the sac.
✔✔The mother of a 5-week-old tells the nurse that her baby has acne and asks if she
can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which
answer should the nurse to provide? - ✔✔" Your baby may be showing signs of a
systemic disease and needs to be seen by a healthcare
provider"
✔✔An infant is placed in a radiant warmer immediately after birth. At one hour of age,
the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action
that the nurse should take?
A. Notify the health care provider immediately
B. Increase the temperature of the radiant warmer
C. Assess infant heart rateD.
Determine the infants blood sugar level - ✔✔D. Determine the infant's blood sugar
level.
✔✔A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - ✔✔B. Notify the
healthcare provider from the client's bedside
✔✔A laboring client's membranes rupture spontaneously. The nurse notices that the
amniotic fluid is greenish-brown. What intervention should the nurse implement first?
A. Turn the client to her left side
B. Contact the healthcare provider
AND QUESTIONS SET A+
✔✔The nurse is planning discharge teaching for a client who had an evacuation of
gestational
trophoblastic disease (GTD) two days ago. Which information is most important for the
nurse to
include in this client's teaching plan? - ✔✔Oral contraceptive use for at least one year.
✔✔A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl
and a hematocrit of 25.1%. What food should the nurse encourage this client to include
in her diet?
A. Carrots
B. Chicken
C. Yogurt
D. Cheese - ✔✔B. Chicken
✔✔The newborn nursery admission protocol includes a prescption for phytonadione
(Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule
provides 2 mg/ml. How
many ml should the nurse administer? - ✔✔0.3
✔✔The nurse places one hand above the symphysis while massaging the fundus of a
multiparous client
whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce infant.
Which information
should the nurse provide the client about this finding? - ✔✔Both the lower uterine
segment and the fundus must be massaged.
✔✔The nurse is preparing to administer methylergonovine maleate (Methergine)
to a postpartum client. Based on what assessment finding should the nurse
withhold the drug?
A. Respiratory rate of 22 breaths/min
,B. A large amount of lochia rubra
C. Blood pressure 149/90
D. Positive Homan's sign - ✔✔C. Blood pressure 149/90
✔✔At 6-weeks gestation, the rubella titer of a client indicates she is non-immune. When
is the best time
to administer a rubella vaccine to this client? - ✔✔Early postpartum, within 72 hours of
delivery.
✔✔A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern - ✔✔D. Contraction pattern.
✔✔A client delivers a viable infant , but begins to have excessive uncontrolled vaginal ..
notifying the healthcare provider of the clients condition ,What information is most
important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed
D. Total amount of pitocin infused - ✔✔A. Maternal blood pressure.
✔✔A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous
genitalia. What is the primary nursing consideration when
supporting the parents of a child with this anomaly?
A. Discuss the need for cortisol and aldosterone replacement therapy after discharge
B. Support the parents in their decision to assign sex of their child according to their
preference
C. Offer information about ultrasonography and genotyping to determine sex
assignment
D. Explain that corrective surgical procedures consistent with sex
assignment can be delayed - ✔✔C. Offer information about ultrasonography and
genotyping to determine sex assignment
✔✔During a 26-week gestation prenatal exam, a client reports occasional dizziness and
lightheadness
when she is lying down. What intervention is best for the nurse to recommend to this
client. - ✔✔Elevate the head with two pillows while sleeping.
✔✔The current vital signs for a primipara who delivered vaginally during the previous
shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16
, breaths/minute, and blood pressure 130/74. What action should the nurse implement? -
✔✔Document the vital signs in the record.
✔✔A 4-day postpartum client calls the clinic and reports that her nipples are so sore
that she does not know if she can continue to breastfeed her infant. What instruction is
best for the nurse to provide? - ✔✔Apply hot packs just before each feeding.
✔✔A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in
preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution
should the nurse administer? (Enter numeric value only) - ✔✔13
✔✔A newborn with myelomeningocele is admitted to the neonatal intensive care unit.
Which preoperative nursing intervention should the nurse implement first? - ✔✔Place
the infant on the abdomen to protect the sac.
✔✔The mother of a 5-week-old tells the nurse that her baby has acne and asks if she
can use her teenage son's acne cream, benzoyl peroxide, on the baby's face. Which
answer should the nurse to provide? - ✔✔" Your baby may be showing signs of a
systemic disease and needs to be seen by a healthcare
provider"
✔✔An infant is placed in a radiant warmer immediately after birth. At one hour of age,
the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action
that the nurse should take?
A. Notify the health care provider immediately
B. Increase the temperature of the radiant warmer
C. Assess infant heart rateD.
Determine the infants blood sugar level - ✔✔D. Determine the infant's blood sugar
level.
✔✔A 36-week primigravida is admitted to labor and delivery with severe abdominal pain
and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal
heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute.
What action should the nurse implement first?
A. Alert the neonatal team and prepare for neonatal resuscitation
B. Notify the healthcare provider from the client's bedside
C. Obtain written consent for an emergency cesarean section
D. Draw a blood sample for stat hemoglobin and hematocrit - ✔✔B. Notify the
healthcare provider from the client's bedside
✔✔A laboring client's membranes rupture spontaneously. The nurse notices that the
amniotic fluid is greenish-brown. What intervention should the nurse implement first?
A. Turn the client to her left side
B. Contact the healthcare provider
