HESI MATERNITY EXAM WITH COMPLETE SOLUTIONS

HESI MATERNITY EXAM WITH COMPLETE SOLUTIONS
Maternity HESI
• The LPN/LVN identifies crepitus when examining the chest of a newborn who
was delivered vaginally. Which further assessment should the nurse perform?
A. Elicit a positive scarf sign on the affected side.
B. Observe for an asymmetrical Moro (startle) reflex.
C. Watch forswelling of fingers on the affected side.
D. Note paralysis of affected extremity and muscles.
Correct Answer: B
• 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 Å~ 1. What action should the LPN/LVNtake immediately?
A. Give the medication as prescribed and monitor for efficacy.
B. Encourage the client to breastfeed rather than bottle feed.
C. Have the client empty her bladder and massage the fundus.
D. Call the healthcare provider to question the prescription.
Correct Answer: D
• The LPN/LVN is preparing to give an enema to a laboring client. Which client
requires the most caution when carrying out this procedure?
A. A gravida 6, para 5 who is 38 years of age and in early labor.
B. A 37-week primigravida who presents at 100% effacement, 3 cm
cervicaldilatation, and a -1 station.
C. A gravida 2, para 1 who is at 1 cm cervical dilatation and a 0 station
admitted for induction of labor due to post dates.
D. A 40-week primigravida who is at 6 cm cervical dilatation and the
presenting part is not engaged.
Correct Answer: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 LPN/LVN to ask this client?
A. Which symptom did you experience first?
B. Are you eating large amounts of salty foods?
C. Have you visited a foreign country recently?
D. Do you have a history of rheumatic fever?
Correct Answer: D
• The LPN/LVN 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 FHRaccelerations are occurring.
What action should the nurse take?
A. Check the client for urinary bladder distention.
B. Notify the healthcare provider of the nonreactive results.
C. Have the mother stimulate the fetus to move.
D. Ask the client if she has felt any fetal movement.
Correct Answer: D
• A client in active labor is admitted with preeclampsia. Which
assessmentfinding is most significant in planning this client's care?
A. Patellar reflex 4+
B. Blood pressure 158/80.
C. Four-hour urine output 240 ml.
D. Respiration 12/minute.
Correct Answer: A
• At 14-weeks gestation, a client arrives at the Emergency Center
complaining of a dull pain in the right lower quadrant of her abdomen.
The LPN/LVN obtains a blood sample and initiates an IV. Thirty minutes
after admission, the client reports feeling a sharp abdominal pain and a
shoulder pain. Assessment findings include diaphoresis, a heart rate of
120 beats/minute, and a blood pressure of 86/48. Which action should
the nurse implement next?
A. Check the hematocrit results.
B. Administer pain medication.
C. Increase the rate of IV fluids.
D. Monitor client for contractions.
Correct Answer: C
• During a prenatal visit, the LPN/LVN discusses with a client the effects of
smoking on the fetus. When compared with nonsmokers, mothers who
smoke during pregnancy tend to produce infants who have
A. lower Apgar scores.
B. lower birth weights.
C. respiratory distress.
D. a higher rate of congenital anomalies.
Correct Answer: D
• Which action should the LPN/LVN implement when preparing to measure
thefundal
height of a pregnant client?
A. Have the client empty her bladder.
B. Request the client lie on her left side.
C. Perform Leopold's maneuvers first.
D. Give the client some cold juice to drink.
Correct Answer:A
• The LPN/LVN assesses a client admitted to the labor and delivery unit and
obtains the following data: dark red vaginal bleeding, uterus slightly tense
between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated
and uneffaced. Based on these assessment findings, what intervention
should the nurse implement?
A. Insert an internal fetal monitor.
B. Assess for cervical changes q1h.
C. Monitor bleeding from IV sites.
D. Perform Leopold's maneuvers.
Correct Answer: C
• A client at 32-weeks gestation is diagnosed with preeclampsia.
Whichassessment finding is most indicative of an impending
convulsion?
A. 3+ deep tendon reflexes and hyperclonus.
B. Periorbital edema, flashing lights, and aura.
C. Epigastric pain in the third trimester.
D. Recent decreased urinary output.
Correct Answer: A