MATERNAL CHILD NURSING ASSESSMENT TEST II
(QUESTIONS AND ANSWERS 2024/2025)
Q1. The nurse assisted with the delivery of a newborn. Which nursing action is most
effective in preventing heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer (CORRECT ANSWER) 3. Drying the
infant with a warm blanket
Q2. The mother of a newborn calls the clinic and reports that when cleaning the
umbilical cord, she noticed that the cord was moist and that discharge was present.
What is the most appropriate nursing instruction for this mother?
1. Bring the infant to the clinic.
2. This is a normal occurrence.
3. Increase the number of times that the cord is cleaned per day.
4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge
continues. (CORRECT ANSWER) 1. Bring the infant to the clinic.
Q3. The nurse is assessing a newborn after circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which nursing
action is most appropriate ?
1. Apply gentle pressure.
2. Reinforce the dressing.
3. Document the finding.
4. Contact the health care provider (HCP). (CORRECT ANSWER) 3. Document the
finding.
Q4. The nurse adminsters erythromycin ointment (0.5%) to the eyes of a newborn
and the mother asks the nurse why this is performed. Which explanation is best for
the nurse to provide about neonatal eye prophylaxis ?
1. Protects the newborn's eyes from possible infections acquired while hospitalized.
2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
3. Minimizes the spread of microorganisms to the newborn from invasive procedures
during labor.
4. Prevents an infection called ophthalmia neonatorum from occuring after delivery in
a newborn born to a mother with an untreated gonococcal infection. (CORRECT
ANSWER) 4. Prevents an infection called ophthalmia neonatorum from occuring
after delivery in a newborn born to a mother with an untreated gonococcal infection.
Q5. The nurse prepares to administer a vitamin K injection to a newborn, and the
mother asks the nurse why her infant needs the injection. What best response
should the nurse provides?
1. "Your newborn needs vitamin K to develop immunity."
2. "The vitamin K will protect your newborn form being jaundiced."
3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in
the bowel."
,4. "Newborns are deficient in vitamin K, and this injection prevents your newborn
from bleeding." (CORRECT ANSWER) 4. "Newborns are deficient in vitamin K, and
this injection prevents your newborn from bleeding."
Q6. At each well-child visit, the neonate's anterior and posterior fontanelles are
inspected and palpated. The posterior fontanelle should be closed by age:
1. 2 months
2. 6 months
3. 9 months
4. 12 months (CORRECT ANSWER) 1. 2 months
Q7. A 12-hour-old neonate has edema on the scalp that crosses the suture lines.
This is:
1. Cephalohematoma
2. Caput succedaneum
3. Molding
4. Craniosynostosis (CORRECT ANSWER) 2. Caput succedaneum
Q8. The corneal blink reflex disappears:
1. Approximately 4 hours after birth
2. At age 4 to 6 months
3. After the child is walking
4. Never (CORRECT ANSWER) 4. Never
Q9. Of the following, which assessment finding is most indicative of a full-term
infant?
1. Long lanugo present on the infant's back
2. Incurving of the upper pinnae only
3. Palpable breast tissue of 8mm
4. Transparent skin over the abdomen (CORRECT ANSWER) 3. Palpable breast
tissue of 8mm
Q10. An otherwise healthy 3-day-old infant has small, yellowish-white, 1 mm papules
scattered in a transverse, linear distribution along the nasal groove. These lesions
are most likely:
1. Erythema toxicum
2. Millia
3. Cutis aplasia
4. Telangiectatic nevi (CORRECT ANSWER) 2. Millia
Q11. Of the following assessment findings in the newborn, which is considered an
abnormal finding?
1. Deconjugate gaze
2. Webbed neck
3. Sebaceous cyst on gums
4. Head lag (CORRECT ANSWER) 2. Webbed neck
Q12. Most primitive reflexes in the newborn disappear by age:
1. 2 to 3 months
2. 4 to 6 months
,3. 6 to 8 months
4. 8 to 10 months (CORRECT ANSWER) 4. 8 to 10 months
Q14. Which of the following is true regarding Mongolian spots?
