Nursing Care for Maternal and Newborn Health, Exams of Nursing

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A home care nurse is instructing a client with hyperemesis gravidarum about measures to ease the nausea and vomiting. The nurse tells the client to: A Eat foods high in calories and fat B Lie down for at least 20 minutes after meals C Eat carbohydrates such as cereals, rice, and pasta Correct D Consume primarily soups and liquids at mealtimes Incorrect
Rationale: Low-fat foods and easily digested carbohydrates such as fruit, breads, cereals, rice, and pasta provide important nutrients and help prevent a low blood glucose level, which can cause nausea. Soups and other liquids should be taken between meals to avoid distending the stomach and triggering nausea. Sitting upright after meals reduces gastric reflux. Additionally, food portions should be small and foods with strong odors should be eliminated from the diet, because food smells often incite nausea.
Test-Taking Strategy: Use the process of elimination and focus on the client’s diagnosis and the subject, ways to ease and prevent nausea and vomiting. Knowing that foods high in fat may be difficult to digest will assist you in eliminating this option. Next eliminate the option that involves consuming primarily soups and fluids at meals, recalling that liquids will cause distention of the stomach. To select from the remaining options, recall that lying down after meals can cause gastric reflux; this will direct you to the correct option. Review measures to ease and prevent nausea and vomiting if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Fluid and Electrolytes, Nutrition
HESI Concepts: Fluids and Electrolytes, Nutrition
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 589-590). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points.
2.ID: 9476908110A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate infusion to prevent eclampsia. Which finding indicates to the nurse that the medication is effective?

A Clonus is present. B Magnesium level is 10 mg/dL (4.11 mmol/L) C Deep tendon reflexes are absent. D The client experiences diuresis within 24 to 48 hours. Correct
Rationale: Magnesium sulfate is effective in preventing seizures (eclampsia) if diuresis occurs within 24 to 48 hours of the start of the infusion. As part of the therapeutic response, renal perfusion is increased and the client is free of visual disturbances, headache, epigastric pain, clonus (the rapid rhythmic jerking motion of the foot that occurs when the client’s lower leg is supported and the foot is sharply dorsiflexed), and seizure activity. Hyperreflexia indicates cerebral irritability. Clonus is normally not present. The therapeutic magnesium level is 4 to 8 mg/dL (1.64 to 3.29 mmol/L). Reflexes range from 1+ to 2+ but should not be absent.
Test-Taking Strategy: Use the process of elimination and focus on the strategic words “medication is effective.” Recalling the actions of this medication and expected assessment findings after a client receives magnesium sulfate will direct you to this option. Review the expected assessment findings for a client receiving magnesium sulfate if you had difficulty with this question.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology
Giddens Concepts: Evidence , Perfusion
HESI Concepts: Evidence-Based Practice/Evidence , Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 594-595). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
3.ID: 9476908130A client with preeclampsia who is receiving magnesium sulfate in an intravenous infusion exhibits signs of magnesium toxicity. The nurse immediately prepares for the administration of: A Vitamin K B Protamine sulfate C Calcium gluconate Correct

D Naloxone hydrochloride
Rationale: Calcium gluconate is the antidote to magnesium sulfate because it antagonizes the effects of magnesium at the neuromuscular junction. It should be readily available whenever magnesium is administered. Vitamin K is the antidote in cases of hemorrhage induced by the administration of oral anticoagulants such as warfarin sodium (Coumadin). Protamine sulfate is the antidote in cases of hemorrhage induced by the administration of heparin. Naloxone hydrochloride is administered to treat opioid- induced respiratory depression.
Test-Taking Strategy: Focus on the subject of the question, the treatment for magnesium toxicity. Specific knowledge regarding antidotes and the process of elimination will assist in directing you to the correct option. Review common antidotes if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Pharmacology
Giddens Concepts: Clinical Judgment, Safety
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Safety


Reference: Gahart, B., & Nazareno, A. (2015). 2015 Intravenous medications (31st ed., p. 773). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
4.ID: 9476908194A nurse instructs a pregnant client about foods that are high in folic acid. Which item does the nurse tell the client is the best source of folic acid? A Milk B Steak C Chicken D Lima beans Correct
Rationale: The best sources of folic acid are liver; kidney, pinto, lima, and black beans; and fresh dark-green leafy vegetables. Other good sources of folic acid are orange juice, peanuts, refried beans, and peas. Milk is high in calcium. Chicken and steak are high in protein.

