Which finding for a client in labor at 41weeks gestation requires
additional assessment by the nurse?
Cervix dilated 2 cm and 50% effaced.
Score of 8 on the biophysical profile.
Fetal heart rate of 116 beats per minute.
One fetal movement noted in an hour.
A client at 28weeks 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?
Contraction stress test.
Internal fetal monitoring.
Abdominal ultrasound.
Lecithinsphingomyelin ratio.
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon
fundal assessment, the nurse determines the uterus is boggy and is
displaced above and to the right of the umbilicus. Which action should
the nurse implement next?
Document the color of the lochia.
Observe maternal vital signs.
Assist the client to the bathroom.
Notify the healthcare provider.
A multiparous client is experiencing bleeding 2 hours after a vaginal
delivery. What action should the nurse implement next?
HESI MATERNAL NEWBORN GUIDE 2019
Correct Questions & Answers
Determine the firmness of the fundus.
Give oxytocin (Pitocin) intravenously.
Inform the healthcare provider of the bleeding.
Assess the vital signs for indicators of shock.
The nurse notes a pattern of the fetal heart rate decreasing after each
contraction. What action should the nurse implement?
Give 10 liters of oxygen via face mask.
Prepare for an emergency cesarean section.
Continue to monitor the fetal heart rate pattern.
Obtain an oral maternal temperature.
A client at 28weeks gestation experiences blunt abdominal trauma.
Which parameter should the nurse assess first for signs of internal
hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate patterns.
Alteration in maternal blood pressure.
Which client should the nurse report to the healthcare provider as
needing a prescription for Rh Immune Globulin (RhoGAM)?
Woman whose blood group is AB Rhpositive.
Newborn with rising serum bilirubin level.
Newborn whose Coombs test is negative.
Primigravida mother who is Rhnegative.
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HESI MATERNAL NEWBORN PROCTORED EXAM
(STUDY GUIDE) 2021/2022
- Good source of folic acid – peanuts
- Mom getting hypotensive on spine board after car wreck – roll her on her side on spine board
- Mom goes to bathroom with contractions 5 min apart, you hear baby cry – hit call light for help
- Iron (SATA) – dark stool normal, give at bedtime
- Man calls clinic says his wife has been sad, happy, moody – tell him normal hormonal changes
- Mag question – stop infusion due to mag tox
- One question her contractions get really close and she is dilated, stop Pitocin, then contractions get 5 min apart –
restart Pitocin per agency policy - Bright red trickling blood – lacerated cervix
- Teach adolescent pregnant girls – proper nutritional needs
- 42 wk ballard score – check blood sugar
- Breast feeding woman asks about birth control – breast feed only every 2-3 hrs
- Rubella vaccine – use birth control for 28 days
- Baby as white curd patches in his mouth – discuss medicine with mother (candidiasis infection)
- Mom has baby – she reaches out and traces profile with fingertips
- HIV positive mom gives birth and is worried about passing it to baby – explain to mom AZT for baby after birth
- Baby has to have COOMBS test, mom doesn’t want rhogam but will keep her from building up antibodies for future
babies - HSV 2, baby born, vaginal delivery – isolate in nursery
- Hormone for positive pregnancy test – human chorionic gonadotropin (HCG)
- Swollen vagina is normal in female infant
- Moro reflex is normal in infant
- 800 ml output in an hour with mag question – just continue whatever you are doing
- Woman has baby in a cab – start pitocin, massage fundus
- Woman comes in with pain in her stomach – you start an IV, not type and cross blood
- Put eye ointment in conjunctival sac of newborn (erythromycin) as prophylactic eye ointment for prevention of eye
infections contracted from bacteria in birth canal - Had kid now complains of vaginal pain fullness – check vaginal/perineal area
- Swollen vagina question is long and talks about salt wasting – normal finding explain about androgens
- -1 placement of baby active labor 3 cm dilated, has to go to bathroom – check the patient’s cervix
- Baby born to diabetic mother – check baby’s blood sugar
- PKU baby – 25% any babies will have it too
- Baby with clavicle problem – will have intracurvature
- One question about a woman who drinks and has cut down – give her an “atta boy” and encourage her to reduce the
amount even more - Woman getting radiation iodine – hold off on test to confirm if pregnant or not
- Some type of fertility drugs – you need to report sudden increase in abdominal girth
- Breast feeding baby and sore nipples – start feeding on the unaffected breast
- Breast feeding mother has a diaphragm – use condom and foam until diaphragm can be refitted
- Baby born to mother who has a positive drug screen for something – monitor baby for seizures
- Baby has an apgar score of 3 – continue resuscitation
- Baby is jaundice and brought back to hospital after 7 to 10 days – provide eye protection and placed under light or
phototherapy - Pregnant woman with low Hct Hgb levels – this is normal because of increase in plasma levels
- Woman in labor lying in supine position states she is finally comfortable – place a wedge under her right hip
- Preparing a woman for triple screen or something test – you need to prepare to draw blood lab work
- Woman comes in stating her water broke – test with nitrate paper and if it turns blue then prepare to admit
- Woman is having an amniocentesis test – nurse should check for signs of labor once it is complete
- A newborn weighs 7.5 lbs at birth and weighs 7 lbs 24 hrs later – this is normal weight loss
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- Something about woman 12 weeks prenatal visit. What is important to discuss at this time? It is a cultural question
answer is something about – birthing plans or techniques - Baby weighs over 9 lbs – assess for fracture of clavicle
- Patient with non-reassuring pattern – stop Pitocin infusion
- Baby 28 weeks – hemodilution – anemia (hemodilution of pregnancy peaks at 28 weeks results in decreased Hct)
