CMS Maternal Newborn Practice A Questions and Answers Rated A
A nurse is collecting data from a client who is at before the newborn is discharged from the
36 weeks of gestation during a prenatal hospital
examination. Which of the following findings - Critical Congenital Heart Disease screen should
should the nurse report to the provider? - be completed 24- 28 hours following birth and
ANSWER -Blurred vision - indication of before the newborn is discharged from the
preeclampsia hospital
Expected findings: non pitting ankle edema, 10
fetal movements in 2 hr, leg cramps
A nurse is assisting in the care of a newborn
immediately following birth. Which of the
A nurse is caring or a newborn who is receiving following images should the nurse identify as an
phototherapy. Which of the following actions indication that the newborn has a
should the nurse take? - ANSWER -Place myelomeningocele? - ANSWER -Occurs
an opaque mask over the newborn's eyes - to when the neural tube fails to close, and the
prevent damage to the retinas meninges and spinal cord herniate
Occurs in the lumbar area and may be covered
- Should remove mask for feedings by a thin membranous sac
DO NOT apply a thin layer of lotion to the - Exstrophy of the bladder; occurs from abnormal
newborn's skin development of the abdominal wall, symphysis
pubis and bladder ; visible in the suprapubic area
and requires surgical intervention soon after birth
A nurse is caring for a client who is at 11 weeks - Omphalocel: occurs when abdominal organs
of gestation and reports frequent vomiting. Which herniate through the umbilical ring at the base of
of the following findings should the nurse identify the umbilical cord
as an indication that the client has hyperemesis - Cephalohematoma; collection of blood between
gravidarum? - ANSWER -Ketonuria the skull bone and its covering, the periosteum. A
cephalohematoma does not cross the suture
Occurs due to the breakdown of fat secondary to lines of the newborn's skull and will
malnutrition or starvation spontaneously resolve in 2-8 weeks
Tachycardia and tachypnea due to dehydration
A nurse is collecting data from a newborn who is
A nurse is caring for a newborn who has a high- 8hr old. Which of the following findings should the
pitched cry and does not respond to consoling nurse report to the provider? - ANSWER -
efforts. Which of the following neonatal data Apical heart rate of 90/min while crying - normal
collection tools should the nurse expect to range 110 - 160 for a newborn, heart rate of 80-
complete? - ANSWER -Neonatal 100/min while asleep and up to 180/min while
Abstinence Scoring System: exhibiting opioid crying
withdrawal - Apneic episode of 20 seconds or less - normal;
newborns respirations are normally shallow and
Additional manifestations: restlessness, tremors, irregular
increased muscle tone, and an exaggerated - Positive moro reflex present from birth up to 8
Moro reflex weeks
- Apgar score: heart rate, respiratory rate, muscle - Vernix in the skin folds - normal
tone, reflex irritability and skin color
- Newborn Hearing Screen should be completed
, CMS Maternal Newborn Practice A Questions and Answers Rated A
A nurse is caring for a client 6 hr after a vaginal should the nurse include?
birth who is going to breastfeed her newborn. a. cord compression
The client reports perineal pain of 6 on a scale b. chronic hypertension
from 0 to 10. The nurse also notes mild perineal c. alcohol use during pregnancy
edema and ecchymosis, with a fundus that is 2 d. prematurity - ANSWER -d. prematurity
cm above the umbilicus with deviation to the
right. Which of the following actions is the nurse's A newborn who is premature has inadequate
priority? surfactant production, which can lead to RDS.
a. administer analgesics Alcohol syndrome can result in fetal alcohol
b. apply an ice pack to the perineum syndrome, developmental delay, and birth
c. assist the client with breastfeeding defects. Cord compression can result in fetal
d. help the client ambulate to the toilet - anoxia.
ANSWER -d. help the client ambulate to
the toilet
A nurse is caring for a client who is planning to
The greatest risk for this client is postpartum become pregnant. The client asks the nurse why
hemorrhage from uterine atony. Therefore, the folic acid supplements are necessary. The nurse
priority intervention by the nurse is to assist the should inform the client that the purpose of the
client to urinate and completely empty the folic acid supplement is to do which of the
bladder, which will allow the uterus to contract. following?
a. facilitate the storage of iron in the fetus liver
b. prevent certain kinds of birth defects
A nurse is reinforcing teaching with a client who c. inhibit premature labor
is at 20 wks of gestation and has gestational d. aid in the absorption of other important
diabetes mellitus. Which of the following nutrients - ANSWER -b. prevent certain
information should the nurse include in the kinds of birth defects
teaching?
a. exercise before meals
b. consume at least 2,000 cal/day A nurse is reinforcing discharge teaching about
c. avoid consuming an evening snack methods to prevent engorgement during lactation
d. maintain a fasting blood glucose of 110 to 120 suppression with a client who is bottle-feeding
mg/dL - ANSWER -b. consume at least her newborn. Which of the following statements
2,000 cal/day should the nurse identify as an indication that the
client understands the instructions?