1. These lesions are often mistaken for bruising.
2. These birthmarks occur predominantly in Caucasian children.
3. These lesions are at high risk for becoming malignant.
4. The birthmarks are bright red in color. (CORRECT ANSWER) 1. These lesions
are often mistaken for bruising.
Q15. Weak or absent femoral pulses in the neonate are indicative of:
1. Coarctation of the aorta
2. Ventricular septal defect
3. Normal transition from fetal circulation
4. Atrial septal defect (CORRECT ANSWER) 1. Coarctation of the aorta
Q1. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to
prepare for the admission of a 43 weeks gestation newborn with Apgar scores of 1
and 4. In planning for admission of this newborn, what is the nurse's highest priority?
1. Turn on the apnea and cardiorespiratory monitors.
2. Connect the resuscitation bag to the oxygen outlet.
3. Set up the intravenous line with 5% dextrose in water.
4. Set the radiant warmer control temperature at 36.5 °C (97.6 °F). (CORRECT
ANSWER) 2. Connect the resuscitation bag to the oxygen outlet.
Q2. The nurse is in a newborn nursery is monitoring a preterm infant newborn for
respiratory distress syndrome. Which assessment findings would alert the nurse to
the possibility of this syndrome ?
1. Tachypnea and retraction
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. Presence of a barrel chest and acrocyanosis (CORRECT ANSWER) 2.
Acrocyanosis and grunting
Q3. The postpartum nurse is providing instructions to the mother of a newborn with
hyperbilirubinemia who is being breast-fed. The nurse should provide which most
appropriate instruction to the mother ?
1. Feed the newborn less frequently.
2. Continue to breast-feed every 2 to 4 hours.
3. Switch to bottle-feeding the infant for 2 weeks.
4. Stop breast-feeding and switch to bottle-feeding permanently. (CORRECT
ANSWER) 2. Continue to breast-feed every 2 to 4 hours.
Q4. The nurse is assessing a newborn who was born to a mother who is addicted to
drugs. Which assessment finding would the nurse expect to note during the
assessment of this newborn ?
1. Lethargy
2. Sleepiness
3. Constant crying
4. Cuddles when being held (CORRECT ANSWER) 3. Constant crying
, Q5. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term
newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome
and is aware that which additional sign would be consistent with this syndrome ?
1. Length of 19 inches (48cm)
2. Abnormal palmar creases
3. Birth weight of 6 lb, 14 oz (2890grams)
4. Head circumference appropriate for gestational age (CORRECT ANSWER) 2.
Abnormal palmar creases
Q6. The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome.
The nurse should include which priority intervention in the plan of care ?
1. Allow the newborn to establish own sleep-rest pattern.
2. Maintain the newborn in a brightly lightened area of staff and parents.
3. Encourage frequent handling of the newborn by staff and parents.
4. Monitor the newborn's response to feedings and weight gain pattern. (CORRECT
ANSWER) 4. Monitor the newborn's response to feedings and weight gain pattern.
Q7. The nurse is preparing to care for a newborn receiving phototherapy. Which
interventions should be included in the plan of care ? Select all that apply.
1. Avoid stimulation.
2. Decreased fluid intake.
3. Expose all of the newborn's skin.
4. Monitoring skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches. (CORRECT ANSWER) 4.
Monitoring skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches.
Q8. The nurse develops a plan of care for a woman with human immunodeficiency
virus infection and her newborn. The nurse should include which intervention in the
plan of care ?
1. Monitoring the newborn's vital signs routinely
2. Maintaining standard precautions at all times while caring for the newborn 3.
Initiating referral to evaluate for blindness, deafness, learning problems, or
behavioral problems
4. Instructing the breast-feeding mother regarding the treatment of the nipples with
nystatin ointment (CORRECT ANSWER) 2. Maintaining standard precautions at all
times while caring for the newborn
Q9. The nurse is planning care for a newborn of a mother with diabetes mellitus.
What is the priority nursing consideration for this newborn ?
