HESI-MATERNITY & PEDIATRICS
QUESTIONS AND ANSWERS WITH
SOLUTIONS 2024
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which
instruction should the nurse provide to this client? - ANSWER Breastfeed the infant, ensuring that both
breasts are completely emptied.
An insulin-dependent client with gestational diabetes mellitus is in the second stage of labor. What
supplies will the delivery nurse gather for care of the newborn? (Select all that apply.) - ANSWER
Erythromycin ointment
Scale
Measuring tape
Blood glucose testing kit
A client is admitted to the hospital at 28 weeks of gestation in preterm labor. The nurse administers
three doses of terbutaline sulfate, 0.25 mg subcutaneously. Which side effects will the nurse anticipate
for this client? (Select all that apply.) - ANSWER Feeling of nervousness
Tachycardia
Restlessness
The nurse is interviewing a newly pregnancy client who is 16-years old. Which client statement indicates
teaching is necessary for a safe pregnancy? (Select all that apply.) - ANSWER "I hate milk."
"I only want to gain 10 pounds."
"I refuse to wear maternity clothes."
The nurse is preparing to administer an IV pain medication to a client in labor. What will the nurse
include in this client's plan of care related to the administration of the medication? (Select all that apply.)
- ANSWER Administer the medication only when the client is having a contraction.
Assess the fetal heart rate (FHR) for 10 minutes prior to administering the pain medication.
The nurse is providing care to a laboring client with a GTPAL of 75015. The client reports contractions
every 2 to 8 minutes, of moderate intensity, for the past 6 hours. Her cervical exam upon admission is
,4/0/75%, and membranes are intact. In the next 20 minutes, what supplies will the nurse gather for this
client? (Select all that apply.) - ANSWER Amnihook
1000 mL of D5LR
Oxytocin
The nurse is providing care to a postpartum client with O negative blood who is antibody positive. The
newborn is O negative. What is the best nursing action for this client? - ANSWER Ask the mother if she
desires any more children.
The nurse is preparing a newborn for discharge. There is an order for a hepatitis B vaccination prior to
discharge. When planning to administer the vaccination, what information must the nurse obtain from
the infants chart? - ANSWER Site of the vitamin K injection
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of
tingling fingers and dizziness. Which action should the nurse take next? - ANSWER Have the client
breathe into her cupped hands.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the
nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? - ANSWER Two
weeks before menstruation
A mother expresses fear about changing the infant's diaper after circumcision. What information should
the nurse include in the teaching plan? - ANSWER Place petroleum ointment around the glans with each
diaper change and cleansing.
The clinic nurse takes a phone call from a client who reports she is at 12 weeks gestation. Which
statements indicate to the nurse the client may be having a spontaneous abortion? (Select all that
apply.) - ANSWER "I am having severe abdominal cramping."
"I am passing blood clots from my vagina."
A 25-year-old client has a positive pregnancy test. One year ago she had a spontaneous abortion at 3
months of gestation. What will the nurse document in the client's chart regarding her GTPAL? - ANSWER
20010
,A client in active labor is becoming increasingly fearful because her contractions are occurring more
often than she had expected. Her partner is also becoming anxious. What is the nurse's best action? -
ANSWER Asking the client and her partner if they would like the nurse to stay in the room
What specific instructions will the nurse include in the pregnancy client's teaching plan who is also
human immunodeficiency virus (HIV) positive? (Select all that apply.) - ANSWER Use condoms when
having sex.
Zidovudine prescription helps decrease risk of fetal exposure
Breastfeeding is not recommended.
A 41-week multigravida is receiving oxytocin 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. What is the next nursing action? - ANSWER Increase the rate of
the oxytocin infusion.
On admission to the prenatal clinic, a client tells the nurse that her last menstrual period began on
February 15 and that previously her periods were regular (28-day cycle). Her pregnancy test is positive.
What is this client's expected date of birth? - ANSWER November 22
A client at 39 weeks gestation overhears her health care provider say to the nurse, "Her Bishop score is
10." The client asks the nurse, "What does that mean?" What is the nurse's best response? - ANSWER
"Your cervix is ready for labor."
The clinic nurse is reviewing signs of pre-term labor with a client at 28 weeks gestation. Which client
statements indicate to the nurse further teaching is necessary? (Select all that apply.) - ANSWER "I
expect the discharge from my vagina will change from thick to brown over the next two weeks."
"The baby's movements will decrease and be almost still from here on out."
"I should expect low back pain and diarrhea as the baby grows."
When a new mother receives her infant for the first time, which behavior is most reassuring to the
nurse? - ANSWER Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
, A client presents to the emergency department with complaints of severe lower left abdominal pain and
vaginal spotting. Her last menstrual period was 5 weeks ago. What are the nurse's next actions? (Select
all that apply.) - ANSWER Check the results of the HCG test.
Ask the client to describe the color of the vaginal bleeding.
Ask the client if she has ever been diagnosed with pelvic inflammatory disease.
Draw the client's blood for a type and cross match.
The nurse is providing care to a primipara's whose most recent cervical exam at 0700 was 6/+1/100.
Assuming an expected progression of labor, approximately what time will the client enter into the
second stage of labor? - ANSWER 1100
The nurse is teaching a group of teen girls about their reproductive system and pregnancy. What risk
factors for an unplanned pregnancy will the nurse include in the teaching plan for these girls? (Select all
that apply.) - ANSWER Poverty
Family problems
Early onset of menarche
Sexual exploration
Group think
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions
and will not grasp the nipple. Which intervention should the nurse implement? - ANSWER Encourage the
mother to stop feeding for a few minutes and comfort the infant.
The nurse is providing care to a laboring client at term. Which client statement indicates to the nurse
that the client is entering stage two of labor? - ANSWER "I feel like I have to push down."
The clinic nurse is reviewing phone messages left from postpartum clients during the lunch break. Which
calls will the nurse return before the others? (Select all that apply.) - ANSWER The mother who reports
her vaginal discharge went from brown to bright red.
The mother who reports her vaginal flow smells "like a chicken farm."
The breast-feeding mother who reports redness and a painful right breast.
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