HESI RN Maternity Exam

HESI RN Maternity Exam

VERSION 21

• The nurse is teaching a client with gestational diabetes about nutrition and insulin need for

pregnancy. Which content should the nurse include in this client’s teaching plan?

• Insulin production is decreased during pregnancy
• increase daily caloric intake is needed ?
• injection requirements remain the same
• Blood sugars need less monitoring in the first trimester
• A 38-week primigravida client who is positive for Group A Beta Streptococcus receives a

prescription for cefazolin 2 grams IV to be infused over 30 minutes. The medications available in

• grams/100 ml of normal saline. The nurse should program the infusion pump to deliver how

many ml/hour?

1.6ml/hr

• When performing the daily head-to-toe assessment of a 1-day-old newborn, the nurse observes

yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?

• Measure bilirubin levels using transcutaneous bilirubinometry
• Review maternal medical records for blood type and Rh factor
• Prepare the newborn for phototherapy ?
• Evaluate cord blood Coomb’s test results

• A new mother asks the nurse about an area of swelling on her baby’s head near the posterior

fontanel that lies across the suture line. How should the nurse respond?

• “That is called caput succedaneum. It will absorb and cause no problems.”
• “That is called a cephalhematoma. It will cause no problems.” ?
• “That is called a cephalhematoma. It can cause jaundice as it is absorbed.”
• “That is called caput succedaneum. It will have to be drained.”

9.A 39-week-gestational multigravida is admitted to labor and delivery with spontaneous rupture of membranes (SROM) and contractions occurring every 2 to 3 minutes. A vaginal exam indicates that the cervix is dilated 6 cm, 90% effaced, and the fetus is at a +2 station. During the last 45 minutes the fetal heart rate (FHR) has ranged between 170 and 180 beats/minute. What 1 / 4

action should the nurse implement?

• Obtain a blood specimen for hemoglobin
• Take an oral maternal temperature ?
• Straight catheterize the client
• Send amniotic fluid for analysis
• An obviously pregnant woman walks into the hospital’s emergency department entrance,

shouting, “Help me! Help me! My baby is coming! I’m so afraid!” The nurse determines if delivery is indeed imminent. What action is most important for the nurse to take?

• Determines the gestational age of the fetus
• Assess the amount and color of the amniotic fluid
• Obtain peripheral IV access and begin administration of IV fluids
• Provide clear, concise instructions in a calm, deliberate manner

• During a routine prenatal health assessment for a client in her third trimester, the client

reports that she had fluid leakage on her way to the appointment. Which technique should the nurse implement to evaluate the leakage?

• Palpate suprapubic area for fetal head position
• Insert straight urinary catheter to drain bladder
• Test the fluid with a nitrazine strip
• Scan the bladder for urinary retention

• A client who is 3-weeks postpartum tells the nurse, “I am so tired all the time. I didn't know

having a baby would be so hard.” What response should the nurse provide?

• It is common to feel exhausted for the first 3 months. Try to sleep when the baby sleeps.
• It is normal to feel tired for the first couple weeks. Be patient with yourself and rest more.
• You should not be doing any housework. Are any of your family members helping you?
• Adjusting to a new baby can be difficult. Tell me more about any help you are receiving.

• The home health nurse visits a client who delivered a full term baby three days ago. The

mother reports that the infant is waking up every 2 hours to bottle feed. The nurse notes white, curd-like patches on the newborn’s oral mucous membranes. What action should the nurse implement?

• Discuss the need for medication to treat curd-like oral patches
• Suggest switching the infant’s formula
• Assess the baby’s blood glucose level
• Remind mother not put the baby to bed with a propped bottles 2 / 4

• Which action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs

(3,317 grams), weighs 7 lbs (3,175 grams) today.

• Monitor the stool and urine output of the neonate for the last 24 hours
• Inform and assure the mother that this is a normal weight loss
• Encourages the mother to increase frequency of breastfeeding.
• After verifying the accuracy of the weight, notify the healthcare provider.

• A term multigravida, who is receiving oxytocin (Pitocin) for labor augmentation, is

requesting pain medication. Review of the client’s record indication that she was medicated 30 minutes ago with butorphanol (Stadol) 2 mg and promethazine (Phenergan) 25 mg IV push.Vaginal examination reveals that the client’s cervical dilation is 3 cm, 70% effaced, and at a 0 station. What action should the nurse implement?

• Discontinue the Pitocin infusion
• Medicate the client with an additional 1 mg of Stadol IV push
• Notify the healthcare provider
• Instruct the client to use deep breathing during a contraction

• A women who delivered a 9 pound baby boy by cesarean section under spinal anesthesia is

recovering in the postanesthesia care unit. Her fundus is firm, at the umbilicus, and a continuous trickle of bright red blood with no clots from the vagina in observed by the nurse. Which action should the nurse implement?

• Massage the fundus vigorously
• Assess her blood pressure
• Apply ice pack to perineum
• Let the infant breast feed

• When teaching a gravid client how to perform kick (fetal movement) counts, which

instruction should the nurse include?

• Exercise for 15 minutes before starting the counting to help increase fetal movement
• Count the movements once daily, for one hour, before breakfast 3 / 4

• Avoid caffeinated drinks for 24 hours before conducting the kick test.
• If 10 kicks are not felt within one hour, drink orange juice and count for another hour.

• A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her

fundal height in measured at 29 cm. Based on these findings, what actions the nurse implement?

• Notify the healthcare provider of the finding
• Document the finding in the medical record
• Schedule the client for a biophysical profile
• Request another nurse measure the fundus

• The nurse is performing a newborn assessment. Which symptoms, if present in newborn,

would indicate respiratory distress?

• Abdominal breathing with synchronous chest movement
• Shallow and irregular respirations
• Flaring of the nares
• Respiratory rate of 50 breaths per minute

• The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which

immediate treatment is indicated for this client?

• Administration of Pitocin
• Artificial rupture of the membranes
• Amnioinfusion for the baby
• Administration of antibiotics

• 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?

• Check the pH of the vaginal fluid
• Review the fetal heart rate pattern
• Palpate the client’s bladder
• / 4