While inspecting a newborn’s head, the nurse identifies a swelling of the scalp that does not cross the suture line. Which finding should the nurse document?
Cephalohematoma
A cephalohematoma (B) should be documented because it is a collection of blood beneath the periosteum of the cranial bone...
Maternity HESI Questions And Answers
Assessment 2024/2025
While inspecting a newborn’s head, the nurse identifies a swelling of the scalp that does not cross the
suture line. Which finding should the nurse document?
Cephalohematoma
A cephalohematoma (B) should be documented because it is a collection of blood beneath the
periosteum of the cranial bone causing scalp swelling that does not cross the suture line. Molding (A)
is overlapping of cranial bones that occurs as the fetal head accommodates for the descent through
the vaginal vault. Caput succedaneum (C) is differentiated from a cephalohematoma by generalized
edematous swelling of the presenting part of the head. Fontanel tension should feel slightly concave
and well defined against the edges of the cranial bones, whereas a bulging anterior fontanel (D) is
tense and distends from an increased intracranial pressure, such as seen in congenital hydrocephalus.
What assessment finding should the nurse report to the healthcare provider that is consistent with
concealed hemorrhage in an abruptio placenta?
Hard, board-like abdomen
Abruptio placenta causes concealed intrauterine hemorrhage when the placenta separates and its
edges do not. The formation of a hematoma behind the placenta and subsequent infiltration of the
blood manifests as a firm, board-like abdomen (B), which should be reported immediately to the
healthcare provider. As bleeding occurs, fetal oxygenation and maternal stability are compromised
leading to fetal and maternal tachycardia, not (A). With abruptio placenta, fundal height and
abdominal pain increase, not (C and D).
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While assessing a newborn the nurse observes diffuse edema of the soft tissues of the scalp that cross
the suture lines. How should the nurse document this finding?
Caput succedaneum
Caput succedaneum (D) is characterized by swelling of the soft tissues of the scalp that extends across
suture lines. Molding (A) of the head results from adjustment of the infant’s skull structure, which
allows for the passage of the infant’s head through the birth canal and is a common occurence in
vaginal deliveries. Hemangioma (B) is a collection of blood vessels close to the skin.
, Cephalohematoma (C) is an edematous area caused by extravasation of blood between the skull bone
and periosteum and does not cross the suture lines, which differentiates it from caput succedaneum.
The nurse notes an irregular bluish hue on the sacral area of a 1-day old Hispanic infant. How should
the nurse document this finding?
Mongolian spots
Mongolian spots (usually in the sacral, lumbar, and gluteal regions) are a common skin variation in
newborns of African, Asian, Native American, and Hispanic descent (B). (A) refers to cyanosis of the
hands and feet, a normal finding in newborns soon after birth. (C) is a pink, papular rash that may
appear on the thorax, back, buttocks, and abdomen within 24 to 48 hours after birth. (D) is visible
when an infant lies on the side and the lower half of the body is pink or red and the upper half is pale.
A client at 39-weeks gestation is admitted to the labor and delivery unit. Her obstetrical history
includes 3 live births at 39-weeks, 34-weeks, and 35-weeks gestation. Using the GTPAL system, which
designation is the most accurate summary of this client's obstetrical history?
4-1-2-0-3
The client with 3 previous gravid experiences and this current pregnancy totals 4 gravid experiences,
and 1 term delivery (37-weeks or greater), 2 preterm deliveries (20 to 37 weeks, whether viable or not
viable), no spontaneous abortions and 3 living children. (B) best designates this client's obstetrical
history. (A, C, and D) are inaccurate for this client's history using the TPAL system.
An infant who weighs 3.8 kg is delivered vaginally at 39-weeks gestation with a nuchal cord after a 30-
minute second stage. The nurse identifies petechiae over the face and upper back of the newborn.
What information should the nurse provide the parents about this finding?
The pinpoint spots are benign and disappear within 48 hours.
Rapid delivery and a tight nuchal cord cause the presenting parts (head) to have bruising and pin point
hemorrhages (petechiae), which are benign and usually disappear within two days after birth (D). (A)
is not indicated. Birth injuries caused by forceps (B) present as linear configuration across both sides
of the face and outline the placement of the forceps. (C) is inaccurate.
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to
60 seconds. An internal uterine pressure catheter (IUPC) is inserted. The intrauterine pressure is 65 to
70 mm Hg at the peak of a contraction and the resting tone is 6 to 10 mm Hg. Based on this
information, what action should the nurse implement?
Document the findings in the client's record.
This labor pattern indicates that the client is in the active phase of the first stage of labor and has a
normal labor pattern, so the findings should be documented in the client’s medical record (D). There is
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