lOMoAR cPSD|19500986
lOMoAR cPSD|19500986
MATERNITY HESI EXIT 2023 VERSION D/HESI
EXIT MATERNITY HESI EXIT LATEST EXAM
QUESTIONS AND DETAILED ANSWERS WITH
RATIONALES|AGRADE
VERSION D
- A 38-week primigravida who works as a secretary and sits at a computer for 8 hours
each day tells the nurse that her feet have begun to swell. Which instruction would be
most effective in preventing pooling of blood in the lower extremities?
Move about every hour
Pooling of blood in the lower extremities results from the enlarged uterus exerting
pressure on the pelvic veins. Moving about every hour willstraighten out the pelvic
veins and increase venous return. - A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation
in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg
subcutaneously to stop her labor contractions. The nurse plans to monitor for which
primary side effect of terbutaline sulfate?
Tachycardia and a feeling of nervousness
Terbutaline sulfate (Brethine), a beta-sympathomimetic drug,stimulates beta-adrenergic
receptors in the uterine muscle to stop contractions. The beta-adrenergic agonist
properties of the drug may cause tachycardia, increased cardiac output, restlessness,
lOMoAR cPSD|19500986
headache, and a feeling of “nervousness”.
- When do the anterior and posterior fontanels close?
anterior fontanel closes at 12 to 18 months and the posterior by the end of the second
month. - 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?
30 weeks gestation
at 30 weeks gestation is closest (of the options) 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. - The nurse should encourage the laboring client to begin pushing when…
the cervix is completely dilated.
Pushing begins with the second stage of labor, i.e., when the cervix is completely
dilated at 10 cm (C). If pushing begins before the cervix is completely dilated the cervix
can become edematous and may never completely dilate, necessitating an operative
delivery. Many primigravida’s begin active labor 100% effaced and then proceed to
dilate.
lOMoAR cPSD|19500986
- The nurse instructs a laboring client to use accelerated-blow breathing. The client
beginsto complain of tingling fingers and dizziness. What action should the nurse take?
Have the client breathe into her cupped hands
Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon
dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated
by breathing into a paper bag or cupped hands. - Twenty-four hours after admission to the newborn nursery, a full-term male infant
develops localized edema on the right side of his head. The nurse knows that, in the
newborn, an accumulation of blood between the periosteum and skull which does not
cross the suture line is a newborn variation known as…
a cephalohematoma, caused by forceps trauma and may last up to 8 weeks.
Cephalohematoma, a slight abnormal variation of the newborn, usually arises within the
first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the
periosteum and the skull. - When does the head return to its normal shape?
7-10 days - What did Nurse theorist Reva Rubin describe?
The initial postpartum period as the “taking-in phase,” which is characterized by
maternal reliance on others to satisfy the needs for comfort, rest, nourishment, and
lOMoAR cPSD|19500986
closeness to families and the newborn.
- 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 post procedure complaint indicates that the fallopian tubes are patent?
Shoulder pain
If the tubes are patent (open), pain is referred to the shoulder from a sub diaphragmatic
collection of peritoneal dye/gas. - Which nursing intervention is most helpful in relieving postpartum uterine contractions or
“afterpains?”
Lying prone with a pillow on the abdomen
Lying prone keeps the fundus contracted and is especially useful with multiparas, who
commonly experience afterpains due to lack of uterine tone. - Which maternal behavior is the nurse most likely to see when a new mother receives
her infant for the first time?
Her arms and handsreceive the infant and she then traces the infant’s profile with her
fingertips.
Attachment/bonding theory indicatesthat most mothers will demonstrate behaviors
described in during the first visit with the newborn, which may be at delivery or later. - A client at 32-weeks gestation is hospitalized with severe pregnancy-induced
lOMoAR cPSD|19500986
MATERNITY HESI EXIT EXAM 2023 VERSION C/HESI
EXIT MATERNITY VERSION C REAL EXAM QUESTIONS
AND CORRECT ANSWERS|AGRADE
VERSION C
1 The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse
observes red marks on the head with swelling that does not cross the suture line. Which condition
should the nurse documents in the medical record?