Test-Taking Strategy: Use the process of elimination and focus on the subject, the best source of folic acid. Eliminate the options that are comparable or alike in that they are high in protein. Next eliminate milk, recalling that milk is high in calcium. Review the foods high in folic acid if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Nutrition
Giddens Concepts: Nutrition, Reproduction
HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 282-283). St. Louis: Elsevier.
Nix, S. (2013). Williams’ basic nutrition and diet therapy (14th ed., pp. 114, 119). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
5.ID: 9476904403A nurse is providing instructions to a mother of an infant with seborrheic dermatitis (cradle cap) about treatment of the condition. The nurse tells the mother to: A Avoid the use of shampoo on the infant’s scalp B Apply oil to the affected area on the infant’s scalp Correct C Wash the infant’s scalp daily, using only tepid water D Shampoo the infant’s scalp, avoiding the anterior fontanel area
Rationale: Seborrheic dermatitis, a chronic inflammation of the scalp or other areas of the skin, is characterized by yellow, scaly, oily lesions. It sometimes results when parents do not wash over the anterior fontanel carefully for fear that they will hurt the infant. Treatment includes the application of oil (e.g., mineral oil) to the area to help soften the lesions followed by gentle removal of the scaly lesions with a comb before the head is shampooed. The nurse should teach the mother how to shampoo the scalp and explain that she will not damage the fontanel with normal gentle shampooing. The scalp should be rinsed well to remove all soap, which could cause irritation.
Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the closed-ended word “only.” To

select from the remaining options, recall that this condition is characterized by the presence of scaly lesions; this will direct you to the correct option. Review the treatment for seborrheic dermatitis (cradle cap) if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Newborn
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity
Reference: Hockenberry, M, & Wilson, D. (2015). Wong’s nursing care of infants and children (10th ed. pp. 467-468). St Louis: Mosby. Awarded 1.0 points out of 1.0 possible points.
6.ID: 9476901633A nurse is monitoring a client who was given an epidural opioid for a cesarean birth. The nurse notes that the client’s oxygen saturation on pulse oximetry is 92%. The nurse first: A Documents the findings B Contacts the health care provider C Administers 100% oxygen by way of face mask D Instructs the client to take several deep breaths Correct
Rationale: If the client has been given an epidural opioid, the nurse should monitor the client’s respiratory status closely. If the oxygen saturation falls below 95%, the nurse instructs the client to take several deep breaths to increase the level. Although the finding would be documented, action is required to increase the oxygen saturation level. It is not necessary to contact the health care provider. If the deep breaths fail to increase the oxygen saturation level, the health care provider is notified and may prescribe oxygen.
Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Noting the oxygen saturation level will assist you in eliminating this option. Noting the strategic word “first” will direct you to the correct option. Review care of the client after a cesarean birth if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Clinical Judgment, Gas Exchange
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Oxygenation/Gas Exchange
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 430-431). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
7.ID: 9476904487A client who delivered a healthy newborn 11 days ago calls the clinic and tells the nurse that she is experiencing a white vaginal discharge. The nurse tells the client: A To perform a vaginal douche B To come to the clinic for a checkup C That this is an indication of an infection D That this is a normal postpartum occurrence Correct
Rationale: For the first 3 days following childbirth, lochia consists almost entirely of blood, with small particles of decidua and mucus, and is called lochia rubra because of its red color. The amount of blood decreases by about the fourth day, and which time the lochia changes from red to pink or brown-tinged; this stage is called lochia serosa. By about the 11th day, the erythrocyte component of lochia has decreased and the discharge becomes white or cream-colored. This final stage is known as lochia alba. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria. It is present in most women until the third week after childbirth but may persist for as long as 6 weeks. Lochia alba is a normal finding during the postpartum course, and no intervention is required, so the other options are incorrect.
Test-Taking Strategy: Use your knowledge of expected postpartum findings to answer the question. Recalling the normal expected occurrences in regard to vaginal discharge will direct you to the correct option. Also, noting that the incorrect options are comparable or alike will direct you to the correct option. Review normal postpartum findings in regard to lochia if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation

