*ATI RN MATERNAL NEWBORN EXAM QUESTIONS
AND VERIFIED CORRECT ANSWERS
**Question 1. A nurse is assessing a newborn 1 minute after birth and
notes the following: heart rate 130/min, loud crying, some flexion of
extremities, crying when the soles of the feet are flicked, and a pink
body with blue hands and feet. Which of the following APGAR scores
should the nurse assign?**
* A. 7
* B. 8
* C. 9
* D. 10
* **Rationale:** The score is calculated as follows: Heart rate >100 (2
points), Loud cry (2 points), Some flexion (1 point), Cry/Grimace (2
points), and Acrocyanosis/Blue extremities (1 point). Total = 8.
**Question 2. A nurse is assessing a newborn's reflexes. Which of the
following techniques should the nurse use to elicit the Moro reflex?**
* A. Tap the bridge of the newborn's nose suddenly.
* B. Hold the newborn in a semi-sitting position and allow the head and
trunk to fall backward.
* C. Stroke the lateral column of the newborn's foot upward from the
heel.
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,* D. Place a finger in the palm of the newborn's hand.
* **Rationale:** The Moro reflex (startle reflex) is elicited by a sudden
change in equilibrium. The newborn should respond by extending the
arms and legs, then bringing them together in an embracing motion.
**Question 3. A nurse is assessing a newborn who is 12 hours old.
Which of the following findings should the nurse report to the
provider?**
* A. Small white cysts on the gums (Epstein pearls).
* B. Bluish-purple pigmented spots on the sacrum (Mongolian spots).
* C. Jaundice of the sclera and skin.
* D. Erythema toxicum (pink rash) on the trunk.
* **Rationale:** Jaundice appearing within the first 24 hours of life is
**pathological jaundice**, which can indicate hemolytic disease or ABO
incompatibility. Jaundice after 24 hours is typically physiological and
considered normal.
**4. A nurse is providing umbilical cord care to a client who is about to
be discharged with their newborn. Which of the following instructions
should the nurse include?**
* A. "Clean the cord with alcohol at every diaper change."
* B. "Keep the diaper folded down below the cord stump."
* C. "The cord will fall off in about 3 to 5 days."
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, * D. "Give the baby a tub bath daily until the cord falls off."
* **Rationale:** Keeping the diaper folded down prevents irritation and
allows the cord to stay dry, which facilitates healing. Tub baths are
contraindicated until the cord stump has fallen off (usually 10–14 days).
**Question 5. A nurse is assessing a newborn for developmental
dysplasia of the hip (DDH). Which of the following findings should the
nurse expect?**
* A. Symmetrical gluteal folds.
* B. Trendelenburg sign.
* C. Asymmetric thigh folds.
* D. Inward turning of the feet.
* **Rationale:** Asymmetric gluteal or thigh folds and a positive
Ortolani or Barlow maneuver are classic signs of hip dysplasia in a
newborn.
**Question 6. A nurse is preparing to administer Vitamin K
(phytonadione) to a newborn. Which of the following is the correct
rationale for this medication?**
* A. To prevent ophthalmia neonatorum.
* B. To stimulate the production of red blood cells.
* C. To provide immunity against hepatitis B.
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AND VERIFIED CORRECT ANSWERS
**Question 1. A nurse is assessing a newborn 1 minute after birth and
notes the following: heart rate 130/min, loud crying, some flexion of
extremities, crying when the soles of the feet are flicked, and a pink
body with blue hands and feet. Which of the following APGAR scores
should the nurse assign?**
* A. 7
* B. 8
* C. 9
* D. 10
* **Rationale:** The score is calculated as follows: Heart rate >100 (2
points), Loud cry (2 points), Some flexion (1 point), Cry/Grimace (2
points), and Acrocyanosis/Blue extremities (1 point). Total = 8.
**Question 2. A nurse is assessing a newborn's reflexes. Which of the
following techniques should the nurse use to elicit the Moro reflex?**
* A. Tap the bridge of the newborn's nose suddenly.
* B. Hold the newborn in a semi-sitting position and allow the head and
trunk to fall backward.
* C. Stroke the lateral column of the newborn's foot upward from the
heel.
1
,* D. Place a finger in the palm of the newborn's hand.
* **Rationale:** The Moro reflex (startle reflex) is elicited by a sudden
change in equilibrium. The newborn should respond by extending the
arms and legs, then bringing them together in an embracing motion.
**Question 3. A nurse is assessing a newborn who is 12 hours old.
Which of the following findings should the nurse report to the
provider?**
* A. Small white cysts on the gums (Epstein pearls).
* B. Bluish-purple pigmented spots on the sacrum (Mongolian spots).
* C. Jaundice of the sclera and skin.
* D. Erythema toxicum (pink rash) on the trunk.
* **Rationale:** Jaundice appearing within the first 24 hours of life is
**pathological jaundice**, which can indicate hemolytic disease or ABO
incompatibility. Jaundice after 24 hours is typically physiological and
considered normal.
**4. A nurse is providing umbilical cord care to a client who is about to
be discharged with their newborn. Which of the following instructions
should the nurse include?**
* A. "Clean the cord with alcohol at every diaper change."
* B. "Keep the diaper folded down below the cord stump."
* C. "The cord will fall off in about 3 to 5 days."
2
, * D. "Give the baby a tub bath daily until the cord falls off."
* **Rationale:** Keeping the diaper folded down prevents irritation and
allows the cord to stay dry, which facilitates healing. Tub baths are
contraindicated until the cord stump has fallen off (usually 10–14 days).
**Question 5. A nurse is assessing a newborn for developmental
dysplasia of the hip (DDH). Which of the following findings should the
nurse expect?**
* A. Symmetrical gluteal folds.
* B. Trendelenburg sign.
* C. Asymmetric thigh folds.
* D. Inward turning of the feet.
* **Rationale:** Asymmetric gluteal or thigh folds and a positive
Ortolani or Barlow maneuver are classic signs of hip dysplasia in a
newborn.
**Question 6. A nurse is preparing to administer Vitamin K
(phytonadione) to a newborn. Which of the following is the correct
rationale for this medication?**
* A. To prevent ophthalmia neonatorum.
* B. To stimulate the production of red blood cells.
* C. To provide immunity against hepatitis B.
3
