Maternity HESI Test bank (combined
red hesi and other sources)
An expectant father tells the nurse he fears that his wife is "losing her mind." He
states that she is constantly rubbing her abdomen and talking to the baby and that
she actually reprimands the baby when it moves too much. Which recommendation
should the nurse make to this expectant father?
A.Suggest that his wife seek professional counseling to deal with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D.Reassure him that normal maternal-fetal bonding is occurring. - ANSWER D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of
prenatal bonding during the second trimester. Options A and C are not necessary
because the behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the
procedure is completed, it is most important for the nurse to obtain which
information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - ANSWER C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that
may indicate the presence of cord compression or prolapse. An amniotomy (artificial
rupture of membranes [AROM]) is used to stimulate labor when the condition of the
cervix is favorable. The fluid should be assessed for color, odor, and consistency.
Option A should be assessed every 15 to 20 minutes during labor but is not specific
for AROM. Option B is monitored hourly after the membranes are ruptured to detect
the development of amnionitis. Option D should be determined for all clients in labor.
, A nurse receives a shift change report for a newborn who is 12 hours post-vaginal
delivery. In developing a plan of care, the nurse should give the highest priority to
which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - ANSWER B. Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of
bilirubin, which should be further evaluated in a newborn <24 hours old.
Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it
occurs because the capillary system is immature. Milia are small white papules
present on the nose and chin that are caused by sebaceous gland blockage and
disappear in a few weeks. Small red patches on the cheeks and trunk are called
erythema toxicum neonatorum, a common finding in newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic
therapy is prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the
infected breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on
the infant. - ANSWER A.Breastfeed the infant, ensuring that both breasts are
completely emptied.
Rationale: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. Option B is less
painful but does not facilitate complete emptying of the breast tissue. Option C will
not relieve the engorgement on the affected side. Option D will not decrease
antibiotic effects on the infant.
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. - ANSWER 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.
Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized swelling on the right side of his head. In a newborn, what is the
most likely cause of this accumulation of blood between the periosteum and skull
that does not cross the suture line?
A.Cephalhematoma, which is caused by forceps trauma
B.Subarachnoid hematoma, which requires immediate drainage
C.Molding, which is caused by pressure during labor
D.Subdural hematoma, which can result in lifelong damage - ANSWER
A.Cephalhematoma, which is caused by forceps trauma
Rationale: 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 skull. Option C is a cranial distortion lasting 5
to 7 days, caused by pressure on the cranium during vaginal delivery, and is a
common variation of the newborn. Options B and D both involve intracranial bleeding
and could not be detected by physical assessment alone.
Prior to discharge, what instructions should the nurse give to parents regarding
the newborn's umbilical cord care at home?
A.Wash the cord frequently with mild soap and water.
B.Cover the cord with a sterile dressing.
C.Allow the cord to air-dry as much as possible.
D.Apply baby lotion after the baby's daily bath - ANSWER C.Allow the cord to air-
dry as much as possible.
Rationale:Recent studies have indicated that air drying or plain water application
may be equal to or more effective than alcohol in the cord healing process. Options
A, B, and D are incorrect because they promote moisture and increase the potential
for infection.
, A mother expresses fear about changing the infant's diaper after circumcision.
What information should the nurse include in the teaching plan?
A.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B.Wash off the yellow exudate on the glans once every day to prevent infection.
C.Place petroleum ointment around the glans with each diaper change and
cleansing.
D.Apply pressure by squeezing the penis with the fingers for 5 minutes if bleeding
occurs. - ANSWER C.Place petroleum ointment around the glans with each diaper
change and cleansing.
Rationale:
With each diaper change, the glans penis should be washed with warm water to
remove any urine or feces, and petroleum ointment should be applied to prevent the
diaper from sticking to the healing surface. Prepackaged wipes often contain other
products that may irritate the site. The yellow exudate, which covers the glans penis
as the area heals and epithelializes, is not an infective process and should not be
removed. If bleeding occurs at home, the client should be instructed to apply gentle
pressure to the site of the bleeding with sterile gauze squares and call the health
care provider.
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 - ANSWER 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 mother who is breastfeeding her baby receives instructions from the nurse.
Which instruction is most effective in preventing nipple soreness?
A.Wear a cotton bra with nonbinding support.