- Parents in transition stage – maintain relationship with extended family
- Which block deadens vagina and perineum – pudendal block
- Woman comes in vomiting with low BP – give antiemetic
- There are two questions on apneic baby – rub baby’s trunk & flick soles of feet
- Neonate is apneic for 20 seconds – rub baby’s trunk
- Teaching pregnant teenagers about pregnancy – iron deficiency anemia
- A woman is 5 hrs postpartum with fundus 3 cm above the umbilicus and to the left – encourage her to void/urinate
- Woman is certain number of weeks, which method is best to determine fetal position – ultrasound
- Baby born to mother that tested positive for cocaine – nursing priority is seizure precautions
- Neonate respiratory distress – nasal flaring
- Mother has a firm fundus but continues to have bright red blood trickling from vagina, what is possible indication –
lacerated cervix - During fundal massage, place one hand at the fundus, what is the second hand used for – to anchor fundus
- There is a question that has to be put in order – isolate the baby, move mom to private room, collect u/a, start iv
- How do you measure the frequency of contractions – from the beginning of one to the beginning of the next
- Mothers Hemoglobin A1C – give her a consultation to a nutritionist
- Baby shows cyanosis in hands and feet and has elevated respirations – gradually warm the baby
- Baby is showing signs of mottling – check temperature
- Mom is at 20 week gestation and has gained 20 lbs, what is of most concern out of the data of mom – increased
weight gain - Mom asks why her baby is being screened for T4 and TSH levels – it is state protocol to monitor for metabolic
abnormalities - Patient is having labor back pain – counter pressure on lower back (sacrum)
- Woman had cleft lip, dads uncle had cleft lip – send them for genetic testing
- Woman in labor and they look at vagina and see cord – put woman in Trendelenburg position
- Pregnant woman has a diaphragm – she needs to have it refitted for another diaphragm
- Baby starts showing signs of respiratory difficulty (nasal flaring, expiratory grunt, cyanosis) – check O2 saturation
levels - Baby progressing in extrauterine life would show what signs – good vigorous cry with stimulation
- Baby has peri-oral cyanosis – assess the oral mucosa
- Before surgery mom is given an anticholinergic/atropine with anesthesia. What is the therapeutic response of the
anticholinergic – increase pulse and decrease oral secretions - Question about cytotec – answer is you are at an increased risk for abortion
- Patients uterus is above the umbilicus and to the right during postpartum, what do you do first – palpate the bladder
for distention - Mom feels the urge to defecate during labor – do a vagina exam
- What is the reason to do an ultrasound on a mother at 20 weeks gestation – ultrasound for gestation and fetal growth
- Patient is taking mag sulfate and urine output is 25 mL/hr, respirations 14/min, pulse is 116/min, what should the
nurse do first – discontinue mag sulfate (signs of mag tox) - Postpartum with bathroom privileges, what possible condition would the nurse place the patient on temporary bed
rest for – possible thrombus in the leg if positive Homan’s sign is present - Pregnant woman has an increased costal angle and diaphragm is elevated , how does the nurse document this – as a
normal finding - Moms Hgb and Hct is low, what food to tell her to eat that contains the most iron? – chicken (other sources: liver,
meats, whole grains, enriched bread, cereal, dried fruits) - Mom wakes up in a pool of blood and comes to emergency room. What to check first – blood pressure
- Nurse anticipates that the prenatal lab will be performed at 28 weeks – 1 hr glucose (140 between 24-28 weeks)
- What medication to give mom to prevent RDS in fetus – betamethasone
- Pt is induced for labor contractions begin occurring 1 ½ to 2 min apart with no resting in between contractions,
what to do first – stop pitocin infusion
HESI MATERNAL NEWBORN 2019 EXAM – REVISION GUIDE
190+ Correct Questions & Answers
- Good source of folic acid – peanuts
- Mom getting hypotensive on spine board after car wreck – roll her on her side on spine board
- Mom goes to bathroom with contractions 5 min apart, you hear baby cry – hit call light for help
- Iron (SATA) – dark stool normal, give at bedtime
- Man calls clinic says his wife has been sad, happy, moody – tell him normal hormonal changes
- Mag question – stop infusion due to mag tox
- One question her contractions get really close and she is dilated, stop Pitocin, then contractions get 5 min apart –
restart Pitocin per agency policy - Bright red trickling blood – lacerated cervix
- Teach adolescent pregnant girls – proper nutritional needs
- 42 wk ballard score – check blood sugar
- Breast feeding woman asks about birth control – breast feed only every 2-3 hrs
- Rubella vaccine – use birth control for 28 days
- Baby as white curd patches in his mouth – discuss medicine with mother (candidiasis infection)
- Mom has baby – she reaches out and traces profile with fingertips
- HIV positive mom gives birth and is worried about passing it to baby – explain to mom AZT for baby after birth
- Baby has to have COOMBS test, mom doesn’t want rhogam but will keep her from building up antibodies for future
babies - HSV 2, baby born, vaginal delivery – isolate in nursery
- Hormone for positive pregnancy test – human chorionic gonadotropin (HCG)
- Swollen vagina is normal in female infant
- Moro reflex is normal in infant
- 800 ml output in an hour with mag question – just continue whatever you are doing
- Woman has baby in a cab – start pitocin, massage fundus
- Woman comes in with pain in her stomach – you start an IV, not type and cross blood
- Put eye ointment in conjunctival sac of newborn (erythromycin) as prophylactic eye ointment for prevention of eye
infections contracted from bacteria in birth canal - Had kid now complains of vaginal pain fullness – check vaginal/perineal area
- Swollen vagina question is long and talks about salt wasting – normal finding explain about androgens
