Maternity HESI Test bank (combined red hesi and other sources) Answered
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Maternity HESI
Maternity HESI Test bank (combined red hesi and other sources) Answered
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...
Maternity HESI Test bank (combined red
hesi and other sources) Answered
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.
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)
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
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.
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.
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
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
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.
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
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
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