This will ensure adequate glucose intake and a. "I will massage my breasts while I take a
prevent hypoglycemia. Exercise should be done shower."
after meals to prevent hypoglycemia. Should b. "I should wear an underwire bra during the
have an evening snack to prevent hypoglycemia day."
during the night. Should maintain a fasting blood c. "I should use a breast pump several times a
glucose of less than 95 mg/dL. day to relieve discomfort."
d. "I will apply cold cabbage leaves to my breasts
throughout the day." - ANSWER -d. "I will
A nurse is reinforcing teaching about risk factors apply cold cabbage leaves to my breasts
for respiratory distress syndrome (RDS) in throughout the day."
newborns with a group of clients who are
pregnant. Which of the following risk factors Should also apply ice packs or cold compresses
A nurse is collecting data from a client who is at before the newborn is discharged from the
36 weeks of gestation during a prenatal hospital
examination. Which of the following findings - Critical Congenital Heart Disease screen should
should the nurse report to the provider? - be completed 24- 28 hours following birth and
ANSWER -Blurred vision - indication of before the newborn is discharged from the
preeclampsia hospital
Expected findings: non pitting ankle edema, 10
fetal movements in 2 hr, leg cramps
A nurse is assisting in the care of a newborn
immediately following birth. Which of the
A nurse is caring or a newborn who is receiving following images should the nurse identify as an
phototherapy. Which of the following actions indication that the newborn has a
should the nurse take? - ANSWER -Place myelomeningocele? - ANSWER -Occurs
an opaque mask over the newborn's eyes - to when the neural tube fails to close, and the
prevent damage to the retinas meninges and spinal cord herniate
Occurs in the lumbar area and may be covered
- Should remove mask for feedings by a thin membranous sac
DO NOT apply a thin layer of lotion to the - Exstrophy of the bladder; occurs from abnormal
newborn's skin development of the abdominal wall, symphysis
pubis and bladder ; visible in the suprapubic area
and requires surgical intervention soon after birth
A nurse is caring for a client who is at 11 weeks - Omphalocel: occurs when abdominal organs
of gestation and reports frequent vomiting. Which herniate through the umbilical ring at the base of
of the following findings should the nurse identify the umbilical cord
as an indication that the client has hyperemesis - Cephalohematoma; collection of blood between
gravidarum? - ANSWER -Ketonuria the skull bone and its covering, the periosteum. A
cephalohematoma does not cross the suture
Occurs due to the breakdown of fat secondary to lines of the newborn's skull and will
malnutrition or starvation spontaneously resolve in 2-8 weeks
Tachycardia and tachypnea due to dehydration
A nurse is collecting data from a newborn who is
A nurse is caring for a newborn who has a high- 8hr old. Which of the following findings should the
pitched cry and does not respond to consoling nurse report to the provider? - ANSWER -
efforts. Which of the following neonatal data Apical heart rate of 90/min while crying - normal
collection tools should the nurse expect to range 110 - 160 for a newborn, heart rate of 80-
complete? - ANSWER -Neonatal 100/min while asleep and up to 180/min while
Abstinence Scoring System: exhibiting opioid crying
withdrawal - Apneic episode of 20 seconds or less - normal;
newborns respirations are normally shallow and
Additional manifestations: restlessness, tremors, irregular
increased muscle tone, and an exaggerated - Positive moro reflex present from birth up to 8
Moro reflex weeks
- Apgar score: heart rate, respiratory rate, muscle - Vernix in the skin folds - normal
tone, reflex irritability and skin color
- Newborn Hearing Screen should be completed
, CMS Maternal Newborn Practice A Questions and Answers Rated A
A nurse is caring for a client 6 hr after a vaginal should the nurse include?
birth who is going to breastfeed her newborn. a. cord compression
The client reports perineal pain of 6 on a scale b. chronic hypertension
from 0 to 10. The nurse also notes mild perineal c. alcohol use during pregnancy
edema and ecchymosis, with a fundus that is 2 d. prematurity - ANSWER -d. prematurity
cm above the umbilicus with deviation to the
right. Which of the following actions is the nurse's A newborn who is premature has inadequate
priority? surfactant production, which can lead to RDS.
a. administer analgesics Alcohol syndrome can result in fetal alcohol
b. apply an ice pack to the perineum syndrome, developmental delay, and birth
c. assist the client with breastfeeding defects. Cord compression can result in fetal
d. help the client ambulate to the toilet - anoxia.
ANSWER -d. help the client ambulate to
the toilet
A nurse is caring for a client who is planning to
The greatest risk for this client is postpartum become pregnant. The client asks the nurse why
hemorrhage from uterine atony. Therefore, the folic acid supplements are necessary. The nurse
priority intervention by the nurse is to assist the should inform the client that the purpose of the
client to urinate and completely empty the folic acid supplement is to do which of the
bladder, which will allow the uterus to contract. following?
a. facilitate the storage of iron in the fetus liver
b. prevent certain kinds of birth defects
A nurse is reinforcing teaching with a client who c. inhibit premature labor
is at 20 wks of gestation and has gestational d. aid in the absorption of other important
diabetes mellitus. Which of the following nutrients - ANSWER -b. prevent certain
information should the nurse include in the kinds of birth defects
teaching?
a. exercise before meals
b. consume at least 2,000 cal/day A nurse is reinforcing discharge teaching about
c. avoid consuming an evening snack methods to prevent engorgement during lactation
d. maintain a fasting blood glucose of 110 to 120 suppression with a client who is bottle-feeding
mg/dL - ANSWER -b. consume at least her newborn. Which of the following statements
2,000 cal/day should the nurse identify as an indication that the
client understands the instructions?
This will ensure adequate glucose intake and a. "I will massage my breasts while I take a
prevent hypoglycemia. Exercise should be done shower."
after meals to prevent hypoglycemia. Should b. "I should wear an underwire bra during the
have an evening snack to prevent hypoglycemia day."
during the night. Should maintain a fasting blood c. "I should use a breast pump several times a
glucose of less than 95 mg/dL. day to relieve discomfort."
d. "I will apply cold cabbage leaves to my breasts
throughout the day." - ANSWER -d. "I will
A nurse is reinforcing teaching about risk factors apply cold cabbage leaves to my breasts
for respiratory distress syndrome (RDS) in throughout the day."
newborns with a group of clients who are
pregnant. Which of the following risk factors Should also apply ice packs or cold compresses