Content Area: Maternity/Postpartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 435). St. Louis: Elsevier. Awarded 1.0 points out of 1. possible points.
8.ID: 9476908170A rubella antibody screen is performed in a pregnant client, and the results indicate that the client is not immune to rubella. The nurse tells the client that: A A rubella vaccine must be administered immediately B A rubella vaccine must be administered after childbirth Correct C She will not contract rubella if she is exposed to the disease D She does not need to be concerned about being exposed to rubella
Rationale: A prenatal rubella antibody screen is performed in every pregnant woman to determine whether she is immune to rubella, which can cause serious fetal anomalies. If she is not immune, rubella vaccine is offered after childbirth to keep her from contracting rubella during subsequent pregnancies. The vaccine is a live virus, and defects might occur in the fetus if the vaccine were administered during pregnancy or if the mother were to become pregnant soon after it was administered. Administering a rubella vaccine immediately places the fetus at risk. Telling the client that she does not need to be concerned about being exposed to rubella is incorrect, because the possibility of exposure, which could be harmful to the fetus, does exist.
Test-Taking Strategy: Use the process of elimination. Eliminate first the options that are comparable or alike (i.e., the client will not acquire rubella and does not need to be concerned about exposure). To select from the remaining options, recall that rubella vaccine is a live virus; this will direct you to the correct option. Review rubella vaccine and its implications during pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum

Giddens Concepts: Immunity, Safety
HESI Concepts: Immunity, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 439-440). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
9.ID: 9476908162A nurse is monitoring a client who delivered a healthy newborn 12 hours ago. The nurse takes the client’s temperature and notes that it is 38° C (100.4° F). The most appropriate nursing action would be to: A Contact the health care provider B Recheck the temperature in 1 hour C Encourage the intake of oral fluids Correct D Tell the client that antibiotics will be prescribed
Rationale: A temperature of 38° C (100.4° F) is common during the 24 hours after childbirth. It may be the result of dehydration or normal postpartum leukocytosis. If the increased temperature persists for longer than 24 hours or exceeds 38° C, infection is a possibility, and the fever is reported to the health care provider or nurse midwife. Because the client delivered her baby just 12 hours ago, the most appropriate nursing action is to encourage the intake of oral fluids.
Test-Taking Strategy: Use the process of elimination. Note the strategic words “12 hours ago.” Recalling that a low-grade temperature is a common postpartum assessment finding will direct you to the correct option. Review normal vital sign findings during a postpartum assessment if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Thermoregulation
HESI Concepts: Sexuality/Reproduction, Thermoregulation
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 441). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
10.ID: 9476910071A nurse is assessing the uterine fundus of a client who has just delivered a baby and notes that the fundus is boggy. The nurse massages the fundus, and then presses to expel