1. Developmental delays because of excessive size
2. Maintaining safety because of low blood glucose level
3. Choking because of impaired suck and swallow reflexes
4. Elevated body temperature because of excess fat and glycogen (CORRECT
ANSWER) 2. Maintaining safety because of low blood glucose level
(QUESTIONS AND ANSWERS 2024/2025)
Q1. The nurse assisted with the delivery of a newborn. Which nursing action is most
effective in preventing heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer (CORRECT ANSWER) 3. Drying the
infant with a warm blanket
Q2. The mother of a newborn calls the clinic and reports that when cleaning the
umbilical cord, she noticed that the cord was moist and that discharge was present.
What is the most appropriate nursing instruction for this mother?
1. Bring the infant to the clinic.
2. This is a normal occurrence.
3. Increase the number of times that the cord is cleaned per day.
4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge
continues. (CORRECT ANSWER) 1. Bring the infant to the clinic.
Q3. The nurse is assessing a newborn after circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which nursing
action is most appropriate ?
1. Apply gentle pressure.
2. Reinforce the dressing.
3. Document the finding.
4. Contact the health care provider (HCP). (CORRECT ANSWER) 3. Document the
finding.
Q4. The nurse adminsters erythromycin ointment (0.5%) to the eyes of a newborn
and the mother asks the nurse why this is performed. Which explanation is best for
the nurse to provide about neonatal eye prophylaxis ?
1. Protects the newborn's eyes from possible infections acquired while hospitalized.
2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
3. Minimizes the spread of microorganisms to the newborn from invasive procedures
during labor.
4. Prevents an infection called ophthalmia neonatorum from occuring after delivery in
a newborn born to a mother with an untreated gonococcal infection. (CORRECT
ANSWER) 4. Prevents an infection called ophthalmia neonatorum from occuring
after delivery in a newborn born to a mother with an untreated gonococcal infection.
Q5. The nurse prepares to administer a vitamin K injection to a newborn, and the
mother asks the nurse why her infant needs the injection. What best response
should the nurse provides?
1. "Your newborn needs vitamin K to develop immunity."
2. "The vitamin K will protect your newborn form being jaundiced."
3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in
the bowel."
,4. "Newborns are deficient in vitamin K, and this injection prevents your newborn
from bleeding." (CORRECT ANSWER) 4. "Newborns are deficient in vitamin K, and
this injection prevents your newborn from bleeding."
Q6. At each well-child visit, the neonate's anterior and posterior fontanelles are
inspected and palpated. The posterior fontanelle should be closed by age:
1. 2 months
2. 6 months
3. 9 months
4. 12 months (CORRECT ANSWER) 1. 2 months
Q7. A 12-hour-old neonate has edema on the scalp that crosses the suture lines.
This is:
1. Cephalohematoma
2. Caput succedaneum
3. Molding
4. Craniosynostosis (CORRECT ANSWER) 2. Caput succedaneum
Q8. The corneal blink reflex disappears:
1. Approximately 4 hours after birth
2. At age 4 to 6 months
3. After the child is walking
4. Never (CORRECT ANSWER) 4. Never
Q9. Of the following, which assessment finding is most indicative of a full-term
infant?
1. Long lanugo present on the infant's back
2. Incurving of the upper pinnae only
3. Palpable breast tissue of 8mm
4. Transparent skin over the abdomen (CORRECT ANSWER) 3. Palpable breast
tissue of 8mm
Q10. An otherwise healthy 3-day-old infant has small, yellowish-white, 1 mm papules
scattered in a transverse, linear distribution along the nasal groove. These lesions
are most likely:
1. Erythema toxicum
2. Millia
3. Cutis aplasia
4. Telangiectatic nevi (CORRECT ANSWER) 2. Millia
Q11. Of the following assessment findings in the newborn, which is considered an
abnormal finding?
1. Deconjugate gaze
2. Webbed neck
3. Sebaceous cyst on gums
4. Head lag (CORRECT ANSWER) 2. Webbed neck
Q12. Most primitive reflexes in the newborn disappear by age:
1. 2 to 3 months
2. 4 to 6 months
,3. 6 to 8 months
4. 8 to 10 months (CORRECT ANSWER) 4. 8 to 10 months
Q14. Which of the following is true regarding Mongolian spots?