- -1 placement of baby active labor 3 cm dilated, has to go to bathroom – check the patient’s cervix
- Baby born to diabetic mother – check baby’s blood sugar
- PKU baby – 25% any babies will have it too
- Baby with clavicle problem – will have intracurvature
- One question about a woman who drinks and has cut down – give her an “atta boy” and encourage her to reduce the
amount even more - Woman getting radiation iodine – hold off on test to confirm if pregnant or not
- Some type of fertility drugs – you need to report sudden increase in abdominal girth
- Breast feeding baby and sore nipples – start feeding on the unaffected breast
- Breast feeding mother has a diaphragm – use condom and foam until diaphragm can be refitted
- Baby born to mother who has a positive drug screen for something – monitor baby for seizures
- Baby has an apgar score of 3 – continue resuscitation
- Baby is jaundice and brought back to hospital after 7 to 10 days – provide eye protection and placed under light or
phototherapy - Pregnant woman with low Hct Hgb levels – this is normal because of increase in plasma levels
- Woman in labor lying in supine position states she is finally comfortable – place a wedge under her right hip
- Preparing a woman for triple screen or something test – you need to prepare to draw blood lab work
- Woman comes in stating her water broke – test with nitrate paper and if it turns blue then prepare to admit
- Woman is having an amniocentesis test – nurse should check for signs of labor once it is complete
- A newborn weighs 7.5 lbs at birth and weighs 7 lbs 24 hrs later – this is normal weight loss
- Something about woman 12 weeks prenatal visit. What is important to discuss at this time? It is a cultural question
answer is something about – birthing plans or techniques - Baby weighs over 9 lbs – assess for fracture of clavicle
- Patient with non-reassuring pattern – stop Pitocin infusion
- Baby 28 weeks – hemodilution – anemia (hemodilution of pregnancy peaks at 28 weeks results in decreased Hct)
- Parents in transition stage – maintain relationship with extended family
- Which block deadens vagina and perineum – pudendal block
- Woman comes in vomiting with low BP – give antiemetic
- There are two questions on apneic baby – rub baby’s trunk & flick soles of feet
- Neonate is apneic for 20 seconds – rub baby’s trunk
- Teaching pregnant teenagers about pregnancy – iron deficiency anemia
- A woman is 5 hrs postpartum with fundus 3 cm above the umbilicus and to the left – encourage her to void/urinate
- Woman is certain number of weeks, which method is best to determine fetal position – ultrasound
- Baby born to mother that tested positive for cocaine – nursing priority is seizure precautions
- Neonate respiratory distress – nasal flaring
- Mother has a firm fundus but continues to have bright red blood trickling from vagina, what is possible indication –
lacerated cervix - During fundal massage, place one hand at the fundus, what is the second hand used for – to anchor fundus
- There is a question that has to be put in order – isolate the baby, move mom to private room, collect u/a, start iv
- How do you measure the frequency of contractions – from the beginning of one to the beginning of the next
- Mothers Hemoglobin A1C – give her a consultation to a nutritionist
- Baby shows cyanosis in hands and feet and has elevated respirations – gradually warm the baby
- Baby is showing signs of mottling – check temperature
- Mom is at 20 week gestation and has gained 20 lbs, what is of most concern out of the data of mom – increased
weight gain - Mom asks why her baby is being screened for T4 and TSH levels – it is state protocol to monitor for metabolic
abnormalities - Patient is having labor back pain – counter pressure on lower back (sacrum)
- Woman had cleft lip, dads uncle had cleft lip – send them for genetic testing
- Woman in labor and they look at vagina and see cord – put woman in Trendelenburg position
- Pregnant woman has a diaphragm – she needs to have it refitted for another diaphragm
- Baby starts showing signs of respiratory difficulty (nasal flaring, expiratory grunt, cyanosis) – check O2 saturation
levels - Baby progressing in extrauterine life would show what signs – good vigorous cry with stimulation
- Baby has peri-oral cyanosis – assess the oral mucosa
- Before surgery mom is given an anticholinergic/atropine with anesthesia. What is the therapeutic response of the
anticholinergic – increase pulse and decrease oral secretions - Question about cytotec – answer is you are at an increased risk for abortion
- Patients uterus is above the umbilicus and to the right during postpartum, what do you do first – palpate the bladder
for distention - Mom feels the urge to defecate during labor – do a vagina exam
- What is the reason to do an ultrasound on a mother at 20 weeks gestation – ultrasound for gestation and fetal growth
- Patient is taking mag sulfate and urine output is 25 mL/hr, respirations 14/min, pulse is 116/min, what should the
nurse do first – discontinue mag sulfate (signs of mag tox) - Postpartum with bathroom privileges, what possible condition would the nurse place the patient on temporary bed
rest for – possible thrombus in the leg if positive Homan’s sign is present - Pregnant woman has an increased costal angle and diaphragm is elevated , how does the nurse document this – as a
normal finding - Moms Hgb and Hct is low, what food to tell her to eat that contains the most iron? – chicken (other sources: liver,
meats, whole grains, enriched bread, cereal, dried fruits) - Mom wakes up in a pool of blood and comes to emergency room. What to check first – blood pressure
- Nurse anticipates that the prenatal lab will be performed at 28 weeks – 1 hr glucose (140 between 24-28 weeks)
- What medication to give mom to prevent RDS in fetus – betamethasone
- Pt is induced for labor contractions begin occurring 1 ½ to 2 min apart with no resting in between contractions,
what to do first – stop pitocin infusion
HESI MATERNAL NEWBORN
EXAM (STUDY GUIDE)
2020/2021
- A 25-year-old woman comes to the clinic and says she thinks she is pregnant.
