What nursing action should be implemented when intermittently gavage-feeding a
preterm infant?
Allow formula to flow by gravity.
Avoid letting infant suck on tube.
Insert feeding tube through
nares.Apply steady pressure to
syringe.Rationale
Gavage feeding is commonly used to feed preterm infants who are born at less
than 32-weeks gestation, infants who weigh less than 1500 grams, or infants who
are unable to tolerate oral feedings. The feeding should flow by gravity (A) to
avoid over-distention and a sudden sensation of fullness that may cause vomiting.
Allowing the infant to suck on the tube, not (B), permits observation of the sucking
response. The feeding tube should be inserted orally, since nasal insertion (C)
impedes obligatory nose breathing and may irritate delicate nasal mucosa. (D) can
result in vomiting if the rate of administration is too fast. A
client is receiving an oxytocin infusion for induction of labor. When the client
begins active labor, the fetal heart rate (FHR) slows at the onset of several
contractions with subsequent return to baseline before each contraction ends.
What action should the nurse implement?
Insert an internal monitor
device.Change the woman's
position.
Discontinue the oxytocin infusion.
Document the finding in the client
record.Rationale
Early FHR decelerations are a normal finding during active labor that occurs due to
fetal head compression, so the finding should be documented in the client record
(D). Although the client's status should be monitored continuously, this is a
reassuring FHR pattern, so (A, B, and C) are not indicated.
The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
Avoid alcohol because it is excreted in breast milk.
Avoid spicy foods to prevent infant colic.
Increase caloric intake by approximately 500 calories/day.
Double prenatal milk intake to improve Vitamin D transfer to the infant.
Rationale
Alcohol should be avoided while breastfeeding because, when consumed by the
mother, it is excreted in breast milk (A). It also adversely effects the milk ejection
HESI OB 2023/ 2024 EXAM QUESTIONS AND
ANSWERS

reflex. While (B) may cause some gastric upset in some babies, it does not cause
colic. (C) should also be included in diet teaching for a breastfeeding mother, but
because it does not involve safety to the infant it does not have the same degree
of importance as (A). Recent research has shown that infants receive very little
Vitamin D via the breastmilk and some sources recommend Vitamin D
supplementation in exclusively breastfed babies to prevent rickets.

An infant born at 37-weeks gestation, weighing 4.1 kg (9.02 pounds) is 2 hours
old and appears large for gestational age, flushed, and tremulous. What
procedure should the nurse follow to implement a glucose screening? (Arrange
the examination process from first on top to last on the bottom.)
Correct Answer:
• 1.
Wrap the infant's foot with a heel warmer for 5 minutes.
• 2.
Collect a spring-loaded automatic puncture device.
• 3.
Restrain the newborn's foot with your free hand.
• 4.
Cleanse puncture site on the lateral aspect of the heel.
Rationale
Obtaining capillary blood for the glucose screening for a infant that is macrosomic
and at risk for hypoglycemia should begin with wrapping the infant'sfoot with a
heel warmer for 5 to 10 minutes to facilitate vasodilation to obtain an adequate
blood sample volume. Next, a spring loaded automatic puncture device should be
obtained to puncture the skin because it is less traumatic than a manual lancet.
Then, the nurse's hand is used to restrain the foot as the puncture site on the
lateral aspect of the heel is cleansed.
The nurse observes a male newborn who is displaying a rigid posture with his eyes
tightly closed and grimacing as he is crying after an invasive procedure. Thebaby's
blood pressure is elevated on the Dinamap display. What action should the nurse
implement?
Obtain a serum glucose level.
Give the infant medication for
pain. Feed the newborn 1 ounce of
f o r m u l a . R e q u e s t a g e n e t i c
consultation.
Rationale
A cry face (or crying with the eyes squeezed or closed tightly), a rigid posture,
and an increase in blood pressure are indicative of pain in the neonate, so