clots from the uterus. To prevent uterine inversion during this procedure, the nurse: A Has the client void before the uterine assessment B Tells the woman to bear down during fundal message C Simultaneously provides pressure over the lower uterine segment Correct D Asks the client to take slow, deep breaths during fundal assessment
Rationale: After massaging a boggy fundus until it is firm, the nurse presses the fundus to expel clots from the uterus. The nurse must also keep one hand pressed firmly just above the symphysis (over the lower uterine segment) the entire time. Removing the clots allows the uterus to contract properly. Providing pressure over the lower uterine segment prevents uterine inversion. Having the client void before uterine assessment will not prevent uterine inversion. Telling the woman to bear down while the nurse performs fundal message and asking the client to take slow, deep breaths during fundal assessment also will not prevent uterine inversion.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, prevention of uterine inversion. Visualizing each of the actions in the options and relating the action to the subject of the question will direct you to the correct option. Review fundal assessment and massage if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Safety
HESI Concepts: Sexuality/Reproduction, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 442, 668). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
11.ID: 9476918821A nurse is monitoring a client after vaginal delivery notes a constant trickle of bright-red blood from the client’s vagina. In which order would the nurse perform the following actions? Assign the number 1 to the first action and the number 5 to the last. Correct A Assessing the client’s fundus

B Checking the client’s vital signs C Contacting the health care provider D Changing the client’s peripads E Documenting the findings
Rationale: A constant trickle of bright-red blood may indicate abnormal bleeding and requires immediate attention. The nurse first checks the client’s fundus. Once it has been determined that the bleeding is not the result of a boggy uterus, the nurse should check the vital signs to determine whether the blood loss has compromised the client’s condition. Next the nurse would contact the health care provider and report the bleeding, fundal height and condition, and vital signs. After contacting the health care provider the nurse would attend to the client’s comfort needs, including, in this case, frequent changes of peripads. The nurse would document the findings once assessment and implementation had been completed and the client’s condition was considered stable.
Test-Taking Strategy: Think about the normal and abnormal postpartum assessment findings related to lochial flow. A constant trickle of bright-red lochia indicates bleeding, and further assessment to determine the origin of bleeding should be performed and the results reported to the health care provider. Once the health care provider has been contacted, the client’s comfort needs and documentation would be the final priority. Review postpartum assessment findings and actions to take if they are abnormal if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Giddens Concepts: Reproduction, Perfusion
HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 441). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
12.ID: 9476911276A nonstress test is performed, and the health care provider documents “accelerations lasting less than 15 seconds throughout fetal movement.” The nurse interprets these findings as:

A Normal B Reactive C Nonreactive Correct D Inconclusive
Rationale: A reactive nonstress test is a normal, or negative, result and indicates a healthy fetus. The result requires two or more fetal heart rate accelerations of at least 15 beats/min lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, during a 20-minute period. A nonreactive test is an abnormal test, showing no accelerations or accelerations of less than 15 beats/min or lasting less than 15 seconds during a 40-minute observation. An inconclusive result is one that cannot be interpreted because of the poor quality of the fetal heart rate recording.
Test-Taking Strategy: Use the process of elimination. Eliminate a reactive nonstress test and a normal nonstress test first because they are comparable or alike. To select from the remaining options, note the relationship between “less than 15 seconds” in the question and “nonreactive” in the correct option. If you had difficulty answering this question, review the interpretation of nonstress test results.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Analysis
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 309). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
13.ID: 9476911242A stillborn infant was delivered a few hours ago. After the birth, the family remains together, holding and touching the baby. Which statement by the nurse is appropriate? A “I know how you feel.” B “This must be hard for you.” Correct C “Now you have an angel in heaven.” D “You’re young. You can have other children.”
Rationale: Therapeutic communication helps the mother,

father, and other family members express their feelings and emotions. “This must be hard for you” is a caring and empathetic response, focused on feelings and encouraging communication. The other options are nontherapeutic and may devalue the family members' feelings.
Test-Taking Strategy: Use your knowledge of therapeutic communication techniques. The correct option is the only option that is focused on the family members’ feelings. Review therapeutic communication techniques if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Maternity/Postpartum
Giddens Concepts: Communication, Coping
HESI Concepts: Communication, Grief and Loss
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 30-31, 566). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
14.ID: 9476904447A nurse is providing nutritional counseling to pregnant client with a history of cardiac disease. What does the nurse advise the client to eat? A Water and pretzels B Low-fat cheese omelet C Nachos and fried chicken D Apple and whole-grain toast Correct
Rationale: The pregnant woman needs a well-balanced diet high in iron and protein and adequate in calories for weight gain. Iron supplements that are taken during pregnancy tend to cause constipation. Constipation causes the client to strain during defecation, inadvertently performing the Valsalva maneuver, which causes blood to rush to the heart and overload the cardiac system. The pregnant woman, then, should increase her intake of fluids and fiber. An unlimited intake of sodium (pretzels, cheese, nachos) could cause overload of the circulating blood volume and contribute to the cardiac condition.
Test-Taking Strategy: Use the process of elimination and note that the client has a history of cardiac disease. Recalling the concepts of care of the client with cardiac disease and noting that

