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FORTIS PN MATERNITY HESI PRACTICE
EXAM QUESTION AND ANSWER A+
ULTIMATE GUIDE
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- CORRECT ANSWER -1
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What is the most important action by the practical nurse (PN) in preventing
neonatal infection?
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- CORRECT ANSWER -1
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Other measures
include implementing isolation policies for infants with potentially

infectious conditions (B) and standard precautions (D)
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The practical nurse (PN) palpates fundal height at the umbilicus of a
multiparous client who has just given birth to an 8-pound boy when dark
red blood comes from the client's vagina
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Continue to massage the fundus until firm
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Obtain serial vital signs every 15 minutes
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Observe the perineum for hematoma formation
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Determine if clots have formed in the lochia
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Determine if clots have formed in the lochia
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The client's fundal height and dark red lochia indicates
inadequate uterine contraction, so the fundus should be massaged until
firm (B)
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An infant who weighs 4550 grams is delivered using forceps-assisted
vaginal delivery
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Palpate the clavicle for irregularity
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Place the infant to the mother's breast
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Monitor for signs of hypoglycemia
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Complete a gestational age assessment
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Monitor for
signs of hypoglycemia
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Monitoring for signs of hypoglycemia (C), such as
jitteriness, is the priority so early corrective action can be initiated to
reduce CNS irritability
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(B) is implemented to meet a basic need, but additional monitoring is
required for a macrosomic newborn who is at risk for hypoglycemia
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The practical nurse (PN) is reviewing the informational packets with a
client who is at risk for preeclampsia
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Notify the clinic if any vision changes are experienced
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Rest frequently with both feet elevated after long periods of standing
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Pack personal belongings for admission to the hospital
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Record daily weight for review by the healthcare provider at the next
visit
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Notify the clinic if any vision changes are
experienced
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Although (B, C, and D) should be reviewed with the client,
the early signs of toxemia of pregnancy should be emphasized
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The client has no complaints of abdominal
pain and no evidence of vaginal bleeding
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Transfer to a trauma unit
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Monitor a ruptured spleen
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Prepare for Cesarean section
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Obtain a biophysical profile
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Obtain a biophysical
profile
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A biophysical profile (D),
which includes a fetal non-stress test and an ultrasound, is prescribed to
determine fetal well-being
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A mother who is preparing for discharge begins asking the practical nurse
(PN) questions about bottle feeding her infant
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Place leftover formula in the refrigerator for 24 hours only
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Burp the newborn periodically during the feeding
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Heat the bottle of formula in the microwave oven
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Add extra formula powder to increase the concentration
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Burp the newborn periodically during the feeding
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Leftover formula (A) should be
discarded due to risk of spoilage and contamination by temperature
changes caused by cold storage, warming of the formula, and the duration

of feeding
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(D) should not be used because the newborn's kidneys are
unable to excrete the increase amounts of protein
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What action should the PN implement?
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- CORRECT
ANSWER -1
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The Moro reflex is a normal neonatal reflex that can be elicited when the
infant's crib is jarred or a loud noise is made
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The presence of a Moro is not an indication to evaluate a newborn's hearing
During pregnancy, the enlarging uterus compresses and displaces the colon
(A), which leads to a decrease in peristalsis (E), which contribute to
constipation during pregnancy
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Which intervention should the practical nurse (PN) provide a neonate
during hospitalization?
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- CORRECT ANSWER 2
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The neonate needs opportunities for nonnutritive sucking and oral
stimulation using a pacifier (B)
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Which client is a candidate for the administration of human immune
globulin (RhoGam) after delivery?
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- CORRECT
ANSWER -4
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RhoGam is a human immune globulin that prevents the formation of antiRh antibodies in an Rh-negative mother who has given birth to an Rhpositive infant (D)
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A client who took iron supplements during pregnancy delivers an infant by
cesarean section
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Which action should the
practical nurse (PN) implement?
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- CORRECT ANSWER -3
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Iron supplements cause constipation and contribute to the dark greenblack color in stool, which should be documented (C) as an expected
finding
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The mother asks the practical nurse (PN) what her infant may need if the
phenylketonuria (PKU) test is positive
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Blood transfusions
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Iron-enriched formula
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Lifelong dietary management
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Medications to prevent infection
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Lifelong dietary
management

PKU is a condition related to the infant's inability to utilize the amino acid,
phenylalanine, which must be omitted or strictly minimized in the diet
throughout life (C)
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A young adult female comes to the health clinic to confirm a positive home
pregnancy test
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April 29
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July 1
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May 12