and possibly crying (C). A high-pitched shrill cry is associated with neurologic and
genetic anomalies (D).
The nurse assesses a high-risk neonate under a radiant warmer who has an
umbilical catheter and identifies that the neonate's feet are blanched. What
nursing action should be implemented?
Place socks on infant.
Elevate feet 15 degrees.
Wrap feet loosely in prewarmed blanket.
Report findings to the healthcare provider.
Rationale
Vasoconstriction of peripheral vessels, which can seriously impair circulation, is
triggered by arterial vasospasm caused by the presence of the catheter, the
infusion of fluids, or the injection of medication. Blanching of the buttocks,
genitalia, or the legs or feet is an indication of vasospasm and should be reported
immediately to the healthcare provider (D). (A, B, and C) do not provide effective
resolution of this potentially serious complications. A
gravid client develops maternal hypotension following regional anesthesia.
What intervention(s) should the nurse implement? (Select all that apply.)
Select all that apply
Some correct answers were not selected
Administer oxygen.
Increase IV fluids.
Perform a vaginal examination.
Assist client to a sitting
position.
Place the client in a lateral position.
Monitor fetal status.
Rationale
Correct selections are (A, B, E, and F). Oxygen (A), fluids (B), lateral position (E),
and evaluating fetal response (F) effectively manage maternal hypotension
following regional anesthesia. Placing the client in a sitting position (D) does not
facilitate venous return to the heart and limits perfusion of the fetus. A sterile
vaginal examination (C) does not increase blood flow and oxygenation to the
placenta and fetus.
A newborn infant who is 24-hours-old is on a 4-hour feeding schedule of formula.
To meet daily caloric needs, how many ounces are recommended at each feeding?
2 ounces.
4 ounces.
1.5 ounces.
3 . 5

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may be insufficient to meet the newborn's calorie needs. (B) may cause the infant
to spit-up due to over-feeding. A
client at 28-weeks gestation arrives at the labor and delivery unit with a complaint
of bright red, painless vaginal bleeding. For which diagnostic procedure should the
nurse prepare the client?
Contraction stress test.
Internal fetal monitoring.
Abdominal ultrasound.
Lecithin-sphingomyelin
ratio.Rationale
Bright red, painless vaginal bleeding occuring after 20-weeks gestation can be an
indicator of placenta previa, which is confirmed by abdominal ultrasound (C). (A, B
and D) are invasive procedures that increase the risk for premature onset of labor,
and are not indicated at this client's gestation. A
primigravida at 12-weeks gestation who just moved to the United States indicates
she has not received any immunizations. Which immunization(s) shouldthe nurse
administer at this time? (Select all that apply.)
Select all that apply
Some correct answers were not selected
Tetanus.
Rubella.
Diphtheria.
Chickenpox
.Hepatitis
B.Rationale
Correct selections are (A, C, and E). Vaccines composed of killed viruses may be
administered during pregnancy. Rubella (B) and chickenpox (D) consist of live or
attenuated live viruses which would be contraindicated during pregnancy due to
potential teratogenicity. A
client in labor receives an epidural block. What intervention should the nurse
implement first?
Encourage oral fluids.
Assess contractions.
Monitor blood
pressure.Obtain a radial
pulse.
Rationale
The risk for maternal hypotension is commonly increased by an epidural, so blood
pressure should be monitored immediately after the first epidural dose (C) and for
15 minutes thereafter. Oral fluids should be encouraged to help keep the client
hydrated (A), but the first action is to evaluate the client for side effects of the
epidural block. Although (B and D) should be continuously monitored after an

