Download 2025 Maternity HESI Assignment Exam Review: Comprehensive Study Guide with Questions and more Exams Nursing in PDF only on Docsity!
2025 Maternity HESI Assignment Exam Review:
Comprehensive Study Guide with Practice Questions
and Expert Answers
A female client who wants to delivery at home asks the nurse to explain the role of a nurse- midwife in providing obstetric care. What information should the nurse provide? - - correct ans- - The pregnancy should progress normally and be considered low risk. Rationale: A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric client. What nursing action should be included in the plan of care for a newborn experiencing symptoms of drug withdrawal? - - correct ans- - Swaddle the infant snugly and hold tightly. Rationale: An infant experiencing drug withdrawal should be swaddled, wrapped snugly, or placed in a "kangaroo pouch" to reduce self-stimulation behaviors and protect skin from abrasions that may occur due to muscular irritability. The nurse is teaching a new mother about diet and breastfeeding. Which instruction is most important to include in the teaching plan? - - correct ans- - Avoid alcohol because it is excreted in breast milk. Rationale: Alcohol should be avoided while breastfeeding because, when consumed by the mother, it is excreted in breast milk.
A primigravida at 12-weeks gestation who just moved to the United States indicates she has not received any immunizations. Which immunization(s) should the nurse administer at this time? (Select all that apply.) Tetanus. Rubella. Diphtheria. Chickenpox. Hepatitis B. - - correct ans- - Correct selections are (A, C, and E). Rationale: Vaccines composed of killed viruses may be administered during pregnancy. Rubella (B) and chickenpox (D) consist of live or attenuated live viruses which would be contraindicated during pregnancy due to potential teratogenicity. Which finding in the medical history of a post-partum client should the nurse withhold the administration of a routine standing order for methylergonovine maleate (Methergine)? - - correct ans- - Pregnancy induced hypertension. Rationale: Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension is a contraindication for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order should be withheld and reported to the healthcare provider. A client at 8-months gestation tells the nurse that she knows her baby listens to her, but her husband thinks she is imagining things. What information should the nurse provide? - - correct ans- - The fetus in utero is capable of hearing and does respond to the mother's voice. Rationale: Fetal hearing and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound of the mother's voice.
The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Rate of 58 breaths per minute. Grunting heard with a stethoscope. - - correct ans- - Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant. A woman, whose pregnancy is confirmed, asks the nurse what the function of the placenta is in early pregnancy. What information supports the explanation that the nurse should provide? - - correct ans- - Secretes both estrogen and progesterone. Rationale: One of the early functions of the placenta as an endocrine gland is the production of four hormones, hCG, hPL, estrogen, and progesterone, necessary to maintain the pregnancy and support the embryo and fetus. What nursing action should be implemented when intermittently gavage-feeding a preterm infant? - - correct ans- - Allow formula to flow by gravity. Rationale: Gavage feeding is commonly used to feed preterm infants who are born at less than 32weeks gestation, infants who weigh less than 1500 grams, or infants who are unable to tolerate oral feedings. The feeding should flow by gravity to avoid over-distention and a sudden sensation of fullness that may cause vomiting.
The nurse is assessing a full-term newborn's breathing pattern. Which findings should the nurse assess further? (Select all that apply.) Shallow with an irregular rhythm. Chest breathing with nasal flaring. Diaphragmatic with chest retraction. Abdominal with synchronous chest movements. Heart rate of 158 beats per minute. Grunting heard with a stethoscope. - - correct ans- - Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and grunting are signs of respiratory distress in the infant. The nurse is caring for a client in active labor and observes V shape decelerations in the fetal heart rate occurring with the peak of each contraction. What action should the nurse implement? - - correct ans- - Place the client in a side-lying position. Rationale: Variable decelerations are caused by compression of the umbilical cord and are evidenced by V shape appearance,characterized by a rapid descent and ascent to and from the depth of the deceleration. To alleviate the pressure on the umbilical cord, the nurse should reposition the client into a side-lying position. Which gastrointestinal findings should the nurse be concerned about in a client at 28weeks gestation? - - correct ans- - Pica. Rationale: Pica, the consumption of low- or non-nutrient substances, may cause more nutritious foods to be displaced from the diet, and depending on the substance ingested, may be toxic or interfere with the absorption of nutrients and minerals. When assessing a newborn infant's heart rate, which technique is most important for the nurse to use? - - correct ans- - Count the heart rate for at least one full minute.
A client at 29-weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? - - correct ans- - Ultrasonography. Rationale: Gestational age, fetal growth, and the status and position of the placenta are monitored by ultrasound. A client in the first stage of active labor is using a shallow pattern of rapid breaths that is twice the normal adult breathing rate. The client complains of feeling light-headed, dizzy, and states that her fingers are tingling. What action should the nurse implement?