Her last period was July 20. Based on this fact, what is the expected date of
delivery (EDD)? - April 13
- April 27
- May 20
- March 27
- The patient reports experiencing nausea, vomiting, and breast tenderness
along with missing her period. These symptoms are considered to be what type of
signs of pregnancy? - Probable
- Positive
- Presumptive
- Possible
- A pregnant patient is seen during her second trimester at the health care
provider’s office. She asks the nurse, “What can I do when my leg goes into a
cramp?” The patient demonstrates understanding of the nurse’s instruction
regarding relief of leg cramps if she takes which action? - Wiggles and points her toes during the cramp
- Applies cold compresses to the affected leg
- Extends her leg and dorsiflexes her foot during the cramp
- Avoids weight bearing on the affected leg during the cramp
- A woman who is in her first trimester is talking with the nurse. The patient has
inquired about the feelings she will have when she first feels her baby move.
What information can be provided by the nurse? - The movement will feel like cramps.
- The movement is rhythmic and called Goodell’s sign.
- The movement is flutter-like and is called quickening.
- The movement is like a thud and is called Hëgar’s sign.
- While giving a health history to the nurse, the patient reports that she usually
has a glass of wine with dinner. What is the safe level of alcohol intake for her
during her pregnancy? - No alcohol
- Wine only; one or two glasses daily with meals
- Up to 4 oz daily
- Beer or wine only after the first trimester
- The nurse explains to the patient that she should contact her health care
provider if she experiences any of the danger signs of pregnancy. Which
symptoms are a danger sign during pregnancy? (Select all that apply.) - Urinary frequency
- Severe headaches
- Dyspepsia
- Heartburn
- Diplopia
- A test that may be done in late pregnancy to determine fetal well-being is the
nonstress test. This test is based on which phenomenon? - Fetal heart rate increases in connection with fetal movement.
- Braxton Hicks contractions cause an increase in fetal heart rate.
- Fetal heart rate slows in response to contractions.
- Fetal movement causes an increase in maternal heart rate.
- Constipation is a frequent symptom as a pregnancy progresses. Which
measures should be recommended to the gravid woman? (Select all that apply.) - Drink six to eight glasses of water daily.
- Take an over-the-counter laxative.
- Take an iron supplement only every other day.
- Take mineral oil at bedtime.
- Increase dietary fiber intake.
- At one of her prenatal visits, the patient is scheduled for a sonogram.
Sonography can be used to assess which of the following? (Select all that apply.) - Number of fetuses
- Gestational age of fetus
- Down syndrome
- Congenital anomalies
- Placement of the placenta
- Which symptom is considered a first-trimester warning sign and should be
reported immediately to the health care provider? - Nausea with occasional vomiting
- Fatigue
- Urinary frequency
- Vaginal bleeding
- A pregnant woman at 10 weeks of gestation jogs three or four times per week.
She is concerned about the effect of exercise on the fetus. What information can
be provided by the nurse? - “You do not need to modify your exercising anytime during your pregnancy.”
- “Stop exercising because it will harm the fetus.”
- “You may find that you need to modify your exercising to walking later in
your pregnancy, around the seventh month.” - “Jogging is too hard on your body; switch to walking now.”
- A woman at 23 weeks of gestation calls to tell the nurse she thinks she is
leaking fluid from her vagina. What information should be included in the nurse’s
response to the patient? - “As long as the baby is still moving around, there is nothing to worry about.”
- “Come to the office right away.”
- “Call me back in 2 hours and tell me if there is any change in the leakage.”
- “We can wait until your next appointment to check you.”