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A client at 8-weeks gestation ask the nurse about the risk for a congenital heart
defect (CHD) in her baby. Which response best explains when a CHD may occur?
It depends on what the causative factors are for a
CHD.We don't really know what or when CHDs occur.
They usually occur in the first trimester of pregnancy.
The heart develops in the third to fifth weeks after conception.
Rationale
The cardiovascular system is the first organ system to develop and function in the
embryo. The blood vessel and blood formation begin in the third week, and the
heart is developmentally complete in the fifth week (D). Regardless of the
etiological factor, the heart is vulnerable during its period of development -- the
third to fifth weeks. (A, B, and C) are inaccurate. A
primigravida at 12-weeks gestation tells the nurse that she does not like diary
products. Which food should the nurse recommend to increase the client's calcium
intake?
Canned clams.
Fresh apricots.
Canned sardines.
Spaghetti with meat
sauce.Rationale
A 3 ounce can of sardines (with bones) provides about the same amount of calcium
as 1 cup of milk (C). (A, B, and D) are not good sources for dietary calcium.
When discussing birth in a home setting with a group of pregnant women, which
situation should the nurse include about the safety of a home birth?
Only the woman and her midwife should be present during the
delivery. The woman should live no more than 15 minutes from the
hospital.
The woman's extended family should be allowed to attend the home
birth. Medical backup should be available quickly in case of
complications.Rationale
Access to quick emergency care should be available in the event that an
unforeseen complication arises (D) during a home birth. Although the nurse-
midwife should be a competent healthcare provider during a home birth (A),
access to emergency, surgical, and resuscitation assistance should be readily
available. A 15-minute drive to the hospital is ideal, but (B) does not ensure the
safest situation. The presence and support of family during the home birth (C)
does not necessarily ensure a safe home birth.

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"Protein helps the fetus grow while I am
pregnant.""Gestational diabetes is prevented by
eating protein." "Anemia is averted by consuming
enough protein." "My baby will develop strong teeth
after he is born." Rationale
Adequate protein intake is essential to meet increasing demands of rapid growth
of the fetus (A) and maternal changes during pregnancy, such as enlargement of
the uterus, mammary glands, and placenta, increase in the maternal blood volume,
and formation of amniotic fluid. Protein is essential for anabolism, but its
consumption does not prevent gestational diabetes (B). Iron found in high protein
foods, such as meat, helps prevent anemia (C), but the basic need for protein is the
anabolic growth processes of the fetus. Although calcium is needed for fetal bone
and teeth development (D), it is not found in all protein food sources.
The nurse is assessing a full-term newborn’s breathing pattern. Which findings
should the nurse assess further? (Select all that apply.)
Select all that apply
Shallow with an irregular rhythm.
Chest breathing with nasal flaring.
Diaphragmatic with chest retraction.
Abdominal with synchronous chest
movements.Heart rate of 158 beats per
minute.
Grunting heard with a stethoscope.
Rationale
Breathing with nasal flaring, diaphragmatic breathing with chest retraction, and
grunting are signs of respiratory distress in the infant. A
client is experiencing "back" labor and complains of intense pain in the lower
lumbar-sacral area. What action should the nurse implement?
Perform effleurage on the abdomen.
Encourage pant-blow breathing techniques.
Apply counter pressure against the sacrum.
Assist the client in guided imagery.
Rationale
Counter pressure against the sacrum (C) during contractions often provides
significant relief for "back labor," which results from occipital posterior position.
Effleurage (A) is a helpful distraction strategy many clients use during contractions
but does not assist with lower back pain. Back labor can occur throughout labor if
the fetus does not rotate, and helpful distractions, such as (B),used during
transition, and (D), used during phase one of labor, are not effective for back labor.
A client at 28-weeks gestation experiences blunt abdominal trauma. Which
parameter should the nurse assess first for signs of internal hemorrhage?
Vaginal bleeding.
Complaints of abdominal pain.
Changes in fetal heart rate

