NR 327 Maternal-Child Nursing Week 5 Study Guide 2026
|Chamberlain College
1. A newborn has a heart rate of 110 bpm, a slow and irregular respiratory
effort, some flexion of extremities, a grimace response to suctioning, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: Heart rate >100 (2 points), slow/irregular respirations (1 point), some flexion
(1 point), grimace (1 point), and acrocyanosis (1 point) equals a total score of 6.
2. Which mechanism of heat loss occurs when a newborn is placed on a cold
scale?
A. Convection
B. Radiation
C. Evaporation
D. Conduction
Answer: D
Rationale: Conduction is the loss of heat through direct contact with a cooler surface.
,3. Why is Vitamin K (phytonadione) administered to the newborn within the
first hour of birth?
A. To prevent ophthalmia neonatorum
B. To stimulate the production of insulin
C. To prevent vitamin K deficiency bleeding
D. To treat neonatal jaundice
Answer: C
Rationale: Newborns are born with low levels of vitamin K due to a sterile gut;
administration prevents hemorrhagic disease of the newborn.
4. A nurse observes a bluish-black pigmented area on the newborn’s
lumbosacral region. How should the nurse document this finding?
A. Nevus flammeus
B. Telangiectatic nevi
C. Erythema toxicum
D. Mongolian spots
Answer: D
Rationale: Mongolian spots are common birthmarks in infants of darker skin tones and are
benign pigmented areas.
5. Which of the following findings in a 12-hour-old newborn requires immediate
intervention?
A. Acrocyanosis
B. Respiratory rate of 45 breaths/min
C. Heart rate of 140 bpm
D. Jaundice on the face
Answer: D
Rationale: Jaundice appearing within the first 24 hours of life is considered pathologic and
requires investigation, unlike physiologic jaundice which appears later.
, 6. When assessing the Moro reflex, the nurse should expect which response
from the infant?
A. Fanning of the toes when the sole of the foot is stroked
B. Turning of the head toward the side where the cheek was touched
C. Symmetrical abduction and extension of the arms followed by adduction
D. Curving of the trunk toward the side that was stimulated
Answer: C
Rationale: The Moro reflex, or startle reflex, involves the infant spreading the arms out
and then pulling them back in when feeling a loss of support.
7. What is the primary purpose of administering Erythromycin ophthalmic
ointment?
A. To improve the infant’s vision
B. To keep the eyes moist during the transition period
C. To prevent infections caused by Neisseria gonorrhoeae
D. To prevent viral conjunctivitis
Answer: C
Rationale: Erythromycin is used as a prophylactic treatment to prevent blindness caused
by gonorrhea or chlamydia contracted during birth.
8. A mother is concerned that her 2-day-old newborn has lost 7% of his birth
weight. What is the nurse’s best response?
A. ‘This is a normal finding; newborns often lose up to 10% of their birth weight.’
B. ‘We need to supplement with formula immediately.’
C. ‘This indicates that the baby is dehydrated.’
D. ‘We will need to run blood tests to check his metabolism.’
Answer: A
Rationale: It is normal for newborns to lose 5% to 10% of their birth weight in the first
few days of life due to fluid loss and low intake.
|Chamberlain College
1. A newborn has a heart rate of 110 bpm, a slow and irregular respiratory
effort, some flexion of extremities, a grimace response to suctioning, and a pink
body with blue extremities. What is the APGAR score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: Heart rate >100 (2 points), slow/irregular respirations (1 point), some flexion
(1 point), grimace (1 point), and acrocyanosis (1 point) equals a total score of 6.
2. Which mechanism of heat loss occurs when a newborn is placed on a cold
scale?
A. Convection
B. Radiation
C. Evaporation
D. Conduction
Answer: D
Rationale: Conduction is the loss of heat through direct contact with a cooler surface.
,3. Why is Vitamin K (phytonadione) administered to the newborn within the
first hour of birth?
A. To prevent ophthalmia neonatorum
B. To stimulate the production of insulin
C. To prevent vitamin K deficiency bleeding
D. To treat neonatal jaundice
Answer: C
Rationale: Newborns are born with low levels of vitamin K due to a sterile gut;
administration prevents hemorrhagic disease of the newborn.
4. A nurse observes a bluish-black pigmented area on the newborn’s
lumbosacral region. How should the nurse document this finding?
A. Nevus flammeus
B. Telangiectatic nevi
C. Erythema toxicum
D. Mongolian spots
Answer: D
Rationale: Mongolian spots are common birthmarks in infants of darker skin tones and are
benign pigmented areas.
5. Which of the following findings in a 12-hour-old newborn requires immediate
intervention?
A. Acrocyanosis
B. Respiratory rate of 45 breaths/min
C. Heart rate of 140 bpm
D. Jaundice on the face
Answer: D
Rationale: Jaundice appearing within the first 24 hours of life is considered pathologic and
requires investigation, unlike physiologic jaundice which appears later.
, 6. When assessing the Moro reflex, the nurse should expect which response
from the infant?
A. Fanning of the toes when the sole of the foot is stroked
B. Turning of the head toward the side where the cheek was touched
C. Symmetrical abduction and extension of the arms followed by adduction
D. Curving of the trunk toward the side that was stimulated
Answer: C
Rationale: The Moro reflex, or startle reflex, involves the infant spreading the arms out
and then pulling them back in when feeling a loss of support.
7. What is the primary purpose of administering Erythromycin ophthalmic
ointment?
A. To improve the infant’s vision
B. To keep the eyes moist during the transition period
C. To prevent infections caused by Neisseria gonorrhoeae
D. To prevent viral conjunctivitis
Answer: C
Rationale: Erythromycin is used as a prophylactic treatment to prevent blindness caused
by gonorrhea or chlamydia contracted during birth.
8. A mother is concerned that her 2-day-old newborn has lost 7% of his birth
weight. What is the nurse’s best response?
A. ‘This is a normal finding; newborns often lose up to 10% of their birth weight.’
B. ‘We need to supplement with formula immediately.’
C. ‘This indicates that the baby is dehydrated.’
D. ‘We will need to run blood tests to check his metabolism.’
Answer: A
Rationale: It is normal for newborns to lose 5% to 10% of their birth weight in the first
few days of life due to fluid loss and low intake.
