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Maternity HESI Test bank (combined redhesi and other sources)
A 4 week old premature infant has been receiving epoetin alfa (Epogen) for the last 3
weeks. Which assessment finding indicates to the nurse that the drug is effective?
A. slowly increasing urinary output over the last week
B. respiratory rate changes from the 40s to the 60s.
C. changes in apical heart rate from the 180s to the 140s
D. change in indirect bilirubin from 12 mg/dl to 8 mg/dl - A. slowly increasing urinary
output over the last week
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 - 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 - 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 - C.Gravida 2, para 0
,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 - 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 - 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.
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 - 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 - 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." - 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.
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 - 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 - 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 - C. Move about every hour
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?
A.Wear support stockings.
B.Reduce salt in the diet.
C.Move about every hour.
D.Avoid constrictive clothing. - C.Move about every hour.
Rationale:
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour will relieve pressure on the pelvic
veins and increase venous return. Option A would increase venous return from varicose
veins in the lower extremities but would be of little help with swelling. Option B might be
helpful with generalized edema but is not specific for edematous lower extremities.
Option D does not address venous return, and there is no indication in the question that
constrictive clothing is a problem.
A 40 week gestation primigravada client is being induced with an oxytocin (pitocin)
secondary infusion and complains pain in her lower back. Which intervention should the
nurse implement?
A. discontinue the oxytocin (Pitocin) infusion
B. place the client in a semi-Fowler's position
C. inform the healthcare provider
D. apply firm pressure on the sacral area. - D. apply firm pressure on the sacral area
A 41-week multigravida is receiving oxytocin (Pitocin) 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. Which
action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
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