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Hypoperfusion of the fetus may be present before the onset of clinical signs of
maternal compromise or shock in a pregnant woman, so the external fetal monitor
tracings should be assessed first to determine signs of fetal hypoxia due to
internal bleeding in the mother. (A, B, and D) are not the first findings of internal
hemorrhage in the pregnant client.
Which prescription should the nurse administer to a newborn to reduce
complications related to birth trauma?
Silver nitrate.
Erythromycin (Ilotycin
ointment).Ceftriaxone
(Rocephin).
Vitamin K (AquaMEPHYTON).
Rationale
The normal neonate is vitamin K deficient, so to rapidly elevate prothrombin levels
and reduce the risk of neonatal bleeding, newborns receive a single injection of
vitamin K (AquaMEPHYTON) (D). (A and B) are prophylactic ophthalmic agents
used to prevent neonatal ophthalmia. (C) is an antibiotic used to treat neonatal
infections. A
multiparous client has been in labor for 8 hours when her membranes rupture.
What action should the nurse implement first?
Prepare the client for imminent birth.
Assess the fetal heart rate and
pattern.Document the characteristics of
the fluid.
Notify the client's primary healthcare
provider.Rationale
The fetal heart rate and pattern should be assessed (B) to determine compromise
of fetal well-being caused by compression or prolapse of the umbilical cord. The
intensity and frequency of the uterine contractions often trigger spontaneous
rupture of the membranes (SROM), which does not indicate that birth is imminent
(A). The healthcare provider should be notified of the client and fetal well-being
after evaluation of SROM. Although the characteristics of the amniotic fluid should
be documented (C), assessment of fetal response to the SROM is the priority.
The nurse is teaching a primigravida at 10-weeks gestation about the need to
increase her intake of folic acid. Which explanation should the nurse provide that
supports preventative perinatal care?
The risk for neonatal cerebral palsy increases with folic acid deficiencies during
pregnancy.
Folic acid can significantly reduce the incidence of mental retardation.
Adequate folic acid during embryogenesis reduces the incidence of neural tube
defects.
The incidence of congenital heart defects is related to folic acid intake deficiencies.

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The nurse is preparing to gavage feed a preterm infant who is receiving IV
antibiotics. The infant expels a bloody stool. What nursing action should thenurse
implement?
Institute contact precautions.
Obtain a rectal temperature.
Assess for abdominal distention.
Decrease the amount of the
feeding.Rationale
Etiological factors playing an important role in the development of necrotizing
enterocolitis (NEC), a complication common in premature infants, include intestinal
ischemia, colonization by pathogenic bacteria, and substrate (formula feeding) in
the intestinal lumen. Bloody stools, abdominal distention, diarrhea, and bilious
vomitus are signs of NEC. Nursing responsibilities include measuringthe abdomen
(C) and listening for bowel sounds. Contact precautions (A) are necessary if a
contagious gastrointestinal infection is suspected. Rectal temperatures are
contraindicated (B) because of the risk for perforation of the bowel. Oral or
gavage feeding is stopped, not (D), until necrotizing enterocolitis isruled out. A
client in active labor at 39-weeks gestation tells the nurse she feels a wet sensation
on the perineum. The nurse notices pale, straw-colored fluid with smallwhite
particles. After reviewing the fetal monitor strip for fetal distress, what action
should the nurse implement?
Escort the client to the
bathroom.Offer the client a bed
pan.
Perform a nitrazine
test. Clean the perineal
area. Rationale
The normal characteristic of amniotic fluid is pale, straw-colored fluid, which may
contain white flecks of vernix, with an alkaline pH, so (C) should be done to
confirm the pH of the fluid. (A or B) may be indicated if the fluid is urine. (D)
should be done after determining the type of fluid expelled.
The nurse is providing discharge teaching for a gravid client who is being released
from the hospital after placement of cerclage. Which instruction is the most
important for the client to understand?
Plan for a possible cesarean birth.
Arrange for home uterine
monitoring. Make arrangements for
care at home.
Report uterine cramping or low backache.
Rationale
Uterine cramping and low back pain (D) are symptoms of preterm labor and

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2023-2024 HESI Maternity OB Practice Exam With Answers (108 Solved Questions)

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