HESI OB/MATERNITY V 2

1. The nurse is caring for a client who had an emergency cesarean

section, with her husband in attendance the day before. The baby’s

Apgar was 9/9. The woman and her partner had attended childbirth

education classes and had anticipated having a water birth with family

present. Which of the following comments by the nurse is appropriate?

a) “Sometimes babies just don’t deliver the way we expect them

to.”

b) “With all of your preparations, it must have been disappointing

for you to have had a cesarean.”

c) “I know you had to have surgery, but you are very lucky that

your baby was born healthy.”

d) “At least your husband was able to be with you when the baby

was born.”

2. A nurse has brought a 2-hour-old baby to a mother from the nursery.

The nurse is going to assist the mother with the first breastfeeding

experience. Which of the following actions should the nurse perform

first?

a) Compare mother’s and baby’s identification bracelets.

b) Help the mother into a comfortable position.

c) Teach the mother about a proper breast latch.

d) Tickle the baby’s lips with the mother’s nipple.

3. The obstetrician has ordered that a post-op cesarean section client’s

patient-controlled analgesia (PCA) be discontinued. Which of the

following actions by the nurse is appropriate?

a) Discard the remaining medication in the presence of another

nurse.

b) Recommend waiting until her pain level is zero to discontinue

the medicine.

c) Discontinue the medication only after the analgesia is

completely absorbed.

d) Return the unused portion of medication to the narcotics

cabinet.

4. A client is receiving an epidural infusion of a narcotic for pain relief

after a cesarean section. The nurse would report to the anesthesiologist

if which of the following were assessed?

a) Respiratory rate 8 rpm.

b) Complaint of thirst.

c) Urinary output of 250 cc/hr.

d) Numbness of feet and ankles.

5. A client, 2 days postoperative from a cesarean section, complains to

the nurse that she has yet to have a bowel movement since the surgery.

Which of the following responses by the nurse would be appropriate at

this time?

a) “That is very concerning. I will request that your physician

order an enema for you.”

b) “Two days is not that bad. Some patients go four days or longer

without a movement.”

c) “You have been taking antibiotics through your intravenous.

That is probably why you are constipated.”

d) “Fluids and exercise often help to combat constipation. Take a

stroll around the unit and drink lots of fluid.”

6. A post–cesarean section, breastfeeding client, whose subjective pain

level is 2/5, requests her as needed (prn) narcotic analgesics every 3

hours. She states, “I have decided to make sure that I feel as little pain

from this experience as possible.” Which of the following should the

nurse conclude in relation to this woman’s behavior?

a) The woman needs a stronger narcotic order.

b) The woman is high risk for severe constipation.

c) The woman’s breast milk volume may drop while taking the

medicine.

d) The woman’s newborn may become addicted to the

medication.

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7. A nurse is assessing a 1-day postpartum woman who had her baby

by cesarean section. Which of the following should the nurse report to

the surgeon?

a) Fundus at the umbilicus.

b) Nodular breasts.

c) Pulse rate 60 bpm.

d) Pad saturation every 30 minutes.

8. The nurse is assessing the midline episiotomy on a postpartum

client. Which of the following findings should the nurse expect to see?

a) Moderate serosanguinous drainage.

b) Well-approximated edges.

c) Ecchymotic area distal to the episiotomy.

d) An area of redness adjacent to the incision.

9. A client, G1P1, who had an epidural, has just delivered a daughter,

Apgar 9/9, over a mediolateral episiotomy. The physician used low

forceps. While recovering, the client states, “I’m a failure. I couldn’t

stand the pain and couldn’t even push my baby out by myself!” Which

of the following is the best response for the nurse to make?

a) “You’ll feel better later after you have had a chance to rest and

to eat.”

b) “Don’t say that. There are many women who would be ecstatic

to have that baby.”

c) “I am sure that you will have another baby. I bet that it will be

a natural delivery.”

d) “To have things work out differently than you had planned is

disappointing.”

