HESI RN OB 2021
1. One hour after delivery, the nurse is unable to palpate the uterine fundus of a client who had an epidural and
notes a large amount
... [Show More] of lochia on the perineal pad. The nurse massages at the umbilicus and obtains current
vital signs. Which intervention should the nurse implement next?
A. Document number of pad changes in the last hour
B. Increase the rate of the oxytocin infusion
C. Palpate the suprapubic area for bladder distention
D. Provide bedpan to void if unable to ambulate
2. At 40-week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally
found a comfortable position. What action should the nurse take?
A. Place a pillow under the client’s head and knees.
B. Place a wedge under the client’s right hip.
C. Encourage the client to turn on her left side.
D. Explain to the client that her position is not safe.
3.After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help
change the newborns diaper. As the mother begins the diaper change, the newborn spits up the breast milk.
What action should the nurse implement first?
A. Wipe away the spit-up and assist the mother with the diaper change
B. Turn the newborn to the side and bulb suction the mouth and nares
C. Sit the newborn up and burp by rubbing or patting the upper back
D. Place the newborn in a position with the head lower than the feet
4. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment
finding is most important for the nurse to report to the healthcare provider?
A. History of irritable bowel syndrome (IBS)
B. Pain scale rating of a “9” on a 0-10 scale.
C. Last menstrual period 7 weeks ago.
D. Reports white, curly vaginal discharge.
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5. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela
Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses
placing the nipple’s elongated tip in the back of the oral cavity. What instruction should the nurse provide the
mother about feedings?
A. Alternate milk with water during the feedings.
B. Squeeze the nipple base to introduce milk into the mouth.
C. Position the baby in the left lateral position after feeding.
D. Hold the newborn in an upright position.
6. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the
nurse take?
A. Prepare the client for an echocardiogram.
B. Limit the client’s fluids.
C. Document in the client’s record.
D. Notify the healthcare provider.
7. A client delivers a viable infant but begins to have excessive uncontrolled vaginal bleeding after the IV
Pitocin is infused. When notifying the hcp of the clients condition, what information is most important for the
nurse to provide?
A. Total amount of Pitocin infused
B. Maternal Blood pressure
C. Maternal Apical Pulse rate
D. Time Pitocin infusion completed
8. The nurse is caring for a newborn infant who was recently diagnosed with congenital heart defect. Which
assessment finding warrants immediate intervention by the nurse?
A. Sweating during feedings
B. Weak peripheral pulse
C. Bluish tinge to the tongue
D. Increased respiratory rate
9. A client who delivered a healthy newborn an hour ago asks the nurse when can she go home. Which
information is most important for the nurse to provide the client?
A. When there is no significant vaginal bleeding
B. When ambulating to void does not cause dizziness
C. After the vitamin K injection is given to the baby
D. After the baby no longer demonstrates acrocyanosis
10. A client at 33- weeks gestation is admitted with a moderate amount of vaginal bleeding and no contractions
are noted on the external monitor. Which intervention should the nurse implement?
A. Weight perineal pads
B. Weight daily
C. Measure intake and output
D. Ambulate 15 minutes QID
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11. The nurse is performing a gestational age assessment on a full-term newborn during the first hour of
transition using the Ballard (Dubowitz) scale. Based on this assessment, the nurse determines that the neonate
has a maturity rating of 40-weeks. What findings should the nurse identify to determine if the neonate is small
for gestational age (SGA)? (Select all that apply.)
A. Admission weight of 4 pounds, 15 ounces (2244 grams)
B. Head to heel length of 17 inches (42.5 cm).
C. Frontal occipital circumference of 12.5 inches (31.25 cm).
D. Skin smooth with visible veins and abundant vernix.
E. Anterior plantar crease and smooth heel surfaces.
F. Full flexion of all extremities in resting supine position.
12. A client at 20 weeks gestation comes to the antepartum clinic complaining of vaginal warts (human
papillomavirus). What information should the nurse provide this client?
A. Treatment options, while limited due to the pregnancy, are available
B. The client should be treated with Penicillin G
C. This client should be treat with acyclovir (Zovirax)
D. Termination of the pregnancy should be considered
13. One week after missing her menstrual period, a woman performs an OTC pregnancy test and it is positive.
Which hormone is responsible for producing the positive result?
A. Human placental lactogen
B. Gonadotrophin-releasing hormone
C. Human chorionic gonadotrophin
D. Prostaglandin E2 Aplha
14. A new mother, who is lacto-ovo vegetarian, plans to breastfeed her infant. What information should the
nurse provide prior to discharge?
A. Avoid using lanolin-based nipple cream or ointment
B. Continue prenatal vitamins with B12 while breast feeding
C. Offer iron- fortified supplemental formula daily
D. Weigh the baby weekly to evaluate the newborns growth
15. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess
first?
A. A 3-week multigravida with a prescription for serial blood pressures.
B. A 39-week primigravida with biophysical profile score of 5 out of 8.
C. A 38- week primigravida who reports contractions occurring every 10 minutes.
D. A 41-week multigravida who is scheduled induction of labor today.
16. A primigravida at 36-weeks gestation, who is Rh negative, experienced abdominal trauma in a motor
vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider?
A. Fetal heart rate of 162 beats/minute
B. Trace of protein in the urine
C. Positive fetal hemoglobin test
D. Mild contractions every 10 minutes
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17. The nurse is caring for a postnatal patient who is exhibiting symptoms of spinal headaches 24 hours
following delivery of a normal newborn. Prior to anesthesiologist’s arrival on the unit, which action should the
nurse perform?
A. Place procedure equipment at bedside
B. Apply an abdominal binder
C. Cleanse the spinal injection site
D. Insert an indwelling foley catheter
18. The nurse is counseling a client who is at 6 weeks gestation and is experiencing morning sickness but does
not want to take any drugs for this discomfort. Which herbal supplement is likely to help this client with the
nausea she is experiencing?
A. Ginko
B. Chamomile
C. Peppermint
D. Ginger
19. The nurse is assessing a postpartum client who delivered a 10 pound infant vaginally two hours ago. The
clients fundus is 2 fingerbreadths above the umbilicus, deviated to the right side, and boggy. After the client
voids 250 ml of urine using a bedpan, what action should the nurse implement?
A. Re-evaluate the client in 15 minutes
B. Assist the client to the bathroom to void
C. Palpate the suprapubic region for distention
D. Encourage the client to breastfeed
20. At 0600 while admitting a woman for a scheduled repeat c section, the client tells the nurse that she drank a
cup of coffee at 0400 because she wanted to avoid getting a headache. What action should the nurse take first?
A. Ensure preoperative lab results are available
B. Start prescribed IV with Lactated Ringers
C. Inform the anesthesia care provider
D. Contact the clients obstetrician
21. A client who is in active labor is receiving magnesium sulfate and begin to experience slurred speech and
decreased reflexes. Which action should the nurse implement first?
A. Obtain a serum magnesium level
B. Measure the clients hourly urinary output
C. Provide an emesis basin for vomiting
D. Turn off the magnesium sulfate infusion
22. A 3 hour old male infant’s hands are feet are cyanotic, and he has an axillary temperature of 96.5 F, a
respiratory rate of 40 breaths/min, and a heart rate of 165 beats/min. Which nursing intervention is best for the
nurse to implement?
A. Perform a heel- stick to monitor blood glucose level
B. Gradually warm the infant under a radiant heat source
C. Administer oxygen by mask at 2L/minute
D. Notify the pediatrician of the infants unstable vital signs
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23. Calculated by Naegele’s rule, a primigravida client is at 28 weeks gestation. She is moderately obese an [Show Less]