HESI RN: Maternity - Test Bank EXAM 2024-2025 QUESTIONS AND
CORRECT VERIFIED ANSWERS /100% PASS SOLUTION / ALREADY
GRADED A+
The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head
circumference of 13 inches and a chest circumference of 10 inches. Based on these physical findings,
assessment for which condition has the highest priority?
a. Hyperthermia
b. polycythemia
c. hyperbilirubinemia
d. hypoglycemia - answer>>a. Hyperthermia
The nurse is caring for a client following an emergency cesarean delivery under a general anesthesia.
Which assessment finding, occurring in the first 8 hours after delivery, is more critical and requires
immediate intervention?
a. mild nausea and anorexia
b. uterine atony *
c. a positive Homan's sign
d. Respiratory rate 12 - answer>>b. uterine atony *
The parents of a male newborn have signed an informed consent for circumcision. What priority
intervention should the nurse implement upon completion of the circumcision? a. give a PRN dose of
liquid acetaminophen
b. wrap the infant in warm receiving blankets
c. place petrolatum gauze dressings on the site *
d. offer a pacifier dipped in glucose water - answer>>c. place petrolatum gauze dressings on the
site *
The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated,
50% effaced, and the presenting part is at 0 station. An hour later, she tells the nurse that she wants to
go to the bathroom. Which action should the nurse implement first? a. palpate the client's bladder
b. check the pH of the vaginal fluid
c. determine cervical dilation
d. review the FHR pattern * - answer>>d. review the FHR pattern *
,A 26-week gestation primigravida who is carrying twins is seen in the clinic today. Her final height is
measured at 29 cm. Based on these findings, what action should the nurse implement? a. notify the
HCP of the finding
b. schedule the client for a biophysical profile
c. document the finding in the medical record
d. request another nurse measure the fundus - answer>>c. document the finding in the medical
record
A client at 34 weeks gestation is scheduled to travel for business using a commercial airline. Which
instruction is most important for the nurse to provide this client?
a. explore the availability of medical care at the destination site
b. request an aisle seat in a row that is not designated as an exit row *
c. perform ankle flexion and extension several times throughout the trip
d. wear non-constricting clothing to prevent edema of the feet and hands - answer>>c. perform
ankle flexion and extension several times throughout the trip
Pregnancy is a stage of hypercoagulation. The clotting factors in the body will increase and the platelet
count also will increase, especially towards the end of the pregnancy. Along with this the gravid uterus
will compress the blood vessels of the lower extremities and this may leads to sluggishness of venous
return. This slow venous return leads to the pooling of blood in the lower extremities
Following a precipitous labor, a postpartum client has a continuous trickling of bright red blood from her
vagina. Her uterus is firm, and her vital signs are within normal limits. The nurse determines that this
sign may indicate which condition?
a. expected course in the fourth stage of labor
b. a full urinary bladder
c. early postpartum hemorrhage
d. the laceration on the cervix * - answer>>d. the laceration on the cervix *
postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after
delivery of an infant who is Rh-positive. Which information should the nurse provide this client?
a. RhoGAM is not necessary unless all her pregnancies are Rh-positive
b. RhoGAM prevents maternal antibody formation for future Rh-positive babies
c. the mother should receive RhoGAM when the baby is Rh-negative
d. the R-positive factor from the fetus threatens her blood cells * - answer>>d. the R-positive
factor from the fetus threatens her blood cells *
,A client at 30 weeks gestation is being treated in the emergency department for a broken finger. The
nurse assesses the FHR while the client is in a sitting position and has a heart rate of 92 beats per
minute. What intervention is most important for the nurse to perform?
a. encourage the client to empty her bladder *
b. determine the maternal pulse rate
c. instruct the client to drink a glass a juice
d. place the client in a supine position - answer>>a. encourage the client to empty her bladder *
Vaginal examination reveals that a laboring clients' cervix is dilated to 2 cm, 70% effaced, with the
presenting part at -2 stations. The client tells the nurse, "I need my epidural now! This hurt!" the nurses'
response to the client should be based on what information?
a. the client should be dilated to at least 8 cm before receiving an epidural
b. the baby needs to be at a zero station before an epidural can be administered
c. Administering an epidural at this point would slow the labor process *
d. the client will need to be catheterized before the epidural can be administered. - answer>>c.
Administering an epidural at this point would slow the labor process *
A client at 38 weeks gestation presents to the labor and delivery unit in active labor. Based on which
assessment finding should the nurse notify the surgery team to prepare for a primary cesarean section?
a. treated ten days ago for Chlamydia
b. Group Beta Strep positive
c. Positive western blot for HIV
d. active herpes lesions on the perineum - answer>>d. active herpes lesions on the perineum
A 6 weeks gestation, the rubella titer of a client indicates she is non-immune. When is the best time to
administer a rubella vaccine to this client?
a. immediately, at six weeks gestation to protect this fetus
b. early postpartum within 72 hours of delivery
c. after the client stops breastfeeding
d. after the client reaches 20-weeks' gestation - answer>>b. early postpartum within 72 hours of
delivery
The nurse is receiving a report for a laboring client who arrived in the ER with ruptured membranes that
the client did not recognize. What is the priority nursing action to implement when the client is admitted
to the labor and delivery suite.
a. Prepare to start at IV *
b. take the clients temp
, c. begin a pad count
d. monitor amniotic fluid for meconium - answer>>a. Prepare to start at IV *
The nurse is conducting a postpartum teaching with a mother who is breastfeeding her infant. When
discussing birth control, which method should the nurse recommend to this client as best for her to use
in preventing an unwanted pregnancy?
a. combined estrogen- progesterone oral contraceptives
b. breastfeed exclusively at least every 3 to 4 hours
c. condoms and contraceptive foam or gel
d. rhythm method (natural family planning) - answer>>c. condoms and contraceptive foam or gel
A full-term infant is admitted to the newborn nursery 2 hours after delivery. The delivery record
indicates that the mother is positive for HIV and received zidovudine AZT IV during labor. What action
should the nurse implement?
a. ensure that AZT is given within 6 hours after birth
b. assess for the presence of the Moro reflex
c. collect venous specimen for serum glucose level
d. obtain consent for the Hep B vaccine - answer>>a. ensure that AZT is given within 6 hours after
birth
In determining the one-minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats
per minute and 44 respirations per minute. He has a loud cry with stimulation, good muscle tone and his
color is acrocyanotic. What Apgar score should the nurse assign? a. 7
b. 9 **
c. 10
d. 8 - answer>>b. 9 **
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months
ago when she was informed that her positive pregnancy test was a false positive. Which method of
determining pregnancy provides the greatest degree of accuracy?
a. complaints of feeling tired all the time
b. presence of amenorrhea for 2 months
c. visualization of implantation by vaginal ultrasound
d. maternal blood serum tests positive for alpha-fetoprotein - answer>>c. visualization of
implantation by vaginal ultrasound
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