A Caput succedaneum
B Hydrocephalus
C Cephalhematoma
D Microcephaly
2 A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that
began one hour ago. The nurse assessment reveals approximately 30ML of bright red vaginal bleeding.
lOMoAR cPSD|19500986
Fetal rate of 130 – 140 beats per minute, no contractions and no complaints of pain what is the most
likely cause of these client’s bleeding.
A Abruptio Placenta
B Placenta Previa
C Normal bloody show indicting induction of labor
D A ruptured blood vessel in the vaginal vault.
3 A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours.
Concerned she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital.
which assessment warrants immediate intervention by the nurse.
A Fetal Heart rate 60 beats per minute
B Ruptured amniotic membrane
C onset of uterine contractions
lOMoAR cPSD|19500986
D leaking amniotic fluid.
4 A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes
the nurse observes several shallow small vesicles on her pubis labia and perineum. the nurse should
recognize the clients is prohibiting symptoms of which condition?
A Genital Warts
B Syphilis
C Herpes Simplex Virus
D German Measles
5 The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm
labor which maternity description is most important in preventing this fetus from developing respiratory
distress syndrome.
A Ampicillin 1 gram IV push q8h
B Betamethasone 12 mg deep IM
lOMoAR cPSD|19500986
MATERNITY HESI EXIT 2023 VERSION B/HESI
EXIT MATERNITY HESI EXIT LATEST EXAM
QUESTIONS AND DETAILED ANSWERS WITH
RATIONALES|AGRADE
VERSION B
1.
A full-term infant is admitted to the newborn nursery and, after careful
assessment, the nurse suspects that the infant may have an esophageal atresia.
Which symptoms is this newborn likely to have exhibited?
A) Choking, coughing, and cyanosis.
Feedback: CORRECT
B) Projectile vomiting and cyanosis.
Feedback: INCORRECT
C) Apneic spells and grunting.
Feedback: INCORRECT
D) Scaphoid abdomen and anorexia.
Feedback: INCORRECT
Feedback: INCORRECT
(A) includes the “3 Cs” of esophageal atresia caused by the overflow of secretions into
the trachea. (B) is characteristic of pyloric stenosis in the infant. (C) could be due to
prematurity or sepsis, and grunting is a sign of respiratory distress. (D) is characteristic
of diaphragmatic hernia.
Correct Answer(s): A
2.
A female client with insulin-dependent diabetes arrives at the clinic seeking a plan
to get pregnant in approximately 6 months. She tells the nurse that she want to
have an uncomplicated pregnancy and a healthy baby. What information should
lOMoAR cPSD|19500986
the nurse share with the client?
A) Your current dose of Insulin should be maintained throughout your pregnancy.
B) Maintain blood sugar levels in a constant range within normal limits
during pregnancy.
lOMoAR cPSD|19500986
C) The course and outcome of your pregnancy is not an achievable goal with diabetes.
D) Expect an increase in insulin dosages by 5 units/week during the first trimester.
Feedback: INCORRECT
Maintaining blood sugar within a normal range during pregnancy has a strong
correlation with a good outcome (B). Insulin requirements normally change during
pregnancy (A).
Active participation of the client with her diabetes management during pregnancy is
associated with better outcomes, not (C). Insulin needs are individually determined by
blood glucose values, not a set schedule, not (D).
Correct Answer(s): B
3.
The nurse observes a new mother avoiding eye contact with her newborn. Which
action should the nurse take?
A) Ask the mother why she won’t look at the infant.
Feedback: INCORRECT
B) Observe the mother for other attachment behaviors.
Feedback: CORRECT
C) Examine the newborn’s eyes for the ability to focus.
Feedback: INCORRECT
D) Recognize this as a common reaction in new mothers.
Feedback: INCORRECT
Feedback: INCORRECT
Parent-infant bonding or attachment is based on a mutual relationship between parent
and infant and is commonly established by the “enface position,” which is
demonstrated by the mother’s and infant’s eyes meeting in the same plane. To assess
for other attachment behaviors, continued observation of the new mother’s
interactions with her infant (B) helps the nurse determine problems in attachment.