- A woman admitted in labor has an obstetric history that indicates that she has
had four pregnancies and has 3 living children. One was born at 39 weeks of
gestation, another at 34 of weeks of gestation, and another at 35 weeks of
gestation. She had a miscarriage at 16 weeks gestation. What are her gravidity
and parity with the TPAL system? - 1-2-1-3TERM: 1 @ 39 weeks; Preterm: 2 @ 34 & 35 weeks; Abortion: 1 @ 16
weeks; Living: 3. - 1-2-0-3
- 3-0-3-0
- 2-2-0-3
- The nurse teaches a pregnant woman about the presumptive, probable, and
positive signs of pregnancy. Which are positive signs of pregnancy? (Select all
that apply.) - A positive pregnancy test
- Fetal movement palpated by the primary caregiver
- Braxton Hicks contractions
- Nausea and vomiting
- Presence of fetal heart tones
- A patient is scheduled for an ultrasound scan. She is at 22 weeks’ gestation.
The patient asks how they will be able to tell the gestational age of her fetus.
HESI MATERNAL NEWBORN PROCTORED EXAM STUDY GUIDE 2020/2021
- A client in the 28th week gestation comes to the emergency department because she thinks
that she is in labor. To confirm a diagnosis of preterm labor, the nurse would expect physical
examination to reveal:
a. Irregular uterine contractions with no cervical dilatation
b. Painful contractions with no cervical dilatation
c. Regular uterine contractions with cervical dilatation
d. Regular uterine contractions with no cervical dilatation
Ans: C – regular uterine contractions (every 10 minutes or more) along with cervical
dilation before 36 weeks’ gestation or rupture of fluids indicates preterm labor. Uterine
contractions without cervical change don’t indicate preterm labor. - A client in the active phase of labor has reactive fetal monitor strip and has been
encouraged to walk. When she returns to bed for a monitor check, she complains of an urge
to push. When performing vaginal examination, the nurse accidentally ruptures the amniotic
membranes, the umbilical cord comes out. What should be done next?
a. Put the client in a knee-chest position
b. Call the physician or midwife
c. Push down on the uterine fundus
d. Set up for a fetal blood sampling to assess for fetal acidosis
Ans: A – the knee–to–chest position gets the weight off the baby and umbilical cord, which
would prevent blood flow. Calling d physician or midwife and setting up for blood sampling is
important, but they have a lower priority than getting d baby off the cord. Pushing down on d
fundus would increase d danger by further compromising blood flow. - A client is attempting to deliver vaginally despite the fact that her previous delivery was by
cesarean section. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100 seconds.
Suddenly, the client complaints of intense abdominal pain and the fetal monitor stops picking
up contractions. The nurse recognizes that which of the following has occurred?
a. Abruptio placentae
b. Prolapsed cord
c. Partial placenta previa
d. Complete uterine rupture
Ans: D – in complete uterine rupture, the client would feel a sharp pain in the lower abdomen
and contractions would cease. Fetal heart rate would also cease within a few minutes. Uterine
irritability would continue to be indicated by the fetal heart monitor tracing with abruption
placentae. With a prolapsed cord, contractions would continue and there would be no pain
from d prolapse itself. There would be vaginal bleeding with a partial placenta previa, but no
pain outside of the expected pain of contractions. - A client with gravida 3 para 2 at 40 weeks gestation is admitted with spontaneous
contractions. The physician performs an amniotomy to augment her labor. The priority
nursing action is to:
a. Explain the rationale for the amniotomy to the client
b. Assess fetal heart tones after the amniotomy
c. Ambulate the client to strengthen the contraction pattern
d. Position the client in a lithotomy position to administer perineal care
Ans: B – the nurse should assess fetal heart tones. After an amniotomy is performed, the
umbilical cord may be washed down below the presenting part and cause umbilical cord
compression, which would be indicated by variable deceleration on the fetal heart tracing. An
explanation of the rationale for amniotomy would be given before d procedure. After assessing
the fetal response to the amniotomy, perineal care s provided. The nurse would ambulate
client only if the presenting part were engaged.
- The nurse can consider the fetus’s head to be engaged when:
a. The presenting part moves through the pelvis
b. The fetal head rotates to pass through the ischial spines
c. The fetal head extends as it passes under the symphysis pubis
d. The biparietal diameter passes the pelvic inlet
Ans: D – d fetus’s head s considered engaged when the biparietal diameter passes d pelvic inlet.
The presenting part moving through d pelvis s called descent. The head flexing so that the chin
moves closer to d chest s called flexion. Rotation of the head to pass through the ischial spines
is called internal rotation. Extension of the head as it passes under d symphysis pubis s called
extension. - A client is experiencing true labor when her contraction pattern shows:
a. Occasional irregular contractions
b. Irregular contractions that increase in intensity
c. Regular contractions that remain the same
d. Regular contractions that increase in frequency and duration
Ans: D- regular contractions that increase in frequency and duration as well as intensity indicate
true labor. The other choices don’t describe d contraction pattern of true labor. - A client is admitted to the hospital with contractions that are about 1 to 2 minutes apart
and reveal that her cervix is dilated 8 cm. The client is in which stage of labor?