- correct ans- - Help her breathe into a paper bag. Rationale: Hyperventilation can precipitate respiratory alkalosis and cause light-headedness, dizziness, tingling of the fingers, and circumoral numbness. Breathing into a paper bag held tightly around the mouth and nose enables the client to rebreathe carbon dioxide, which reduces depletion of carbonic acid. and compensates for the respiratory alkalosis. The nurse assesses a male newborn and determines that he has the following vital signs: axillary temperature 95.1 F, heart rate 136 beats/minute and a respiratory rate 48 breaths/minute. Based on these findings, which action should the nurse take first? - - correct ans- - The nurse should first assess the infant's blood glucose level, because the infant is displaying signs of hypothermia (normal newborn axillary temperature is 96 to 98 F) and hypoglycemia may occur as glucose is metabolized in an effort to meet cellular energy demands. 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? - - correct ans- - Document the findings in the client record.
Rationale: 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. 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? - - correct ans- Cephalohematoma. Rationale: A cephalohematoma 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. Which prescription should the nurse administer to a newborn to reduce complications related to birth trauma? - - correct ans- - Vitamin K (AquaMEPHYTON). Rationale: The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels and reduce the risk of neonatal bleeding, newborns receive a single injection of vitamin K (AquaMEPHYTON). At 10-weeks gestation, a high-risk multiparous client with a family history of Down syndrome is admitted for observation following a chorionic villi sampling (CVS) procedure. What assessment finding requires immediate intervention? - - correct ans- Uterine cramping. Rationale: The client should be monitored for 1 to 2 hours following the procedure for the occurrence of uterine cramping so that immediate intervention to decrease the risk of miscarriage can be initiated. This procedure (removal of a small piece of tissue from the fetal portion of the placenta) may cause initiation of labor.
A client who is stable has family members present when the nurse enters the birthing suite to assess the mother and newborn. What action should the nurse implement at this time? - - correct ans- - Observe interactions of family members with the newborn and each other. Rationale: An opportunity to assess the emotional adjustment of individual family members to birth and lifestyle changes is presented, so the nurse should first observe the interaction of the family members. 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? - - correct ans- - Caput succedaneum. Rationale: Caput succedaneum is characterized by swelling of the soft tissues of the scalp that extends across suture lines. The nurse is assisting with the insertion of a pulmonary artery catheter (PAC) for a client at 32 - weeks gestation who has severe preeclampsia with pulmonary edema. As the PAC enters the right ventricle, what is the priority nursing assessment? - - correct ans- Monitor for premature ventricular contractions. Rationale: During and following the insertion of a pulmonary artery catheter (PAC), ECG activity should be monitored for the occurrence of any ventricular ectopy. A multiparous client is admitted to the postpartum unit after a rapid labor and birth of an infant weighing 4,000 grams. The client's fundus is boggy, lochia is heavy, and vital signs are unchanged. After having the client void and massaging the uterus, the client's fundus remains difficult to locate, and the rubra lochia remains heavy. What action should the nurse implement next? - - correct ans- - Notify the healthcare provider. Rationale:
Treatment of excessive bleeding requires the collaboration of the healthcare provider. A client at 28-weeks gestation arrives at the labor and delivery unit with a complaint of bright red, painless vaginal bleeding. For which diagnostic procedure should the nurse prepare the client? - - correct ans- - Abdominal ultrasound. Rationale: Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an indicator of placenta previa, which is confirmed by abdominal ultrasound. A multigravida client at 40+ weeks gestation is induced using oxytocin (Pitocin). An intrauterine pressure catheter (IUPC) is in place when the client's membranes rupture after 5 hours of active labor. Which finding should require the nurse to implement further action?
- correct ans- - Intensity of contractions is 130 mm Hg. Rationale: The goal of induction of labor with oxytocin is to produce an effective labor, which can be measured by an IUPC reading of 40 to 90 mm Hg for contractions when giving oxytocin. A primigravida at 37-weeks gestation tells the nurse that her "bag-of-water" has broken. While inspecting the client's perineum, the nurse notes the umbilical cord protruding from the vagina. What action should the nurse implement first? - - correct ans- - Place the client in the knee-chest position. Rationale: Until an emergency delivery is accomplished, the client should be placed in a kneechest position to relieve compression of the presenting part on the umbilical cord, which can compromise fetal oxygenation. When assessing the integument of a 24-hour-old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back, and abdomen. What action should the nurse implement next? - - correct ans- - Document the finding as erythema toxicum.
