Chapter 23- Maternal Child Nursing Care Exam
Question and Answer
1. The nurse auscultates a neonate in resting position and hears a
murmur. What further assessments should the nurse make to know if
the infant has any cardiac defects? correct answer: Assess BP in all 4 extremities
When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out
congenital heart diseases. Circumference of the head is measured to detect head-related
complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart
disease. Assessing the body movements would correlate more with the muscular activity of the neonate but
not with cardiac activity.
2. The nurse is educating the parents of a newborn about the use of
the bulb syringe. Which statement from the parents indicates
effective learning about the bulb syringe? "It is used in the baby to correct
answer: correct answer: Prevent suttocation and clear airway obstruction
The bulb syringe is used to prevent suttocation and clear airway obstruction of newborns, and hence, it
prevents aspiration. If the newborn's anal opening prevents defecation, it leads to severe
gastrointestinal abnormalities. The bulb syringe is not used to reduce the newborn's temperature
during hypothermia. It is also not used to avoid heat loss from the newborn due to evaporation and
convection. Heat loss from the newborn is avoided by using warm water for bathing, drying the
newborn carefully, and avoiding exposing the newborn to drafts.
3. The nurse is assessing a breastfed newborn 1 hour after birth. The
nurse iden- tified that the glucose levels are less than 25 mg/dL and
immediately reported it to the primary health care provider (PHP).
What medication administration does the nurse expect the PHP to
advise? correct answer: IV dextrose infusion
4. During assessment, the nurse finds that the heart rate of a
neonate is 110 beats/min and respiratory rates vary from 35 to 40
breaths/min. The nurse also finds that the neonate has a pink
complexion. What conclusion regarding the Apgar score would the
,nurse make from these findings? The neonate correct answer:
correct answer: Exhibits normal findings
5. The primary health care provider (PHP) prescribes ventilator
support for a newborn. What finding would the PHP have assessed in
the newborn? correct answer: Bluish discoloration of the skin
6. A mother expresses fear about changing her infant's diaper
after he is cir- cumcised. What does the woman need to be taught
to take care of the infant
, when she gets home? correct answer: Cleanse the penis gently with water and put petroleum
jelly around the glans after each diaper change
7. The nurse observes increased bilirubin levels in the laboratory
reports of a newborn. Which complication does the nurse expect
in the newborn if this condition is poorly monitored?
Syndactyl
y2
Kernicteru
s3
Rectal
fistula 4
Down syndrome correct answer: Kernicterus
Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the
body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can
cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more
digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by
the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not
associated with increased bilirubin levels.
8. The nurse administers concentrated oral sucrose through the
suckling method to a neonate before performing the heelstick
method. Why would the nurse do this? correct answer: As a source of comfort to
the infant
The heelstick method is used to collect blood to estimate various biologic and chemical materials. The nurse
administers oral sucrose to a neonate before performing a painful procedure such as the heelstick
method to comfort the neonate. It is not necessary to hydrate the neonate before performing the
heelstick method. Hydration of a neonate is usually achieved by administering human milk or infant
formula. The infant's glucose levels are maintained by infusing dextrose; it is not used to recognize
reflexes in infant.
9. The nurse is assessing a preterm baby and observes dark red skin
Question and Answer
1. The nurse auscultates a neonate in resting position and hears a
murmur. What further assessments should the nurse make to know if
the infant has any cardiac defects? correct answer: Assess BP in all 4 extremities
When murmurs are heard, the nurse should check the neonates' BP from all four extremities to rule out
congenital heart diseases. Circumference of the head is measured to detect head-related
complications, such as microcephaly and hydrocephaly. However, it is unrelated to congenital heart
disease. Assessing the body movements would correlate more with the muscular activity of the neonate but
not with cardiac activity.
2. The nurse is educating the parents of a newborn about the use of
the bulb syringe. Which statement from the parents indicates
effective learning about the bulb syringe? "It is used in the baby to correct
answer: correct answer: Prevent suttocation and clear airway obstruction
The bulb syringe is used to prevent suttocation and clear airway obstruction of newborns, and hence, it
prevents aspiration. If the newborn's anal opening prevents defecation, it leads to severe
gastrointestinal abnormalities. The bulb syringe is not used to reduce the newborn's temperature
during hypothermia. It is also not used to avoid heat loss from the newborn due to evaporation and
convection. Heat loss from the newborn is avoided by using warm water for bathing, drying the
newborn carefully, and avoiding exposing the newborn to drafts.
3. The nurse is assessing a breastfed newborn 1 hour after birth. The
nurse iden- tified that the glucose levels are less than 25 mg/dL and
immediately reported it to the primary health care provider (PHP).
What medication administration does the nurse expect the PHP to
advise? correct answer: IV dextrose infusion
4. During assessment, the nurse finds that the heart rate of a
neonate is 110 beats/min and respiratory rates vary from 35 to 40
breaths/min. The nurse also finds that the neonate has a pink
complexion. What conclusion regarding the Apgar score would the
,nurse make from these findings? The neonate correct answer:
correct answer: Exhibits normal findings
5. The primary health care provider (PHP) prescribes ventilator
support for a newborn. What finding would the PHP have assessed in
the newborn? correct answer: Bluish discoloration of the skin
6. A mother expresses fear about changing her infant's diaper
after he is cir- cumcised. What does the woman need to be taught
to take care of the infant
, when she gets home? correct answer: Cleanse the penis gently with water and put petroleum
jelly around the glans after each diaper change
7. The nurse observes increased bilirubin levels in the laboratory
reports of a newborn. Which complication does the nurse expect
in the newborn if this condition is poorly monitored?
Syndactyl
y2
Kernicteru
s3
Rectal
fistula 4
Down syndrome correct answer: Kernicterus
Very high levels of bilirubin cause kernicterus. Bilirubin is a yellow pigment that is produced in the
body during the normal recycling of old red blood cells (RBCs). High levels of bilirubin in the body can
cause the skin to look yellow, a condition known as jaundice. Syndactyly is a condition where two or more
digits are fused together. It is not associated with increased bilirubin levels. Rectal fistula is caused by
the absence of the anal opening in the newborn. Down syndrome is a chromosome defect and is not
associated with increased bilirubin levels.
8. The nurse administers concentrated oral sucrose through the
suckling method to a neonate before performing the heelstick
method. Why would the nurse do this? correct answer: As a source of comfort to
the infant
The heelstick method is used to collect blood to estimate various biologic and chemical materials. The nurse
administers oral sucrose to a neonate before performing a painful procedure such as the heelstick
method to comfort the neonate. It is not necessary to hydrate the neonate before performing the
heelstick method. Hydration of a neonate is usually achieved by administering human milk or infant
formula. The infant's glucose levels are maintained by infusing dextrose; it is not used to recognize
reflexes in infant.
9. The nurse is assessing a preterm baby and observes dark red skin