a. Latent phase
b. Active phase
c. Third stage
d. Transitional phase
Ans: D- d client is in d transitional phase of labor. This phase of labor is characterized by cervical
dilation of 8 to 10 cm and contractions that are about 1 to 2 minutes apart and last for 60 to 90
seconds with strong intensity. In the latent phase, the cervix is dilated 0 to 3 cm and
contractions are irregular. During the active phase, the cervix is dilated to 4 to 7 cm and
contractions are about 5 to 8 minutes apart and last 45 to 60 seconds with moderate to strong
intensity. The 3rd stage of labor extends from delivery of the neonate to expulsion of the
placenta and lasts from 5 to 30 minutes. - A client in the second stage of labor experiences rupture of membranes. The most
appropriate intervention by the nurse is to:
a. Assess the client’s vital signs immediately
b. Observe for prolapsed cord and monitor fetal heart rate
c. Administer oxygen through a face mask at 6-10 L per min
d. Position the client on her side
Ans: B – the nurse should immediately check for prolapsed cord and monitor FHR. When the
membranes rupture, the cord may become compressed between the fetus and maternal cervix
or pelvis, thus compromising fetoplacental perfusion. It isn’t necessary to position the client on
her left side, monitor maternal vital signs, or administer oxygen when the client’s membrane
rupture.
- A client in labor is being monitored by an internal electronic device to evaluate fetal
station. The nurse measures the duration of her contractions by:
a. Measuring from the beginning of the increment to the end of the decrement
b. Measuring from the beginning of one contraction to the beginning of the next
c. Measuring from the beginning of the decrement to the end of the increment
d. Using an intrauterine catheter that measures increases in contraction
Ans: A- the duration of a contraction is measured from the beginning of the increment to the
end of the decrement. Measuring from the beginning of one contraction to the beginning of the
next reveals frequency. Measuring from the beginning of one contraction to the beginning of
the next reveals frequency. Measuring during the acme phase of a contraction reveals intensity
(measured with an intrauterine catheter or by palpation). - A client is receiving magnesium sulfate to help suppress preterm labor. The nurse
should watch for which sign of magnesium toxicity?
a. Headache
b. Loss of deep tendon reflexes
c. Palpitations
d. Dyspepsia
Ans: B – magnesium toxicity causes signs of central nervous system depression, such as loss of
deep tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision,
slurred speech, and confusion. Headache may be an adverse effect of calcium channel blockers,
which are sometimes used to treat preterm labor. Palpitations are an adverse effect of
terbutaline and ritodrine, which are also used to treat preterm labor. Dyspepsin may occur as
an adverse effect of indomethacin, a prostaglandin synthesize inhibitor, used to suppress
preterm labor. - When assessing a postpartum client for uterine bleeding, the nurse finds the fundus to be
boggy. After fundal massage, the physician prescribes 0.2 mg of methylergonovine
(Methergine) by mouth. What should the nurse tell the client?
a. “Methergine is commonly used to help the uterus contract so that the bleeding will
decrease. You may experience more cramping as your uterus becomes firmer.”
b. “You will probably take this medication until you are discharged from the hospital.
Every patient usually needs to take this medication.”
c. “If your blood pressure is low, you won’t be able to take this medication; I will establish a
new IV line so I can start Pitocin again.”
d. “Most people don’t experience additional pain or cramping from taking this medication.”
Ans: A – Methylergonovine, an ergot alkaloid, is commonly given to stimulate sustained
uterine contraction. It allows the uterus to remain contracted and firm, thus decreasing
postpartum bleeding. Abdominal cramping, which may become painful, is a common adverse
effect.
Methergine is discontinued when the lochia flow has decreased or the client complains of severe
cramping. Clients may need only a few doses of Methergine to keep the uterus contracted.
Taking Methergine is contraindicated in clients with hypertension.
- The nurse is providing care for a postpartum client. Which of the following conditions
would place this client at greater risk for postpartum hemorrhage?
a. Hypertension
b. Uterine infection
c. Placenta previa
d. Severe pain
Ans: C – d client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta
previa, the lower uterine segment doesn’t contract as well as the fundal part of the uterus;
therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don’t place
the client at increased risk for postpartum hemorrhage. - A client has delivered twins. What is the most important intervention for the nurse
to perform?
a. Assess fundal tone and lochia flow
b. Apply a cold pack to the perineal area
c. Administer analgesics as ordered
d. Encourage voiding by offering the bedpan
Ans: A – women who experience a twin delivery are at a higher risk for postpartum
hemorrhage due to overdistention of d uterus, which causes uterine atony. Assessing fundal
tone and lochia flow helps to determine risks for hemorrhage. Applying cold packs to d
perineum, administering analgesics as ordered, and offering d bedpan r all significant nursing
interventions, however, detecting and preventing postpartum hemorrhage s most important. - Which of the following is a normal physiological response in the early postpartum period?
a. Urinary urgency and dysuria
b. Rapid diuresis
c. Decrease in blood pressure
d. Increased motility of the GI system
Ans: B – in d early postpartum period there s an increase in the glomerular filtration rate and a
lOMoARcPSD|3920845
HESI MATERNAL NEWBORN PROCTORED RETAKE GUIDE
The nurse observes a new mother avoiding eye contact with her newborn. Which action should
the nurse take?
Observe the mother for other attachment behaviors.
The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is
recommended for which purpose?
Screen for neural tube defects.
What action should the nurse implement to decrease the client’s risk for hemorrhage after a
cesarean section?
