MATERNITY NCLEX EVALUATION EXAM 2026 QUESTIONS
AND ANSWERS RATED A+
✔✔The parents of a newborn become concerned when they notice that their baby
seems to stop breathing for a few seconds. After confirming the parents' findings by
observing the newborn, which of the following actions would be most appropriate?
A) Notify the health care provider immediately.
B) Assess the newborn for signs of respiratory distress.
C) Reassure the parents that this is an expected pattern.
D) Tell the parents not to worry since his color is fine. - ✔✔B
Although periods of apnea of less than 20 seconds can occur, the nurse needs to
gather additional information about the newborn's respiratory status to determine if this
finding is indicative of a developing problem. Therefore, the nurse would need to assess
for signs of respiratory distress. Once this information is obtained, then the nurse can
notify the health care provider or explain that this finding is an expected one. However,
it would be inappropriate to tell the parents not to worry, because additional information
is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.
✔✔When assessing a newborn 1 hour after birth, the nurse measures an axillary
temperature of 95.8 degrees F, an apical pulse of 114 beats/minute, and a respiratory
rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?
A) Hypothermia related to heat loss during birthing process
B) Impaired parenting related to addition of new family member
C) Risk for deficient fluid volume related to insensible fluid loss
D) Risk for infection related to transition to extrauterine environment - ✔✔A
The newborn's heart rate is slightly below the accepted range of 120 to 160
beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60
breaths per minute. However, the newborn's temperature is significantly below the
accepted range of 97.7 to 99.7 degrees F. Therefore, the priority nursing diagnosis is
hypothermia. There is no information to suggest impaired parenting. Additional
information is needed to determine if there is a risk for deficient fluid volume or a risk for
infection.
✔✔The nurse places a newborn with jaundice under the phototherapy lights in the
nursery to achieve which goal?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level - ✔✔D
Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the
bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant
levels, or respiratory stability.
,✔✔The nurse assesses a 1-day-old newborn. Which finding indicates that the
newborn's oxygen needs aren't being met?
A) Respiratory rate of 54 breaths/minute
B) Abdominal breathing
C) Nasal flaring
D) Acrocyanosis - ✔✔C
Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54
breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal
findings.
✔✔During a physical assessment of a newborn, the nurse observes bluish markings
across the newborn's lower back. The nurse interprets this finding as:
A) Milia
B) Mongolian spots
C) Stork bites
D) Birth trauma - ✔✔B
Mongolian spots are blue or purple splotches that appear on the lower back and
buttocks of newborns. Milia are unopened sebaceous glands frequently found on a
newborn's nose. Stork bites are superficial vascular areas found on the nape of the
neck and eyelids and between the eyes and upper lip. Birth trauma would be
manifested by bruising, swelling, and possible deformity.
✔✔While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging
and turning bluish. What would the nurse do first?
A) Alert the physician stat and turn the newborn to her right side.
B) Administer oxygen via facial mask by positive pressure.
C) Lower the newborn's head to stimulate crying.
D) Aspirate the oral and nasal pharynx with a bulb syringe. - ✔✔D
The nurse's first action would be to suction the oral and nasal pharynx with a bulb
syringe to maintain airway patency. Turning the newborn to her right side will not
alleviate the blockage due to secretions. Administering oxygen via positive pressure is
not indicated at this time. Lowering the newborn's head would be inappropriate.
✔✔While performing a physical assessment of a newborn boy, the nurse notes diffuse
edema of the soft tissues of his scalp that crosses suture lines. The nurse documents
this finding as:
A) Molding
B) Microcephaly
C) Caput succedaneum
D) Cephalhematoma - ✔✔C
, Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue
swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal
head as it accommodates to the passage through the birth canal. Microcephaly refers to
a head circumference that is 2 standard deviations below average or less than 10% of
normal parameters for gestational age. Cephalhematoma is a localized effusion of blood
beneath the periosteum of the skull.
✔✔Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a
"clunk" when Ortolani's maneuver is performed. Which of the following would the nurse
suspect?
A) Slipping of the periosteal joint
B) Developmental hip dysplasia
C) Normal newborn variation
D) Overriding of the pelvic bone - ✔✔B
A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the
area. This, along with uneven gluteal creases, suggests developmental hip dysplasia.
These findings are not a normal variation and are not associated with slipping of the
periosteal joint or overriding of the pelvic bone.
✔✔The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of
the foot when evaluating which reflex?
A) Babinski
B) Tonic neck
C) Stepping
D) Plantar grasp - ✔✔A
The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the
heel toward and across the ball of the foot. The tonic neck reflex is tested by having the
newborn lie on his back and then turn his head to one side. The stepping reflex is
elicited by holding the newborn upright and inclined forward with the soles of the feet on
a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just
below the newborn's toes.
✔✔The nurse administers vitamin K intramuscularly to the newborn based on which of
the following rationales?
A) Stop Rh sensitization
B) Increase erythopoiesis
C) Enhance bilirubin breakdown
D) Promote blood clotting - ✔✔D
Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the
liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis.
Phototherapy enhances bilirubin breakdown.
AND ANSWERS RATED A+
✔✔The parents of a newborn become concerned when they notice that their baby
seems to stop breathing for a few seconds. After confirming the parents' findings by
observing the newborn, which of the following actions would be most appropriate?
A) Notify the health care provider immediately.
B) Assess the newborn for signs of respiratory distress.
C) Reassure the parents that this is an expected pattern.
