- | P a g e
Maternity HESI Correct and Verified Answers Graded A
- An expectant father tells the nurse he fears that his wife "is losing her mind." He
- A mother who is breastfeeding her baby receives instructions from the nurse. Which
- An off-duty nurse finds a woman in a supermarket parking lot delivering an infant
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?• Correct Answer: 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.
instruction is most effective in preventing nipple soreness?• Correct Answer: Ensure that the baby is positioned correctly for latching on.• Rationale: The most common cause of nipple soreness is incorrect positioning of the infant on the breast for latching on. The baby's body is in alignment with the ears, shoulders, and hips in a straight line, with the nose, cheeks, and chin touching the breast.
while her husband is screaming for someone to help his wife. Which intervention has the highest priority?
• Correct Answer: Put the newborn to the breast immediately.
• Rationale: Putting the newborn to the breast will help contract the uterus and prevent a postpartum hemorrhage. This intervention has the highest priority.
- Which findings are most critical for the nurse to report to the primary health care
provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.)
- | P a g e
• Correct Answer: Increased heartburn that is not relieved with doses of antacids; Chronic headache that has been lingering for a week behind the client's eyes.
- One hour following a normal vaginal delivery, a newborn infant boy's axillary
temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first?
• Correct Answer: Obtain a serum glucose level.
• Rationale: This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level.
- A client who delivered by cesarean section 24 hours ago is using a patient-
- Which findings are of most concern to the nurse when caring for a woman in the first
controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating and states that because she has had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?• Correct Answer: Impaired bowel motility related to pain medication and immobility.• Rationale: Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.
trimester of pregnancy? (Select all that apply.)
• Correct Answer: Cramping with bright red spotting.
- A mother expresses fear about changing the infant's diaper after circumcision.
What information should the nurse include in the teaching plan?
• Correct Answer: 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.
- The nurse is counseling a couple who has sought information about conceiving. The
couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
• Correct Answer: Two weeks before menstruation.
- | P a g e
• Rationale: Ovulation occurs 14 days before the first day of the menstrual period.
- A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce
breast engorgement. Which instruction should the nurse provide?
• Correct Answer: Breastfeed the infant every 2 hours.
• Rationale: The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding.
- Just after delivery, a new mother tells the nurse, "I was unsuccessful breastfeeding
- A client in active labor is becoming increasingly fearful because her contractions
- Prior to discharge, what instructions should the nurse give to parents regarding the
my first child, but I would like to try with this baby." Which intervention should the nurse implement first?• Correct Answer: Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.• Rationale: Infants respond to breastfeeding best when feeding is initiated in the active phase soon after delivery.
are occurring more often than she had expected. Her partner is also becoming anxious. Which of the following should be the focus of the nurse's response?• Correct Answer: Asking the client and her partner if they would like the nurse to stay in the room.• Rationale: Offering to remain with the client and her partner offers support without providing false reassurance.
newborn's umbilical cord care at home?
• Correct Answer: 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.
- 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?
• Correct Answer: 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>
- | P a g e
- The nurse observes that an antepartum client who is on bed rest for preterm labor
is eating ice rather than the food on her breakfast tray. The client states that she has a craving for ice and then feels too full to eat anything else. Which is the best response by the nurse?
• Correct Answer: Notify the health care provider.
• Rationale: The health care provider should be notified when a client practices pica (craving for and consumption of nonfood substances). The practice of pica may displace more nutritious foods from the diet, and the client should be evaluated for anemia.
- 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?
• Correct Answer: 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.
- During the transition phase of labor, a client complains of tingling and numbness in
her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?
• Correct Answer: Have her cup both hands over her nose and mouth while
breathing.• Rationale: Hyperventilation blows off carbon dioxide, depletes carbonic acid in the blood, and causes transient respiratory alkalosis.
- A 25-year-old client has a positive pregnancy test. One year ago she had a
spontaneous abortion at 3 months of gestation. Which is the correct description of this client that should be documented in the medical record?
• Correct Answer: Gravida 2, para 0.
• Rationale: The spontaneous abortion (miscarriage) occurred at 3 months of
gestation (12 weeks), so she is a para 0. Parity cannot be increased unless delivery occurs at 20 weeks of gestation or beyond.