Check the firmness of the uterus every 15 minutes
The nurse attempts to help an unmarried teenager deal with her feelings following a spontaneous
abortion at 8-weeks’ gestation. What type of emotional response should the nurse anticipate?
Grief related to her perceptions about the loss of this child.
The nurse is assessing a 3-day old infant with a cephalohematoma in the newborn nursery.
Which assessment finding should the nurse report to the healthcare provider?
Yellowish tinge to the skin.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple to
attend these classes?
At 30-weeks gestation is closest to the time parents would be ready for such classes. Learning is
facilitated by an interested pupil! The couple is most interested in childbirth toward the end of
the pregnancy when they are psychologically ready for the termination of the pregnancy, and the
birth of their child is an immediate concern.
A client at 32-weeks gestation is diagnosed with preeclampsia. Which assessment finding is
most indicative of an impending convulsion?
Epigastric pain (C) is indicative of an edematous liver or pancreas which is an early warning sign
of an impending convulsion (eclampsia) and requires immediate attention.
A client is admitted with the diagnosis of total placenta previa. Which finding is most important
for the nurse to report to the healthcare provider immediately?
Onset of uterine contractions.
A client who is in the second trimester of pregnancy tells the nurse that she wants to use herbal
therapy. Which response is best for the nurse to provide?
It is important that you want to take part in your care.
A couple, concerned because the woman has not been able to conceive, is referred to a healthcare
provider for a fertility workup and a hysterosalpingography is scheduled. Which postprocedure
complaint indicates that the fallopian tubes are patent?
lOMoARcPSD|3920845
If the tubes are patent (open), pain is referred to the shoulder (C) from a subdiaphragmatic
collection of peritoneal dye/gas.
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her
buttock. The nurse notes that both perineal pads are completely saturated and the client is lying
in a 6-inch diameter pool of blood. Which action should the nurse implement next?
Palpate the firmness of the fundus.
One hour after giving birth to an 8-pound infant, a client’s lochia rubra has increased from small
to large and her fundus is boggy despite massage. The client’s pulse is 84 beats/minute and blood
pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action
should the nurse take immediately?
Methergine is contraindicated for clients with elevated blood pressure, so the nurse should
contact the healthcare provider and question the prescription (D).
A client at 32-weeks gestation comes to the prenatal clinic with complaints of pedal edema,
dyspnea, fatigue, and a moist cough. Which question is most important for the nurse to ask this
client?
Do you have a history of rheumatic fever? Clients with a history of rheumatic fever (D) may
develop mitral valve prolapse, which increases the risk for cardiac decompensation due to the
increased blood volume that occurs during pregnancy, so obtaining information about this
client’s health history is a priority.
A primigravida at 40-weeks gestation is receiving oxytocin (Pitocin) to augment labor. Which
adverse effect should the nurse monitor for during the infusion of Pitocin?
Pitocin causes the uterine myofibril to contract, so unless the infusion is closely monitored, the
client is at risk for hyperstimulation (B) which can lead to tetanic contractions, uterine rupture,
and fetal distress or demise.
A 35-year-old primigravida client with severe preeclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity?
Urine output 90 ml/4 hours. Urine outputs of less than 100 ml/4 hours (D), absent DTRs, and a
respiratory rate of less than 12 breaths/minute are cardinal signs of magnesium sulfate toxicity.
The nurse is planning preconception care for a new female client. Which information should the
nurse provide the client?
Encourage healthy lifestyles for families desiring pregnancy. Planning for pregnancy begins with
healthy lifestyles in the family (D) which is an intervention in preconception care that targets an
overall goal for a client preparing for pregnancy.
A multigravida client at 41-weeks gestation presents in the labor and delivery unit after a nonstress test indicated that the fetus is experiencing some difficulties in utero. Which diagnostic test
should the nurse prepare the client for additional information about fetal status?
lOMoARcPSD|3920845
Biophysical profile (BPP). BPP (A) provides data regarding fetal risk surveillance by examining
5 areas: fetal breathing movements, fetal movements, amniotic fluid volume, and fetal tone and
heart rate.
A client with no prenatal care arrives at the labor unit screaming, “The baby is coming!” The
nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75%
effaced. What additional information is most important for the nurse to obtain?
Date of last normal menstrual period. Evaluating the gestation of the pregnancy (C) takes
priority. If the fetus is preterm and the fetal heart pattern is reassuring, the healthcare provider
may attempt to prolong the pregnancy and administer corticosteroids to mature the lungs of the
fetus.
A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a
small amount of vaginal bleeding which she describes as bright red. She further states that she is
not experiencing any uterine contractions or abdominal pain. What instruction should the nurse
provide?
Come to the clinic today for an ultrasound. Third trimester painless bleeding is characteristic of a
placenta previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous.
Rarely is the first incidence life-threatening, nor cause for hypovolemic shock. Diagnosis is
confirmed by transabdominal ultrasound (A).
A new mother is afraid to touch her baby’s head for fear of hurting the “large soft spot.” Which
explanation should the nurse give to this anxious client?
There’s a strong, tough membrane there to protect the baby so you need not be afraid to wash or
comb his/her hair.
During labor, the nurse determines that a full-term client is demonstrating late decelerations. In
which sequence should the nurse implement these nursing actions? (Arrange in order.)
