NR 327 Maternal-Child Nursing Week 5 Study Guide 2026
|Chamberlain College
1. A nurse is assessing a newborn’s Apgar score at 1 minute. The infant has a
heart rate of 110, a weak cry, some flexion of the extremities, grimace when
stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is 6: Heart rate >100 (2), weak cry (1), some flexion (1), grimace (1),
and acrocyanosis (1).
2. Which of the following findings in a newborn 2 hours after birth should the
nurse report to the provider?
A. Acrocyanosis
B. Generalized petechiae
C. Milia on the nose
D. Occasional sneezing
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
should be reported. Milia, acrocyanosis, and sneezing are normal findings.
,3. A postpartum nurse is caring for a client who is 4 hours post-delivery. The
nurse notes the fundus is firm, shifted to the right, and two fingerbreadths
above the umbilicus. What is the priority nursing action?
A. Perform fundal massage
B. Administer oxytocin
C. Assist the client to the bathroom to void
D. Notify the healthcare provider
Answer: C
Rationale: A fundus shifted to the right and elevated usually indicates a full bladder, which
can interfere with uterine involution and increase the risk of hemorrhage.
4. A nurse is teaching a new mother about breastfeeding. Which statement by
the mother indicates a need for further teaching?
A. ‘I should feed my baby whenever he shows signs of hunger.’
B. ‘The baby’s nose should be close to my breast but not blocked.’
C. ‘I will wash my nipples with soap and water before each feeding.’
D. ‘I should hear swallowing sounds while my baby is nursing.’
Answer: C
Rationale: Soap can be drying and lead to cracked nipples. Mothers should use water or
express milk to clean/moisten the area.
5. Which medication is routinely administered to newborns within 1 hour of
birth to prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Nystatin
Answer: B
, Rationale: Erythromycin ointment is used as a prophylactic treatment against Neisseria
gonorrhoeae and Chlamydia trachomatis.
6. A nurse is caring for a newborn who has hyperbilirubinemia and is receiving
phototherapy. Which nursing intervention is essential?
A. Covering the newborn’s eyes with an opaque mask
B. Dressing the newborn in a t-shirt and diaper
C. Applying lotion to the skin to prevent dryness
D. Limiting fluid intake to 60 mL/kg/day
Answer: A
Rationale: Phototherapy can damage the newborn’s retina, so an opaque mask is
mandatory during treatment.
7. What is the primary reason for administering Vitamin K (Phytonadione) to a
newborn?
A. To stimulate the immune system
B. To prevent hemorrhagic disease of the newborn
C. To enhance the absorption of calcium
D. To prevent neonatal jaundice
Answer: B
Rationale: Newborns are born with low vitamin K levels because it does not cross the
placenta easily and the sterile gut does not yet produce it; it is essential for clotting factor
synthesis.
|Chamberlain College
1. A nurse is assessing a newborn’s Apgar score at 1 minute. The infant has a
heart rate of 110, a weak cry, some flexion of the extremities, grimace when
stimulated, and a pink body with blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The score is 6: Heart rate >100 (2), weak cry (1), some flexion (1), grimace (1),
and acrocyanosis (1).
2. Which of the following findings in a newborn 2 hours after birth should the
nurse report to the provider?
A. Acrocyanosis
B. Generalized petechiae
C. Milia on the nose
D. Occasional sneezing
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
should be reported. Milia, acrocyanosis, and sneezing are normal findings.
,3. A postpartum nurse is caring for a client who is 4 hours post-delivery. The
nurse notes the fundus is firm, shifted to the right, and two fingerbreadths
above the umbilicus. What is the priority nursing action?
A. Perform fundal massage
B. Administer oxytocin
C. Assist the client to the bathroom to void
D. Notify the healthcare provider
Answer: C
Rationale: A fundus shifted to the right and elevated usually indicates a full bladder, which
can interfere with uterine involution and increase the risk of hemorrhage.
4. A nurse is teaching a new mother about breastfeeding. Which statement by
the mother indicates a need for further teaching?
A. ‘I should feed my baby whenever he shows signs of hunger.’
B. ‘The baby’s nose should be close to my breast but not blocked.’
C. ‘I will wash my nipples with soap and water before each feeding.’
D. ‘I should hear swallowing sounds while my baby is nursing.’
Answer: C
Rationale: Soap can be drying and lead to cracked nipples. Mothers should use water or
express milk to clean/moisten the area.
5. Which medication is routinely administered to newborns within 1 hour of
birth to prevent ophthalmia neonatorum?
A. Vitamin K
B. Erythromycin ophthalmic ointment
C. Hepatitis B vaccine
D. Nystatin
Answer: B
, Rationale: Erythromycin ointment is used as a prophylactic treatment against Neisseria
gonorrhoeae and Chlamydia trachomatis.
6. A nurse is caring for a newborn who has hyperbilirubinemia and is receiving
phototherapy. Which nursing intervention is essential?
A. Covering the newborn’s eyes with an opaque mask
B. Dressing the newborn in a t-shirt and diaper
C. Applying lotion to the skin to prevent dryness
D. Limiting fluid intake to 60 mL/kg/day
Answer: A
Rationale: Phototherapy can damage the newborn’s retina, so an opaque mask is
mandatory during treatment.
7. What is the primary reason for administering Vitamin K (Phytonadione) to a
newborn?
A. To stimulate the immune system
B. To prevent hemorrhagic disease of the newborn
C. To enhance the absorption of calcium
D. To prevent neonatal jaundice
Answer: B
Rationale: Newborns are born with low vitamin K levels because it does not cross the
placenta easily and the sterile gut does not yet produce it; it is essential for clotting factor
synthesis.