the question involves a client who is pregnant will direct you to the correct option. Review dietary requirements and examples of foods containing those requirements for a cardiac client who is pregnant if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Nutrition, Reproduction
HESI Concepts: Metabolism – Nutrition, Sexuality, Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 281, 616). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
15.ID: 9476904497A nurse is reviewing the records of the clients admitted to the maternity unit during the past 24 hours. Which clients does the nurse recognize as being at risk for the development of disseminated intravascular coagulation (DIC)? Select all that apply. A A client with septicemia Correct B A client with mild preeclampsia C A client with diabetes mellitus who delivered a 10-lb (4.5 kg) baby Incorrect D A client who had a cesarean section because of abruptio placentae Correct E A client who delivered 12 hours ago and has lost 475 mL of blood
Rationale: DIC is a pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, including platelets, fibrinogen, prothrombin, and factors V and VII. In the obstetric population, DIC occurs as a result of abruptio placentae, amniotic fluid embolism, dead fetus syndrome (in which the fetus has died but is retained in utero for at least 6 weeks), severe preeclampsia, septicemia, cardiopulmonary arrest, or hemorrhage. A loss of 475 mL is not considered hemorrhage .A mild case of preeclampsia is not a risk factor for DIC. It is not unusual for a client with diabetes mellitus to deliver a large baby, and this condition is unrelated to DIC.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the client at risk for DIC. Thinking about the

pathophysiology of DIC and the conditions listed in the options will assist in answering correctly. Review the risk factors associated with DIC if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Intrapartum
Giddens Concepts: Reproduction, Perfusion
HESI Concepts: Sexuality/Reproduction, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 578). St. Louis: Elsevier. Awarded 1.0 points out of 2.0 possible points.
16.ID: 9476904455A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table, and the nurse positions the client: A Prone B In a semi-Fowler position C In the Trendelenburg position D Supine with a wedge under the right hip Correct
Rationale: The pregnant client is positioned so that the uterus is displaced laterally to prevent compression of the inferior vena cava, which causes decreased placental perfusion. This is accomplished by placing a wedge under the hip. Positioning for abdominal surgery necessitates a supine position. The Trendelenburg position places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler or prone position is not practical for this type of abdominal surgery.
Test-Taking Strategy: Focus on the type of surgical procedure and the anatomy of a pregnant woman. Use the process of elimination and visualize each of the positions. This will direct you to the correct option. Review care of the client undergoing a cesarean delivery if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Caregiving , Safety
HESI Concepts: Caregiving , Safety

Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 428). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
17.ID: 9476917441A nurse is preparing to perform the Leopold maneuvers on a pregnant client. The nurse should first: A Locate the fetal heart tone B Position the woman supine C Ask the client to empty her bladder Correct D Count the fetal heart rate for 1 minute
Rationale: In preparation for the Leopold maneuvers, the nurse first asks the woman to empty her bladder, which will contribute to the woman’s comfort during the examination. Next the nurse positions the client supine with a wedge placed under the hip to displace the uterus. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones. Counting the fetal heart rate is not associated with Leopold maneuvers.
Test-Taking Strategy: Note the strategic word “first.” Knowing that Leopold maneuvers are often used to help locate fetal heart tones and involve palpation will assist you in determining that asking the client to empty the bladder is the first action. Review the procedure for the Leopold maneuvers if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 251, 340). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
18.ID: 9476901629A nurse is assessing the lochia of a client who delivered a viable newborn 1 hour ago. Which type of lochia would the nurse expect to note at this time? A Lochia alba B Lochial clots C Lochia serosa D Dark-red lochia rubra Correct