10. The nurse is developing a standard care plan for postpartum clients

who have had midline episiotomies. Which of the following

interventions should be included in the plan?

a) Assist with stitch removal on third postpartum day.

b) Administer analgesics every four hours per doctor orders.

c) Teach client to contract her buttocks before sitting.

d) Irrigate incision twice daily with antibiotic solution.

11. A client, G1P1001, 1-hour postpartum from a spontaneous vaginal

delivery with local anesthesia, states that she needs to urinate. Which

of the following actions by the nurse is appropriate at this time?

a) Provide the woman with a bedpan.

b) Advise the woman that the feeling is likely related to the

trauma of delivery.

c) Remind the woman that she still has a catheter in place from

the delivery.

d) Assist the woman to the bathroom.

12. A nurse is assessing the fundus of a client during the immediate

postpartum period. Which of the following actions indicates that the

nurse is performing the skill correctly?

a) The nurse measures the fundal height using a paper centimeter

tape.

b) The nurse stabilizes the base of the uterus with his or her

dependent hand.

c) The nurse palpates the fundus with the tips of his or her

fingers.

d) The nurse precedes the assessment with a sterile vaginal exam.

13. A 1-day postpartum woman states, “I think I have a urinary tract

infection. I have to go to the bathroom all the time.” Which of the

following actions should the nurse take?

a) Assure the woman that frequent urination is normal after

delivery.

b) Obtain an order for a urine culture.

c) Assess the urine for cloudiness.

d) Ask the woman if she is prone to urinary tract infections.

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14. The nurse is assessing the laboratory report on a 2-day postpartum G1P1001. The woman had a normal postpartum assessment this morning.

Which of the following results should the nurse report to the primary health care provider?

a. White blood cells—12,500 cells/mm3.

b. Red blood cells—4,500,000 cells/mm3.

c. Hematocrit—26%.

d. Hemoglobin—11 g/dL

15. A bottle-feeding woman, 11⁄2 weeks postpartum from a vaginal

delivery, calls the obstetric office to state that she has saturated 2 pads

in the past 1 hour. Which of the following responses by the nurse is

appropriate?

a) “You must be doing too much. Lie down for a few hours and

call back if the bleeding has not subsided.”

b) “You are probably getting your period back. You will bleed like

that for a day or two and then it will lighten up.”

c) “It is not unusual to bleed heavily every once in a while, after a

baby is born. It should subside shortly.”

d) “It is important for you to be examined by the doctor today. Let

me check to see when you can come in.”

16. A client, 2 days postpartum from a spontaneous vaginal delivery,

asks the nurse about postpartum exercises. Which of the following

responses by the nurse is appropriate?

a) “You must wait to begin to perform exercises until after your

six-week postpartum checkup.”

b) “You may begin Kegel exercises today, but do not do any other

exercises until the doctor tells you that it is safe.”

c) “By next week you will be able to return to the exercise

schedule you had during your prepregnancy.”

d) “You can do some Kegel exercises today and then slowly

increase your toning exercises over the next few weeks.”

17. The nurse is examining a 2-day postpartum client whose fundus is

2 cm below the umbilicus and whose bright red lochia saturates about

4 inches of a pad in 1 hour. What should the nurse document in the

nursing record?

a) Abnormal involution, lochia rubra heavy.

b) Abnormal involution, lochia serosa scant.

c) Normal involution, lochia rubra moderate.

d) Normal involution, lochia serosa heavy.

18. The nurse palpates a distended bladder on a woman who delivered

vaginally 2 hours earlier. The woman refuses to go to the bathroom, “I

really don’t need to go.” Which of the following responses by the

nurse is appropriate?

a) “Okay. I must be palpating your uterus.”

b) “I understand but I still would like you to try to urinate.”

c) “You still must be numb from the local anesthesia.”

d) “That is a problem. I will have to catheterize you.”

19. A client, G1P0101, postpartum 1 day, is assessed. The nurse notes

that the client’s lochia rubra is moderate and her fundus is boggy 2 cm

above the umbilicus and deviated to the right. Which of the following

actions should the nurse take first?

a) Notify the woman’s primary health care provider.

b) Massage the woman’s fundus.

c) Escort the woman to the bathroom to urinate.

d) Check the quantity of lochia on the peripad.

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