1. These lesions are often mistaken for bruising.
2. These birthmarks occur predominantly in Caucasian children.
3. These lesions are at high risk for becoming malignant.
4. The birthmarks are bright red in color. (CORRECT ANSWER) 1. These lesions
are often mistaken for bruising.
Q15. Weak or absent femoral pulses in the neonate are indicative of:
1. Coarctation of the aorta
2. Ventricular septal defect
3. Normal transition from fetal circulation
4. Atrial septal defect (CORRECT ANSWER) 1. Coarctation of the aorta
Q1. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to
prepare for the admission of a 43 weeks gestation newborn with Apgar scores of 1
and 4. In planning for admission of this newborn, what is the nurse's highest priority?
1. Turn on the apnea and cardiorespiratory monitors.
2. Connect the resuscitation bag to the oxygen outlet.
3. Set up the intravenous line with 5% dextrose in water.
4. Set the radiant warmer control temperature at 36.5 °C (97.6 °F). (CORRECT
ANSWER) 2. Connect the resuscitation bag to the oxygen outlet.
Q2. The nurse is in a newborn nursery is monitoring a preterm infant newborn for
respiratory distress syndrome. Which assessment findings would alert the nurse to
the possibility of this syndrome ?
1. Tachypnea and retraction
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. Presence of a barrel chest and acrocyanosis (CORRECT ANSWER) 2.
Acrocyanosis and grunting
Q3. The postpartum nurse is providing instructions to the mother of a newborn with
hyperbilirubinemia who is being breast-fed. The nurse should provide which most
appropriate instruction to the mother ?
1. Feed the newborn less frequently.
2. Continue to breast-feed every 2 to 4 hours.
3. Switch to bottle-feeding the infant for 2 weeks.
4. Stop breast-feeding and switch to bottle-feeding permanently. (CORRECT
ANSWER) 2. Continue to breast-feed every 2 to 4 hours.
Q4. The nurse is assessing a newborn who was born to a mother who is addicted to
drugs. Which assessment finding would the nurse expect to note during the
assessment of this newborn ?
1. Lethargy
2. Sleepiness
3. Constant crying
4. Cuddles when being held (CORRECT ANSWER) 3. Constant crying
, Q5. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term
newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome
and is aware that which additional sign would be consistent with this syndrome ?
1. Length of 19 inches (48cm)
2. Abnormal palmar creases
3. Birth weight of 6 lb, 14 oz (2890grams)
4. Head circumference appropriate for gestational age (CORRECT ANSWER) 2.
Abnormal palmar creases
Q6. The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome.
The nurse should include which priority intervention in the plan of care ?
1. Allow the newborn to establish own sleep-rest pattern.
2. Maintain the newborn in a brightly lightened area of staff and parents.
3. Encourage frequent handling of the newborn by staff and parents.
4. Monitor the newborn's response to feedings and weight gain pattern. (CORRECT
ANSWER) 4. Monitor the newborn's response to feedings and weight gain pattern.
Q7. The nurse is preparing to care for a newborn receiving phototherapy. Which
interventions should be included in the plan of care ? Select all that apply.
1. Avoid stimulation.
2. Decreased fluid intake.
3. Expose all of the newborn's skin.
4. Monitoring skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches. (CORRECT ANSWER) 4.
Monitoring skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches.
Q8. The nurse develops a plan of care for a woman with human immunodeficiency
virus infection and her newborn. The nurse should include which intervention in the
plan of care ?
1. Monitoring the newborn's vital signs routinely
2. Maintaining standard precautions at all times while caring for the newborn 3.
Initiating referral to evaluate for blindness, deafness, learning problems, or
behavioral problems
4. Instructing the breast-feeding mother regarding the treatment of the nipples with
nystatin ointment (CORRECT ANSWER) 2. Maintaining standard precautions at all
times while caring for the newborn
Q9. The nurse is planning care for a newborn of a mother with diabetes mellitus.
What is the priority nursing consideration for this newborn ?
1. Developmental delays because of excessive size
2. Maintaining safety because of low blood glucose level
3. Choking because of impaired suck and swallow reflexes
4. Elevated body temperature because of excess fat and glycogen (CORRECT
ANSWER) 2. Maintaining safety because of low blood glucose level