Naegele's rule for calculation of EDB is determined by adding 7 days to the
first day of the LMP and then subtracting 3 months, so (B) is the correct
calculation
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Which client should the practical nurse (PN) closely monitor for severe
afterpains?
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- CORRECT
ANSWER -3
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After multiple deliveries, the over-distended uterus establishes tonicity
during early involution by periodically relaxing and then vigorously
contracting, which is also stimulated by breastfeeding which releases
oxytocin and causes post-delivery uterine contractions
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Oligohydramnios (A) (low amount of amniotic fluid) and bottle
feeding (B) do not place the client at risk for experiencing severe afterpains
related to multiparity
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A primigravida client who is at 39-weeks gestation arrives at the clinic and
tells the practical nurse (PN) she is having contractions every 5 minutes
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What action should the practical nurse (PN) implement when the client
groans with each contraction?
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- CORRECT ANSWER -4
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The use of relaxation techniques (D) is a recommended and effective
method of decreasing the perception of uterine contraction intensity in
early labor
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(B)
is not indicated at this time
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The practical nurse (PN) places a newborn who is 4 hours old with an
axillary temperature of 97
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Which
rationale supports the PN's action?
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- CORRECT
ANSWER -2
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Newborns have a large body surface area (BSA) and a relatively thin layer of
subcutaneous fat which provides poor insulation (B) and predisposes the
newborn to thermoregulation difficulties
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The newborn's BSA favors a more rapid heat loss, not
(D), than what an adult experiences
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Yellowish tinge around the eyes
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Peeling skin on the trunk
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Cool hands compared to body core
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Small pink patch on base of neck
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Small pink patch at base of the neck
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Yellowish tinge
around the eyes
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(B and D)
are expected findings
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A father expresses concern that his 3-day-old infant looks "yellow
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This yellow skin condition is the result of hepatic insufficiency
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Normal signs of jaundice occur during the first 24 hours of life
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Blood incompatibilities between mother and infant blood are common
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Physiologic jaundice occurs from a normal reduction in red blood cells
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Physiologic jaundice occurs from a normal reduction in
red blood cells
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Physiologic
jaundice results in newborns due to the rapid lysis of red blood cells (RBCs)
after birth (D)
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A primiparous client asks the practical nurse (PN) how much her newborn
baby boy should sleep every day
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A primiparous client asks the practical nurse (PN) how much her
newborn baby boy should sleep every day
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Keep the baby awake during the daytime so he sleeps through the night
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A newborn sleeps most of the day and gradually will have increasing
periods of wakefulness
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Expect your baby to follow your sleep and wake patterns once you
establish a pattern at home
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Newborn sleeps most of
the day and gradually will have increasing periods of wakefulness
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(A, B, and D) are not expectations for the normal sleep patterns of a
newborn
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Burst of energy
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Urinary retention
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Increase in fundal height
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Weight gain of 1
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- CORRECT ANSWER -1
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Common information that woman often experience with impending labor is
a burst of energy (A)
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(D) is not a sign of impending labor
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The client's weight
today is 129 pounds
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Document the finding in the medical record
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Retake the weight after calibrating the scale
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Notify the healthcare provider
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Obtain a 24-hour dietary recall
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Document the
finding in the medical record
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The
recommended weight gain during the first trimester is 3 pounds and
approximately 1 pound/week for the remainder of the pregnancy
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(B, C, and D) are not indicated
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2 F and places
the newborn under a radiant heat warmer
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Tremors of the hands during crying
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An increase in heart rate
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Flushing of the skin
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Respiratory depression
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Termors of the hands
during crying
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An early indicator of cold stress is the presence of tremors of
the hands, arms, and lips when the newborn cries (A)
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Cold stress causes an
increased respiratory rate, not (D)
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Which action should the
practical nurse take?
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- CORRECT ANSWER -2
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A 10% weight loss in the first 3 days after birth is normal and related to the
loss of excess extracellular fluid and meconium
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(A, C, and D) are not necessary at this time
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Which
action should the practical nurse implement at this time?
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- CORRECT ANSWER -4
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Assessment of the FHR and pattern (D) evaluates the fetus for distress due
to a possible prolapsed cord
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After assessing the FHR and the appearance of the amniotic fluid, the
healthcare provider (A) should be notified of the findings
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A client who is 5 weeks pregnant calls the clinic to report that her home
pregnancy test is positive
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Which signs and symptoms should
the practical nurse (PN) tell the client to report immediately to the
healthcare provider? (Select all that apply
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Vaginal bleeding
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Decreased libido
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Urinary frequency
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Membrane rupture
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Severe headaches
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Vaginal bleeding
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Vaginal bleeding (A), rupture of membranes (D), and severe headaches (E)
are signs and symptoms that indicate the client is at risk for premature
onset of labor and should be reported immediately
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(C)
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Triple antibiotic ointment (Neosporin)
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Natamycin (Natacyn)
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Tobramycin (Tobrex)
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Erythromycin (Ilotycin)
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Erythromycin (Ilotycin)
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Ophthalmic
medications, such as (A, B, and C), are used in the treatment of eye
infection, but are not indicated for ophthalmia neonatorum prophylaxis
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Prevents the infant's

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