Reposition the client.
Provide oxygen via face mask.
Increase IV fluid.
Call the healthcare provider.
An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her
husband is screaming for someone to help his wife. Which intervention has the highest priority?
Put the newborn to breast. Putting the newborn to breast (D) will help contract the uterus and
prevent a postpartum hemorrhage–this intervention has the highest priority.
A 40-week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary
infusion and complains of pain in her lower back. Which intervention should the nurse
implement?
Apply firm pressure to sacral area. The discomfort of back labor can be minimized by the
application of firm pressure to the sacral area
A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of
water has broken. The nurse identifies the presence of meconium fluid on the perineum and
determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse
implement next?
Complete a sterile vaginal exam. A vaginal exam (A) should be performed after the rupture of
membranes to determine the presence of a prolapsed cord.
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The
nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is
144 bpm, and no FHR accelerations are occurring. What action should the nurse take?
Ask the client if she has felt any fetal movement.
Just after delivery, a new mother tells the nurse, “I was unsuccessful breastfeeding my first child,
but I would like to try with this baby.” Which intervention is best for the nurse to implement
first?
Provide assistance to the mother to begin breastfeeding as soon as possible after delivery.
A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming
to the unit with suspected abruptio placentae. What findings should the charge nurse expect the
client to demonstrate? (Select all that apply.)
Dark, red vaginal bleeding.
Increased uterine
irritability. A rigid abdomen.
The nurse is teaching care of the newborn to a group of prospective parents and describes the
need for administering antibiotic ointment into the eyes of the newborn. Which infectious
organism will this treatment prevent from harming the infant?
Gonorrhea. Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2
hours after birth to prevent ophthalmica neonatorum, an infection caused by gonorrhea, and
inclusion conjunctivitis, an infection caused by chlamydia (C).
In evaluating the respiratory effort of a one-hour-old infant using the Silverman-Anderson Index,
the nurse determines the infant has synchronized chest and abdominal movement, just visible
lower chest retractions, just visible xiphoid retractions, minimal and transient nasal flaring, and
an expiratory grunt heard only on auscultation. What Silverman-Anderson score should the nurse
assign to this infant? (Enter numeral value only.)
A Silverman-Anderson Index has five categories with scores of 0, 1, or 2. The total score ranges
from 0 to 10. Four of the these assessment findings should receive a score of 1, and the 5th
finding (synchronized chest and abdominal movement) receives a score of 0. Therefore, the total
score is 4. A total score of 0 means the infant has no dyspnea, a total score of 10 indicates
maximum respiratory distress.
OB-Maternal Newborn Exit HESI
Client with gestational diabetes; 39 wks gestation; second stage of labor After delivery of fetal head nurse
recognizes shoulder dystocia is occurring.
Assist the client to sharply flex her thighs up against the abdomen
During initial newborn assess, nurse finds HR irregular.
Document finding in infant record
Within 4 wks of birth client is admitted for disorganized speech, bizarre behavior and strange thoughts
about infant being possessed by demons. “altered thought process, secondary to”
Postpartum psychosis
Infant is treated for intussusceptions with hydrostatic reduction. What instructions in parents teaching
plan
Signs and symptoms of recurrence
Nurse teaching primagravida, describes herself as lacto-vegetarian, about nutrition during pregnancy.
Which foods
Cheese, green salad, fruit
Four clients present to L & D unit at the same time. Nurse should assess what complaint first?
Abdominal pain and bright red bleeding
Labor 12 hours suddenly has strong urge to have a BM. Action
Perform a sterile vaginal exam
Client went into labor at 3:15 am. When did the first stage of labor end
full dilation and effacement at 11:45 am
Pregnant with magnesium level 5.0
watch BP
Magnesium antidote
Calcium gluconate
Newborn baby with flea-like rash
normal and will disappear
How to tell if patient is in labor
Fern test
Baby acting jittery
check glucose level
Which will NOT increase breast milk supply
supplemental formula feedings
4 patients with conditions of concern-priority
Make sure patient has units of blood available
When should someone be concerned about decels
To prevent neural tube disorders
Folic acid during PG
Indicators of IICP in infants
Bulging fontanels, high pitched cry, increased head circumference, wide suture lines, lethargy
Avoid in patients with IICP
Suctioning, coughing, straining and bending
Ovulation occurs on day 14 of menses
Menses cycle is 28 days total
Bluish coloration of the vagina
Chadwick’s sign
Hegar’s sign
Softening of isthmus of cervix at 8 weeks of pregnancy
Total weight gain during pregnancy should be
25-30 lbs (11-14kg)
During pregnancy how many calories should the mother intake
Increase of 300/day from pre-pregnancy amount
TORCH
Toxoplasmosis
Having <300 ml of amniotic fluid and leading to fetal kidney problems
Oligohydramnios
The umbilical cord is composed of
2 arteries and 1 vein
Preterm is considered
20-37 weeks gestation
Term is considered
38-42 weeks gestation
Post-term is considered
Any time after 42 weeks
Know Nagal’s rule-you will be given a woman’s last period and you will have to figure her date of
conception (add 7 days to first day of last period, subtract 3 months, add 12 months)
Hyperhydration during pregnancy can lead to
Lower Hgb and Hct