Rationale: When the perineum is assessed, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (1 to 4 hours after birth) is dark red (rubra). This is an expected occurrence until the third day after delivery. Then, from days 4 through 10, the discharge is brownish pink (serosa). Alba is a white discharge that occurs on days 11 to 14.
Test-Taking Strategy: Use the process of elimination. Noting that the question refers to a client who gave birth 1 hour ago will direct you to the correct option. Review postpartum assessment findings and the types of lochia if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Postpartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 360, 441). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
19.ID: 9476908181A nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures for treating the problem. The nurse tells the mother to: A Take a cool shower just before breastfeeding B Avoid breastfeeding during the night time hours to ensure adequate rest C Gently massage the breasts during breastfeeding to help empty the breasts Correct D Apply heat packs to the breasts for 15 to 20 minutes between feedings to reduce swelling
Rationale: Gently massaging the breasts during breast feeding will help empty the breasts. The mother should not avoid breastfeeding during the night; instead, she should breastfeed every 2 hours or pump the breasts. The nurse instructs the woman to apply ice packs, not heat packs, to the breasts between feedings to reduce swelling. It may be helpful for the mother to stand in a warm shower just before feeding to foster relaxation

and letdown.
Test-Taking Strategy: Focus on the subject, breast engorgement, and think about its characteristics. Use the process of elimination and visualize each of the descriptions in the options to identify the measure that will be helpful. If you had difficulty answering the question, review the measures for breast engorgement.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Postpartum
Giddens Concepts: Client Education, Tissue Integrity
HESI Concepts: Teaching and Learning/Patient Education, Tissue Integrity
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 542). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
20.ID: 9476908149When, during the normal postpartum course, would the nurse expect to note the fundal assessment shown in the figure?
A 4 days after delivery B The day after delivery C Immediately after delivery Correct D When the client’s bladder is full
Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. Location of the fundus above the umbilicus may indicate the

presence of blood clots in the uterus that need to be expelled by means of fundal massage. A fundus that is not located in the midline may indicate a full bladder. The fundus descends 1 or 2 cm every 24 hours, so it should be located farther below the umbilicus with every succeeding postpartum day.
Test-Taking Strategy: Focus on the figure and note that the fundus is at the level of the umbilicus. Recalling normal postpartum assessment findings in the mother and recalling the normal anatomy will assist in directing you to the correct option. If you had difficulty with this question, review normal postpartum assessment findings in regard to involution.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Postpartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 442, 668). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
21.ID: 9476908101A nurse assists the health care provider in performing an amniotomy on a client in labor. In which order should the nurse perform the following actions after the amniotomy? Assign the number 1 to the first action and the number 5 to the last action. Incorrect A Determining the fetal heart rate B Taking the client’s temperature, pulse, and blood pressure C Noting the quantity, color, and odor of the amniotic fluid D Replacing soiled underpads from beneath the client’s buttocks E Planning evaluation of the client for signs and symptoms of infection
The correct order is: A Determining the fetal heart rate B Noting the quantity, color, and odor of the amniotic fluid C Taking the client’s temperature, pulse, and blood pressure D Replacing soiled underpads from beneath the client’s buttocks E Planning evaluation of the client for signs and symptoms of infection
Rationale: After amniotomy, the fetal heart rate is assessed