(A) may cause undue confusion, stress, or impact the mother’s self-confidence. (C)
is not indicated. The “enface position” is a significant, early behavior that leads to the
formation of affectional ties and should be encouraged (D).
lOMoAR cPSD|19500986
Correct Answer(s): B
4.
A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse’s response is based on what
knowledge?
A) Supplementary iron is more efficiently utilized during pregnancy.
Feedback: INCORRECT
B) It is difficult to consume 18 mg of additional iron by diet alone.
Feedback: CORRECT
C) Iron absorption is decreased in the GI tract during pregnancy.
Feedback: INCORRECT
D) Iron is needed to prevent megaloblastic anemia in the last trimester.
Feedback: INCORRECT
Feedback: INCORRECT
Consuming enough iron-containing foods to facilitate adequate fetal storage of iron
and to meet the demands of pregnancy is difficult (B) so iron supplements are often
recommended. Dietary iron (A) is just as “good” as iron in tablet form. Iron
absorption occurs readily during pregnancy, and is not decreased within the GI tract
(C).
Megaloblastic anemia (D) is caused by folic acid deficiency.
Correct Answer(s): B
5.
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?
lOMoAR cPSD|19500986
LOMOARCPSD|195
MATERNITY HESI EXIT EXAM 2023 VERSION
A/HESI EXIT MATERNITY VERSION A REAL
EXAM QUESTIONS AND CORRECT
ANSWERS|AGRADE
VERSION A
1.The nurse is planning discharge teaching for a client who had an evacuation of
gestational trophoblastic disease (GTD) two days ago. Which information is most
important for the nurse to include in this client’s teaching plan?
A.Oral contraceptive use for at least one year.
2.The nurse is planning care for a client at 30-weeks’ gestation who is experiencing preterm
labor. What maternal prescription is most important in preventing this fetus from developing
respiratory distress syndrome?
C. Betamethasone (Celestone) 12 mg deep IM.
3.The nurse places one hand above the symphysis while massaging the fundus of a multiparous
client whose uterine tone is boggy 15 minutes after delivering a 7-pound 10-ounce infant.
Which information should the nurse provide the client about this finding?
B. Both the lower uterine segment and the fundus must be massaged.
4.Which instruction should the nurse include in the discharge teaching plan of a 7-year-old girl
with a history of frequent urinary tract infections?
D. Monitor for changes in urinary odor.
- A pregnant woman in the first trimester of pregnancy has a hemoglobin of 8.6 mg/dl and a
hematocrit of 25.1%. What foot should the nurse encourage this client to include in her diet?
B. Chicken. - The newborn nursery admission protocol includes a perception for phytonadione
(Vitamin K1, AquaMEPHYTON) 0.5 mg IM to newborns upon admission. The ampoule
provides 2 mg/ml. How many ml should the nurse administer?
0.3
lOMoAR cPSD|19500986
1 | P a g e
lOMoAR cPSD|19500986
- The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum
client. Based on what assessment finding should the nurse withhold the drug?
C.Blood pressure 149/90. - The nurse is preparing a 10-year-old with a lacerated forehead forsuturing. Both parents and
a 12- year-old sibling are the child bedside. Which instruction best supports this family?
A.“While waiting for the healthcare provider, only one visitor may stay with the child” - The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA).
The nurse includes activities to strengthen and mobilize the joints and surrounding muscle.
Which physical therapy regimen should the nurse encourage the adolescent to implement?
C.Exercise in a swimming pool. - A primigravida arrives at the observation unit of the maternity unit because thinks is in
labor. The nurse applies the external fetal heart monitor and determines that the fetal heart
rate is 140 beats/minute and the contractions are occurring irregularly every 10 to 15
minutes. What assessment finding confirms to the nurse that the client is not labor at this
time?
D.Contractions decrease with walking. - Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is
on strict bedrest?
D. Checkers - The nurse has completed a teaching plan for the mother of a child who is taking digitalis
and a diuretic for treatment of the heart failure. Choosing which lunch would indicate
that the mother understands the best diet for her child?
B. Peanut butter and banana sandwich with orange juice. - A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of
thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). What is the best
explanation for this finding?
2 | P a g e