,HESI RN MATERNAL NEWBORN PROCTORED EXAM
VERSION 1
1. A nurse is teaching a client about Rho(D) immunoglobulin (RhoGAM). Which of the following
statements by the client indicated an understanding of the teaching?
a. I will receive this medication if my baby is Rh-negative
b. I will receive this medication at time of delivery
c. I will need a second dose of this medication when my baby is 6 weeks old
d. I will need this medication if I have an amniocentesis- Recommended because of the
potential of fetal RBCs entering the maternal circulation
2. A nurse is caring for a client who is to receive oxytocin (Pitocin) to augment her labor. Which of
the following contraindicates the initiation of the oxytocin infusion and requires notification of
the provider?
a. Late decelerations- Oxytocin is contraindicated based on late decelerations noted on
fetal assessment findings because they indicate uteroplacental insufficiency.
b. Baseline variability
c. Cessation of uterine dilation
d. Prolonged active phase of labor
3. A nurse on the newborn unit is planning discharge for four clients. Which of the following will
require care beyond that of a standard follow-up visit with the provider after delivery?
a. A newborn being sent home after 22 hr after birth- Screening tests must be repeated if
they were performed before he newborn was 24 hr. old.
b. A newborn at 38 weeks of gestational age
c. A newborn who is bottle feeding
d. Twin newborns with Apgar scores of 8 and 9
4. A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes the
newborn has a heart rate of 102/min, blueish extremities, and a flaccid muscle tone. Which of
the following reflects the appropriate APGAR score?
a. 4
b. 5
c. 6
d. 7
5. A nurse is caring for a client who has a history of rheumatic disease, but no physical symptoms
prior to pregnancy. The client begins to experience dyspnea, orthopnea, and pulmonary edema.
Which of the following biological alterations explains this change?
a. Increased maternal weight
b. Increased blood volume- Increase in blood volume during pregnancy increase the
workload of the heart, which causes the symptoms
c. Change in hematocrit levels
d. Change in heart size
6. A nurse is providing teaching about nonpharmacological pain management for a postpartum
client who is breastfeed and has engorgement. Which of the following methods should the
nurse recommend?
a. Cold cabbage leaves- Application of this is an effective nonpharmacological method to
relieve pain associated with engorgement
b. Modified lanolin cream
, c. A breast binder
d. Breast shells
7. A nurse is providing discharge teaching to a client who is postpartum about resuming sexual
activity. Which of the following instructions should the nurse include in the teaching?
a. You should use a water soluble gel for lubrication- This will prevent discomfort
b. You can resume sexual activity in 10 days
c. Your physical reaction to sexual stimulation ill not be altered
d. You will not ovulate for 3 months after delivery
8. A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which
of the following complications should the nurse assess?
a. Abruptio placenta- Cocaines increases the risk for vasoconstriction and possible
abruption placenta
b. Placenta previa
c. Preeclampsia
d. Maternal bradycardia
9. A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of
the following statements by the client indicates an understanding of the teaching?
a. I should eat to taste instead of trying to balance my meals- Eat to taste to avoid nausea
b. I will avoid having a snack at bedtime
c. I will have 8 oz of hot tea with each meal
d. I should pair my sweets with a starch instead of eating them alone
10. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the
following techniques should the nurse use to help minimize the pain of the procedure for the
newborn?
a. Warm the heel prior to the puncture
b. Request a prescription for IM analgesic
c. Use a manual lance blade to pierce the skin
d. Swaddle the newborn after the heel puncture- Effective technique to diminish the pain
experience for the newborn.
11. A nurse is conducting an initial prenatal visit for a client who is at 6 weeks gestation. Which of
the following laboratory tests should be performed?
a. 24 hour urine for protein
b. Group B streptococcus culture
c. 3-hr glucose tolerance
d. Rubella titer- Obtained at the initial prenatal visit to determine immunity to rubella
12. A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which
of the following actions should the nurse take first?
a. Confirm the newborn’s Apgar score
b. Verify the newborn’s identification- Mandatory to continue ongoing identification of the
newborn whenever the newborn is removed from the mother’s direct presence and
care.
c. Administer vitamin K IM to the newborn
d. Determine the obstetrical risk factors
13. A nurse is assessing a young adult client in a women’s health clinic who asks for a contraceptive.
The client reports to the nurse a familial history of osteoporosis. Which of the following
contraceptive methods is contraindicated for this client?
a. Combined estrogen-progestin oral contraceptives
b. An intrauterine device
, c. Medroxyprogestrone acetate (Depo-provera)- causes a decrease in bone mineral
density and places the client at risk for the development of osteoporosis
d. Norelgestromin/ethinyl estradiol (Ortho Evra)
14. A nurse is admitting a client to the labor and delivery unit when the client states, “my water just
broke”, which of the following is the priority intervention for the nurse to take?
a. Perform Nitrazine testing
b. Assess the amniotic fluid
c. Check cervical dilation
d. Monitor the fetal heart rate- Rupture of the membranes places the fetus at risk for
umbilical cord prolapse.
15. A nurse in a clinic is caring for a client who is at 32 weeks of gestation. Which of the following
clinical findings should alert the nurse to a potential complication?
a. Fundal height is 34 cm
b. Client reports diarrhea for 3 days- Indicates illness or infection
c. Client reports ankle edema
d. Blood pressure is 130/80
16. A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The
fetal monitor shows uterine contractions every 6 min, lasting 20-25 seconds, and an FHR of
150/min. The provider prescribed betamethasone (celestone) 12 mg IM. Which of the following
outcomes should the nurse expect?
a. Decreased uterine contractions
b. An increase in the client’s hemoglobin levels
c. A reduction in respiratory distress in the newborn- Given to stimulate fetal lung
maturity and prevent respiratory distress
d. Increased production of antibodies in the Newborn
17. A nurse is caring for a client newly admitted to the PACU following a cesarean birth. Which of
the following is the priority nursing assessment?
a. Parent-child attachment
b. Amount of postpartum lochia- The greatest risk to the client is bleding. The amount of
lochia can assist the nurse in determining if excessive bleeding is occurring. Assess the
client for postpartum hemorrage.
c. Patency of the IV cathether
d. Quality and quantity of urine output
18. A nurse is caring for a client whose labor is not progressing due to should sytocia of the infant.
Which of the following actions should the nurse take?
a. Apply fundal pressure
b. Apply suprapubic pressure- can be used to attempt to push the shoulder to go under the
symphysis pubis and thus pass through the birth canals
c. Place the client in the trendelenburg position
d. Place the client in the fowlers position
19. A nurse is preparing to initiate IV oxytocin for a client who is admitted for induction of labor.
Oxytocin 30 units is available in 500 ml. At what rate should the nurse set the infusion pump to
deliver 2mu/min?
a. 30units/500ml = 0.06units/ml
b. 0.06units=60mU
c. 60mU/1=2mU/xmL
d. x=0.03mL/min 0.03x60=1.8mL/hr
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