HESI MATERNITY EXAM

HESI MATERNITY EXAM

2020 SUMMER

The nurse performs a routine assessment on a 12-hour-old infant. Which finding requires intervention?

A.      No voiding or stooling since birth

B.      Crying for more than 10 minutes

C.      Respiratory rate of 73 breaths/minute

D.      Acrocyanosis with hands & feet cool to touch

The nurse receives change-of-shift report for four newborns. The nurse should monitor closely which newborn for an increased risk for developing neonatal sepsis

A.      Birth weight of 2.75 kg

B.      Reported prolonged rupture of membranes

C.      Delivered by scheduled Cesarean section

D.      Ballard score of 36-weeks-gestation

A client who is 37 weeks gestation comes to the woman's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure which action should the nurse implement next?

A.      Ask about a history of delivering large babies

B.      Collect urine sample to screen for protein

C.      Examine the client for pedal edema

D.      Establish the frequency of headaches

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 at that sign may indicate which condition?

A.      Expected course in fourth stage of labor

B.      Laceration on the cervix

C.      Early postpartum hemorrhage

D.      A full urinary bladder

A client who suspects she is pregnant tells the nurse she has a peptic ulcer and is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond?

A.      “this medication will have no effect on your unborn child”

B.      “you may have an increased chance of having preeclampsia”

C.      You may experience postpartum hemorrhaging after delivery

D.      You may be at higher risk for having a spontaneous miscarriage”

The nurse is assessing a 38-week gestation newborn infant immediately following a vagina birth. Which assessment finding indicates that the infant is transitioning well too extrauterine life?

A.      A positive Babinski reflex

B.      flexion of all four extremities

C.      heart rate of 220 beats per minute

D.      Cries vigorously when stimulated

A client at 40-weeks’ gestation is admitted to labor and delivery. Her obstetrical history includes three life births at 39, 38, and 35-weeks’ gestation, 2 miscarriages at 6 & 8-weeks’ gestation, and a fetal demise at 33-weeks gestation. Which is an accurate summary of this client’s obstetrical history?

A.      Gravida 7 Term 2 Preterm 2 Abortion 2 Living 3

B.      Gravida 6 Term 3 Preterm 1 Abortion 2 Living 3

C.      Gravida 6 Term 2 Preterm 2 Abortion 2 Living 4

D.      Gravida 7 Term 1 Preterm 3 Abortion 2 Living 4

A term multigravida, who is receiving oxytocin for labor augmentation is requesting pain medication. Review of the client’s record indicates that she was medicated 30 minutes ago with butorphanol tartare 2 mg & promethazine 25 mg IV push. Vaginal examination reveals that the client’s cervical dilation is 3 cm, 70% effaced, and at a 0 station. Which action should the nurse implement?

A.      Instruct the client to use deep breathing during a contraction

B.      Notify the healthcare provider

C.      Discontinue the oxytocin infusion

D.      Medicate the client with an additional 1 mg of butorphanol tartrate IV push

When preparing to assist the healthcare provider with a vaginal examination to assess a client’s cervical dilation during labor, which equipment should the nurse assemble?

A.      Sterile glove & sterile speculum

B.      Sterile glove & speculum

C.      Sterile glove & lubricant

D.      Sterile speculum & lubricant

Following a vaginal delivery, the nurse places the neonate under the radiant warmer, provides naso-oropharyneal suction, and dries the neonate’s skin to elicit spontaneous respirations. The newborn’s heart rate is 100 beats/minute & remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

A.      Assist neonatologist with intubation

B.      Provide positive pressure ventilation

C.      Start IV infusion in a scalp vein

D.      Give blow-by oxygen via cannula

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?

A.      Scan the bladder for urinary retention

B.      Test the fluid with a nitrazine strip

C.      Palpate the suprapubic area for fetal head position

D.      Insert straight urinary catheter to drain bladder