D) Tell the parents not to worry since his color is fine. - ✔✔B
Although periods of apnea of less than 20 seconds can occur, the nurse needs to
gather additional information about the newborn's respiratory status to determine if this
finding is indicative of a developing problem. Therefore, the nurse would need to assess
for signs of respiratory distress. Once this information is obtained, then the nurse can
notify the health care provider or explain that this finding is an expected one. However,
it would be inappropriate to tell the parents not to worry, because additional information
is needed. Also, telling them not to worry ignores their feelings and is not therapeutic.
✔✔When assessing a newborn 1 hour after birth, the nurse measures an axillary
temperature of 95.8 degrees F, an apical pulse of 114 beats/minute, and a respiratory
rate of 60 breaths/minute. Which nursing diagnosis takes highest priority?
A) Hypothermia related to heat loss during birthing process
B) Impaired parenting related to addition of new family member
C) Risk for deficient fluid volume related to insensible fluid loss
D) Risk for infection related to transition to extrauterine environment - ✔✔A
The newborn's heart rate is slightly below the accepted range of 120 to 160
beats/minute; the respiratory rate is at the high end of the accepted range of 30 to 60
breaths per minute. However, the newborn's temperature is significantly below the
accepted range of 97.7 to 99.7 degrees F. Therefore, the priority nursing diagnosis is
hypothermia. There is no information to suggest impaired parenting. Additional
information is needed to determine if there is a risk for deficient fluid volume or a risk for
infection.
✔✔The nurse places a newborn with jaundice under the phototherapy lights in the
nursery to achieve which goal?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level - ✔✔D
Jaundice reflects elevated serum bilirubin levels; phototherapy helps to break down the
bilirubin for excretion. Phototherapy has no effect on body temperature, surfactant
levels, or respiratory stability.
,✔✔The nurse assesses a 1-day-old newborn. Which finding indicates that the
newborn's oxygen needs aren't being met?
A) Respiratory rate of 54 breaths/minute
B) Abdominal breathing
C) Nasal flaring
D) Acrocyanosis - ✔✔C
Nasal flaring is a sign of respiratory difficulty in the newborn. A rate of 54
breaths/minute, diaphragmatic/abdominal breathing, and acrocyanosis are normal
findings.
✔✔During a physical assessment of a newborn, the nurse observes bluish markings
across the newborn's lower back. The nurse interprets this finding as:
A) Milia
B) Mongolian spots
C) Stork bites
D) Birth trauma - ✔✔B
Mongolian spots are blue or purple splotches that appear on the lower back and
buttocks of newborns. Milia are unopened sebaceous glands frequently found on a
newborn's nose. Stork bites are superficial vascular areas found on the nape of the
neck and eyelids and between the eyes and upper lip. Birth trauma would be
manifested by bruising, swelling, and possible deformity.
✔✔While making rounds in the nursery, the nurse sees a 6-hour-old baby girl gagging
and turning bluish. What would the nurse do first?
A) Alert the physician stat and turn the newborn to her right side.
B) Administer oxygen via facial mask by positive pressure.
C) Lower the newborn's head to stimulate crying.
D) Aspirate the oral and nasal pharynx with a bulb syringe. - ✔✔D
The nurse's first action would be to suction the oral and nasal pharynx with a bulb
syringe to maintain airway patency. Turning the newborn to her right side will not
alleviate the blockage due to secretions. Administering oxygen via positive pressure is
not indicated at this time. Lowering the newborn's head would be inappropriate.
✔✔While performing a physical assessment of a newborn boy, the nurse notes diffuse
edema of the soft tissues of his scalp that crosses suture lines. The nurse documents
this finding as:
A) Molding
B) Microcephaly
C) Caput succedaneum
D) Cephalhematoma - ✔✔C
, Caput succedaneum is localized edema on the scalp, a poorly demarcated soft tissue
swelling that crosses the suture lines. Molding refers to the elongated shape of the fetal
head as it accommodates to the passage through the birth canal. Microcephaly refers to
a head circumference that is 2 standard deviations below average or less than 10% of
normal parameters for gestational age. Cephalhematoma is a localized effusion of blood
beneath the periosteum of the skull.
✔✔Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a
"clunk" when Ortolani's maneuver is performed. Which of the following would the nurse
suspect?
A) Slipping of the periosteal joint
B) Developmental hip dysplasia
C) Normal newborn variation
D) Overriding of the pelvic bone - ✔✔B
A "clunk" indicates the femoral head hitting the acetabulum as the head reenters the
area. This, along with uneven gluteal creases, suggests developmental hip dysplasia.
These findings are not a normal variation and are not associated with slipping of the
periosteal joint or overriding of the pelvic bone.
✔✔The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of
the foot when evaluating which reflex?
A) Babinski
B) Tonic neck
C) Stepping
D) Plantar grasp - ✔✔A
The Babinski reflex is elicited by stroking the lateral sole of the newborn's foot from the
heel toward and across the ball of the foot. The tonic neck reflex is tested by having the
newborn lie on his back and then turn his head to one side. The stepping reflex is
elicited by holding the newborn upright and inclined forward with the soles of the feet on
a flat surface. The plantar grasp reflex is elicited by placing a finger against the area just
below the newborn's toes.
✔✔The nurse administers vitamin K intramuscularly to the newborn based on which of
the following rationales?
A) Stop Rh sensitization
B) Increase erythopoiesis
C) Enhance bilirubin breakdown
D) Promote blood clotting - ✔✔D
Vitamin K promotes blood clotting by increasing the synthesis of prothrombin by the
liver. RhoGAM prevents Rh sensitization. Erythropoietin stimulates erythropoiesis.
Phototherapy enhances bilirubin breakdown.
