MATERNITY PRACTICE EXAM - 50
QUESTIONS., NURSING, EVOLVE
OBSTETRICS/MATERNITY,
OBSTETRICS/MATERNITY HESI PREP, HESI
REVIEW TEST-MATERNITY, HESI, OB HESI ,
HESI OB/PEDS 2 EXAM QUESTIONS WITH
COMPLETE ANSWERS
During the transition phase of labor, a client complains of tingling and numbness in her
fingers and tells the nurse that she feels like she is going to pass out. What action
should the nurse take? - Answer-Have her cup both hands over her nose and mouth
while breathing.
Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the
blood, and causes transient respiratory alkalosis, so the client should cup both hands
over her mouth and nose so she can rebreathe carbon dioxide.
A client who delivered by cesarean section 24 hours ago is using a 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 had nothing to eat, she is too weak
to breastfeed her infant. Which nursing diagnosis has the highest priority? - Answer-
Impaired bowel motility related to pain medication and immobility. 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.
A new mother asks the nurse, "How do I know that my daughter is getting enough
breast milk?" Which explanation is appropriate? - Answer-"Your milk is sufficient if the
baby is voiding pale straw-colored urine 6 to 10 times a day."
The urine will be dilute (straw-colored) and frequent (>6 to 10 times/day) , if the infant is
adequately hydrated. Although a weight gain of 30 grams/day is indicative of adequate
nutrition, most home scales do not measure this accurately and this suggestion is likely
to make the mother very anxious.
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.
Ovulation occurs 14 days before the first day of the menstrual period . While ovulation
can occur in the middle of the cycle, or 2 weeks after menstruation, this is only true for a
woman who has a perfect 28-day cycle. For many women, the length of their menstrual
cycle varies.
,The nurse is evaluating a full-term multigravida who was induced 3 hours ago. The
nurse determines the client is dilated 7 cm, is 100% effaced at 0 station, with intact
membranes. The monitor indicates the fetal heart rate (FHR) decelerates at the onset of
several contractions and returns to baseline before each contraction ends. What action
should the nurse take? - Answer-Continue to monitor labor progress.
The fetal heart rate indicates early decelerations, which are not an ominous sign, so the
nurse should continue to monitor the labor progress and document the findings in the
client's record.
The nurse instructs a laboring client to use accelerated-blow breathing. The client
begins to complain of tingling fingers and dizziness. What action should the nurse take?
- Answer-Have the client breathe into her cupped hands.
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much
carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be
facilitated by breathing into a paper bag or cupped hands .
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. What is the most likely cause
of this accumulation of blood between the periosteum and skull that does not cross the
suture line in a newborn? - Answer-A cephalhematoma, which is caused by forceps
trauma.
Cephalhematoma , a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and the skull.
One hour following a normal vaginal delivery, a newborn infant boy's axillary
temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro
reflex, his hands shake. What intervention should the nurse implement first? - Answer-
Obtain a serum glucose level.
This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body
temperature. The nurse should first determine the serum glucose level .
A client in active labor is becoming increasingly fearful because her contractions are
occurring more often than she expected. Her partner is also becoming anxious. The
nurse's response should focus on which content? - Answer-Asking the client and her
partner if they would like the nurse stay in the room.
Offering to remain with the client and her partner (C) offers support without providing
false reassurance. The length of labor is not always predictable, but (A and B) do not
offer the client the support that is needed at this time. (D) may be reassuring regarding
,the fetal heart rate, but it does not provide the client the emotional support she needs at
this time during the labor process.
A breastfeeding postpartum client is diagnosed with mastitis and antibiotic therapy is
prescribed. What instruction should the nurse provide to this client? - Answer-
Breastfeed the infant, ensuring that both breasts are completely emptied.
Mastitis (caused by plugged milk ducts) is related to breast engorgement, and
breastfeeding during mastitis facilitates the complete emptying of engorged breasts ,
eliminating the pressure on the inflamed breast tissue.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring
client's blood pressure drops from 120/80 to 90/60. What action should the nurse take
immediately? - Answer-Place the client in a lateral position. 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 face mask at 10 to 12 L/min. If the
blood pressure remains low after these interventions or decreases further, the
anesthesiologist/healthcare provider should be notified . immediately
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. What
statement is accurate regarding the timing of closure of an infant's fontanels that should
be included in this teaching plan? - Answer-The anterior fontanel closes at 12 to 18
months and the posterior by the end of the second month.
In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the
posterior fontanel by the end of the second month (D). These growth and development
milestones are frequently included in questions on the licensure exam.
A new mother who has just had her first baby says to the nurse, "I saw the baby in the
recovery room. She sure has a funny-looking head." Which response by the nurse is
best? - Answer-"That is normal. The head will return to a round shape within 7 to 10
days."
reassures the mother that this is normal in the newborn and provides correct information
regarding the return to a "normal" shape. NEVER say "Don't Worry".
A primipara presents to the perinatal unit describing rupture of the membranes (ROM),
which occurred 12 hours prior to coming to the hospital. A Pitocin infusion is begun, and
8 hours later the client's contractions are irregular and mild. What vital sign should the
nurse monitor with greater frequency than the typical unit protocol? - Answer-Maternal
temperature.Maternal temperature (A) should be monitored frequently as a primary
indicator of infection. This client's rupture of membranes (ROM) occurred at least 20
hours ago (12 hours before coming to the hospital in addition to 8 hours since hospital
, admission). Delivery is not imminent and there is an increased risk of developing
infection 24 hours after ROM.
A 38-week primigravida 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 will aid in the
prevention of pooling of blood in the lower extremities? - Answer-Move about (around)
every hour.
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will straighten out the pelvic
veins and increase venous return.
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? - Answer-January 29 to 30.
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
A client comes to the OB clinic for her first prenatal visit, and complains of feeling
nauseated every morning. The client tells the nurse, "I'm having second thoughts about
wanting to have this baby." Which response is best for the nurse to make? -
Answer-"Tell me about these second thoughts you are having about this pregnancy."
While ambivalence is normal during the first trimester, (D) is the best nursing response
at this time. It is reflective and keeps the lines of communication open.
A client at 28 weeks of gestation calls the antepartal clinic and states that she 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? -
Answer-"Come to the clinic today for an ultrasound." 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 incidence life threatening, nor 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.
The nurse calls a client who is 4 days postpartum to follow-up about her transition with
her newborn son at home. The woman tells the nurse, "I don't know what is wrong. I
love my son, but I feel so let down. I seem to cry for no reason!" Which adjustment
phase should the nurse determine the client is experiencing? - Answer-Postpartum
blues. During the postpartum period when serum hormone levels fall, women are