What action should the nurse implement to prevent conductive heat loss in a newborn? - - correct ans- - Put a blanket on the scale when weighing the infant. Rationale: Placing a blanket on the scale provides a barrier to prevent conductive heat loss when the infant's body comes in contact with a cooler solid surface. Which cardiovascular findings should the nurse assess further in a client who is at 20weeks gestation? - - correct ans- - Decrease in pulse rate. Rationale: Between 14 and 20 weeks gestation, the pulse increases about 10 to 15 beats/minute, which persists to term, so a decrease should be assessed further. A client at 8-weeks gestation ask the nurse about the risk for a congenital heart defect (CHD) in her baby. Which response best explains when a CHD may occur? - - correct ans- - The heart develops in the third to fifth weeks after conception. Rationale: The cardiovascular system is the first organ system to develop and function in the embryo. The blood vessel and blood formation begin in the third week, and the heart is developmentally complete in the fifth week. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? a. Unequal pupils. b. Loss of central reflexes. c. Inability to open the eyes. d. Change in level of consciousness. - - correct ans- - D
A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide? a. Use a douche preparation no more than once a month. b. Increase daily intake of fiber and leafy green vegetables. c. Select nylon underwear that is loose-fitting, white, and comfortable. d. Avoid tight-fitting clothing and do not use bubble-bath or bath salts. - - correct ans- D A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? a. Place an isolation cart in the hallway. b. Fit the client with a respirator mask. c. Don a clean gown for client care. d. Assign the client to a negative air-flow room. - - correct ans- - D The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? a. A pregnant woman. b. A teenager beginning puberty. c. A 3-month-old infant. d. A school-aged child. - - correct ans- - A What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? a. Team nursing. b. Primary nursing. c. Case management. d. Functional nursing. - - correct ans- - B Which approach should the nurse use when preparing a toddler for a procedure?
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder? a. Grave's disease. b. Cushing syndrome. c. Multiple sclerosis. d. Addison's disease. - - correct ans- - A A young adult female arrives at the emergency department with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings? a. Client alleges that her boyfriend beat her up. Client is bleeding from the left side of the face. b. Client reports her boyfriend hit her in the eye and on the head. Bruises and lacerations present on face. c. Client presents with a right black eye and a cut on the left side of her head that is bleeding. Reports abusive boyfriend responsible for injuries. Needs referral to a safe place to stay. d. Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive. - - correct ans- - D A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? a. Teach that anger will subside after two weeks on antidepressants. b. Ask client to describe triggers of anger. c. Gather more data about social support. d. Collaborate with the treatment team about revising the goal. - - correct ans- - B
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" a. Morbidly obese. b. Markedly obese. c. Inadequate lifestyle changes in diet and exercise. d. Increased morbidity and mortality risks. - - correct ans- - C A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) - - correct ans- - 61 A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture? a. Asymmetry of the face and eye movements. b. Abnormal position and movement of the arm. c. Hematemesis and abdominal distention. d. Rhinorrhoea or otorrhoea with Halo sign - - correct ans- - D The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? a. Purplish-red pinpoint lesions of the skin. b. Purple to bluish discoloration of the skin. c. Small circumscribed elevations containing purulent fluid. d. Generalized reddish discoloration of an area of skin. - - correct ans- - A
c. Verbalizes abdominal comfort without pressure. d. Drinks 240 ml of fluid five times during the shift. - - correct ans- - D The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement? a. Administer the dose as prescribed. b. Withhold the drug and notify the healthcare provider. c. Give intravenous (IV) calcium gluconate. d. Recheck the vital signs in 30 minutes and then administer the dose. - - correct ans- - A A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? a. Liver. b. Kidney. c. Sensory. d. Cardiorespiratory. - - correct ans- - A A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide? a. The dead bone needs to be removed to provide a blood supply for new bone growth. b. The infection is caused by a mutated bacteria that is resistant to most antibiotics. c. If the infected dead bone is not removed, it will make a path to the skin and drain pus. d. The infection has walled off into an area of infected bone creating a barrier to antibiotics.
- correct ans- - D Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first? a. Massage the uterine fundus. b. Palpate above the symphysis for the bladder.
c. Perform bi-manual massage. d. Inspect the perineum for excessive bleeding. - - correct ans- - B After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response? a. Fasting serum glucose. b. Serum liver function test. c. Serum electrolyte levels. d. Erythrocyte sedimentation rate. - - correct ans- - D The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? a. "Addicts who use illegal drugs are trying to escape reality." b. "Addiction causes people to steal and lie." c. "Those who are unhappy with themselves are more likely to become addicts." d. "Wanting the drug is all that matters to an addict." - - correct ans- - D A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet-to-dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement? a. Perform the wound care and have the PN provide the client's morning care. b. Advise the PN to review the procedure in the procedure manual and then complete the wound care. c. Note the PN's learning need to perform a wound packing and contact nursing education to schedule a time for instruction. d. Demonstrate the wound care procedure to the PN while the PN assists. - - correct ans- - D
