RN HESI Maternal Newborn Study Set (RN HESI Maternal
Newborn Version 1 and Version 2) Questions With
Complete Solutions
*A client at 38 weeks gestation is admitted to the labor and
delivery unit with a complaint of contractions 5 minutes apart.
While the client is in the bathroom changing into a hospital
gown, the nurse hears the noise of a baby. What action should
the nurse take first?
a. Push the call light for help
b. Inspect the clients perineum
c. Notify a health care provider
d. Turn on the infant warmer Correct Answer a. Push the call
light for help
12 hours after the birth of a healthy infant, the mother complains
of feeling constant vaginal pressure. The nurse determines the
fundus is firm and at midline, with moderate rubra lochia.
Which action should the nurse take?
a. Check the suprapubic area for distention.
b. Inform the client to take a warm sitz bath
c. Inspect the client's perineal and rectal areas
d. Apply a fresh pad and check in 1 hour. Correct Answer c.
Inspect the client's perineal and rectal areas
A 10-year-old is admitted to the orthopedic unit with a diagnosis
of slipped femoral capital epiphysis (SFCE). What focus should
the nurse include in this child's plan of care?
,a. Ambulation with a walking cast.
b. Pin and incisional care after surgery.
c. Use of injections for pain control.
d. Administration of growth hormone. Correct Answer b. Pin
and incisional care after surgery.
A 16 year old gravida 1 para 0 client has just been admitted to
the hospital with a diagnosis of eclampsia. She's not presently
convulsing. Which intervention should the nurse plan to include
in this client's nursing care plan?
a. Allow liberal family visitation
b. Keep an airway at the bedside
c. Assess temperature every hour
d. Monitor blood pressure, pulse, and respiration every 4 hours.
Correct Answer b. Keep an airway at the bedside
A 16-year-old gravida 1, para 0 client has just been admitted to
the hospital with a diagnosis of eclampsia. She is not presently
convulsing. Which intervention should the nurse plan to include
in this client's nursing care plan?
a. Keep airway equipment at the bedside.
b. Allow liberal family visitation
c. Monitor blood pressure, pulse, and respirations q4h
d. Assess temperature q1h Correct Answer a. Keep airway
equipment at the bedside.
A 17 year old client gave birth 12 hours ago. She states that she
doesn't know how to care for her baby. To promote parent-infant
,attachment behaviors, which intervention should the nurse
implement?
a. Ask if she has help to care for the baby at home.
b. Provide a video on newborn safety and care.
c. Explore the basis of fears with the client.
d. Encourage rooming in while in the hospital. Correct Answer
d. Encourage rooming in while in the hospital.
A 3-hour old male infant presents with hands and feet that
appear cyanotic, axillary temperature of 96.5 degrees Fahrenheit
(35.8 degrees Celsius), respiratory rate of 40 breaths per minute,
and a heart rate of 165 beats per minute. What nursing action
should nurse implement?
a. Administer oxygen by mouth at 2L/min
b. Gradually warm the infant under a radiant heat source.
c. Notify the pediatrician of the infant's vital signs
d. Perform a heel-stick to maintain blood glucose level Correct
Answer b. Gradually warm the infant under a radiant heat
source.
A 3-month-old with myelomeningocele and atonic bladder is
catheterized every 4hrs to prevent urinary retention. The home
health nurse notes that the child has developed episodes of
sneezing, urticarial, watery eyes, and a rash in the diaper area.
What action is most important for the nurse to take?
a. Auscultate the lungs for respiratory pneumonia.
b. Change to latex-free gloves when handling infant.
c. Draw blood to analyze for streptococcal infection.
, d. Apply zinc oxide to perineum with each diaper change.
Correct Answer b. Change to latex-free gloves when handling
infant.
A 30-year-old primigravida delivers a nine-pound (4082 gram)
infant vaginally after a 30-hour labor. What is the priority
nursing action for this client?
a. Assess the blood pressure for hypertension.
b. Gently massage fundus every four hours.
c. Observe for signs of uterine hemorrhage.
d. Encourage direct contact with the infant. Correct Answer c.
Observe for signs of uterine hemorrhage.
A 34-week primigravida woman with preeclampsia is receiving
Lactated Ringer's 500ml with magnesium sulfate 20 grams at the
rate of 3g/hr. How many ml/hr should the nurse program the
infusion pump? (Enter numeric value only.) Correct Answer 75
ml/hr
A 36-week primigravida is admitted to labor and delivery with
severe abdominal pain and bright red vaginal bleeding. Her
abdomen is rigid and tender to touch. The fetal heart rate FHR)
is 90 beats/minute, and the maternal heart rate is 120
beats/minute. What action should the nurse implement first?
a. Alert the neonatal team and prepare for neonatal resuscitation
b. Notify the healthcare provider from the client's bedside
c. Obtain written consent for an emergency cesarean section
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