for at least 1 full minute for changes associated with prolapse or compression of the umbilical cord and the characteristics of the fluid are noted as an indicator of fetal risk. After the fluid has been assessed, the next concern is evaluation of the maternal vital signs. The client’s comfort (i.e., the soiled underpads) is considered next. With the ruptured membranes comes an increased risk for maternal infection. For this reason, the client is frequently assessed for signs and symptoms of infection throughout the course of labor.
Test-Taking Strategy: Use principles of prioritizing and your knowledge of the ABCs (airway, breathing, and circulation) to answer this question. Fetal heart rate is associated with fetal breathing and circulation. Once the fetal condition has been assessed, the focus is turned to the mother’s condition. The amniotic fluid is checked next because this action will take little time, followed by vital signs. Finally client comfort is provided, followed by the planning of further care. If you had difficulty with this question, review the priority nursing actions after amniotomy.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Care Coordination, Reproduction
HESI Concepts: Collaboration/Managing Care – Care Coordination, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 412-414). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points.
22.ID: 9476917484A nurse is monitoring a client in labor for signs of intrauterine infection. Which sign, indicative of infection, would prompt the nurse to contact the health care provider? A Maternal fatigue B Clear amniotic fluid C Strong-smelling amniotic fluid Correct D A fetal heart rate of 140 beats/min
Rationale: Signs associated with intrauterine infection includes fetal tachycardia (rising baseline or faster than 160 beats/min, a maternal fever (38° C or 100.4° F), foul or strong- smelling amniotic fluid, or cloudy or yellow amniotic fluid. The

normal fetal heart rate is 110 to 160 beats/min. Clear amniotic fluid is normal. Maternal fatigue normally occurs during labor.
Test-Taking Strategy: Focus on the subject of the question, a sign of intrauterine infection. Eliminate the options that are comparable or alike in that they are normal expectations during labor. Review the signs of intrauterine infection if you had difficulty with this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Intrapartum
Giddens Concepts: Clinical Judgment, Infection
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Infection
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 643-644). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
23.ID: 9476917431A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing intervention in the care of this client? A Providing pain relief Correct B Preparing the client for amniotomy C Monitoring the oxytocin (Pitocin) infusion closely D Encouraging the client to ambulate every 30 minutes
Rationale: Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention in promoting a normal labor pattern. Therapeutic management of hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate labor progression. The client with hypertonic uterine dysfunction would be encouraged to rest, not to ambulate every 30 minutes.
Test-Taking Strategy: Use the process of elimination, focusing on the strategic words “hypertonic” and “priority.” This, plus knowledge of the management of this condition, should direct you to the correct option. Also eliminate the options that are therapeutic measures for hypotonic uterine dysfunction and would stimulate labor (i.e., oxytocin augmentation and

amniotomy). If you had difficulty with this question, review the management of hypertonic uterine dysfunction.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Care Coordination, Clinical Judgment
HESI Concepts: Clinical Decision-Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 636-637). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
24.ID: 9476911222A nurse is preparing to care for a client experiencing dystocia. To which intervention does the nurse give priority? A Monitoring fetal status Correct B Providing comfort measures C Changing the client’s position D Informing the client’s partner of the progress of the labor
Rationale: The priority intervention is monitoring fetal status. Once this is done, the nurse provides maternal comfort measures, including positioning the client, because this may decrease anxiety and hasten the progression of labor. Keeping the client’s partner informed of the progress of the labor is also an important aspect of client care during labor but is not an immediate priority.
Test-Taking Strategy: Note the strategic word “priority.” Use Maslow’s Hierarchy of Needs theory and your knowledge of the ABCs (airway, breathing, and circulation) to answer the question. Remember that physiological needs are the priority. Review priority nursing interventions for the client with dystocia if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Giddens Concepts: Care Coordination, Reproduction
HESI Concepts: Collaboration/Managing Care – Care Coordination, Sexuality/Reproduction
Reference: McKinney, E., James, S., Murray, S., Nelson, K. &

Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 609, 636). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
25.ID: 9476904493A postpartum client asks a nurse when she may safely resume sexual activity. The nurse tells the client that she may resume sexual activity: A At any time B In 2 to 4 weeks Correct C After the 6-week health care provider checkup D When her normal menstrual period has resumed
Rationale: Usually a woman may engage safely in sexual intercourse during the second to fourth week after childbirth as long as she experiences no discomfort during intercourse. The other options are incorrect. Engaging in intercourse too early in the postpartum course could result in further injury to perineal tissues damaged during childbirth. It usually takes about 3 weeks for an episiotomy to heal; therefore, it is unnecessary to wait 6 weeks. Menstruation may not resume in a postpartum woman for 12 weeks to 6 months after childbirth.
Test-Taking Strategy: Knowledge of the instructions given to a new mother regarding sexual activity after delivery is required to answer this question. Recalling that it takes about 3 weeks for an episiotomy to heal will direct you to the correct option. Review postpartum instructions if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity/Postpartum
Giddens Concepts: Sexuality, Safety
HESI Concepts: Sexuality/Reproduction, Safety
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 449). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
26.ID: 9476915431A pregnant woman reports to the clinic complaining of loss of appetite, weight loss, and fatigue, and tuberculosis is suspected. A sputum culture reveals Mycobacterium tuberculosis. The nurse, providing instructions to the mother regarding therapeutic management of the disease, tells the mother that: A The infant must be isolated from the mother after birth

B Maternal medication will not be started until the baby is born C The infant will require medication therapy immediately after birth D The mother may need to take isoniazid, pyrazinamide, and rifampin (Rifadin) for a total of 9 months Correct
Rationale: More than one medication may be used to prevent the growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must be continued for a prolonged period. The preferred treatment for the pregnant woman is isoniazid plus rifampin for a total of 9 months. Ethambutol is added initially if drug resistance is suspected. Pyridoxine (vitamin B 6 ) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing of the infant should be repeated at 3 months, and isoniazid may be stopped if the result remains negative. If the result is positive, the infant should receive isoniazid for at least 6 months. If the mother’s sputum is free of organisms, the infant does not need to be isolated from the mother while in the hospital.
Test-Taking Strategy: Knowledge regarding the therapeutic management of the mother with tuberculosis and that of the infant is required to answer this question. Eliminate the options containing the closed-ended words “must,” “not,” and “immediately.” If you had difficulty with this question, review treatment measures for the mother with tuberculosis.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity/Antepartum
Giddens Concepts: Client Education, Infection
HESI Concepts: Infection, Teaching and Learning/Patient Education
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 631). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
27.ID: 9476901648A nurse midwife performs an assessment of a pregnant client and documents the station of the fetal head as it is reflected in the figure below. The nurse reviews the assessment findings and determines that the fetal presenting part is:

A At +1 station B At –1 station C At zero station Correct D Stationed at the bottom of the coccyx
Rationale: Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. It is measured in centimeters and is noted as a negative number above the line, a positive number below the line, and zero at the line.
Test-Taking Strategy: Knowing that station is measured in centimeters, with the ischial spines as a reference point, will assist you in answering this question. Focus on the figure and note that the fetal head is at zero station. Review station if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Reproduction
HESI Concepts: Assessment, Sexuality/Reproduction

Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., pp. 330-331). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
28.ID: 9476917467A nurse performing an assessment of a pregnant client is preparing to take the client’s blood pressure. The nurse positions the client: A Supine, on the left side B Supine, on the right side C Lying down with the arm in a horizontal position at heart level D In a sitting position with the arm in a horizontal position at heart level Correct
Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client sitting position and the arm supported in a horizontal position at heart level. Supine on the right or left side and lying down with the arm in a horizontal position at heart level are both incorrect and could cause physiological stress that would affect the blood pressure.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that are comparable or alike in that they involve indicate positioning the client lying down or supine. If you are unfamiliar with the procedure of taking a pregnant client’s blood pressure, review this procedure.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Assessment
Content Area: Maternity/Antepartum
Giddens Concepts: Clinical Judgment, Perfusion
HESI Concepts: Assessment, Perfusion/Clotting
Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal-child nursing (4th ed., p. 248). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points.
29.ID: 9476912968A nurse is performing an assessment of a client who is at 20 weeks of gestation. The nurse asks the client to void, then measures the fundal height in centimeters. Which approximate measurement does the nurse expect to see? A 20 cm Correct B 28 cm