NURS 203 | NURS 203 Maternity Exam 4 Version 2 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse evaluates a newborn at 1 minute of life and finds: Heart rate 110 bpm, slow
and irregular respirations, some flexion of extremities, grimace during suctioning, and
a pink body with blue hands and feet. What is the APGAR score?
A. 5
B. 4
C. 7
D. 6
Correct Answer: D
Expert Explanation: The heart rate over 100 beats per minute provides two points
for the score. Slow and irregular respiratory effort contributes one point to the
evaluation. Some flexion of the extremities is graded as one point for muscle tone. A
grimace during suctioning represents one point for reflex irritability. Finally, the
presence of acrocyanosis results in one point for color.
2. Which mechanism of heat loss is a nurse preventing when they place a newborn on
a pre-warmed scale with a protective cover?
A. Evaporation
,B. Convection
C. Radiation
D. Conduction
Correct Answer: D
Expert Explanation: Conduction is the transfer of heat from the body to a cooler
surface by direct contact. Placing a baby on a cold metal scale would quickly pull
heat away from the skin. Pre-warming the scale or using a cover creates a thermal
barrier to prevent this loss. This is a critical intervention in maintaining the
newborn’s neutral thermal environment. Nurses must always ensure that any
surface touching the infant is appropriately warmed.
3. A mother asks why her newborn is receiving Erythromycin ophthalmic ointment.
Which response by the nurse is most accurate?
A. It is a vitamin supplement to help with visual development.
B. It is used to treat an active eye infection the baby was born with.
C. It helps the baby’s eyes adjust to the bright lights of the nursery.
D. It prevents blindness caused by gonorrhea or chlamydia during birth.
Correct Answer: D
,Expert Explanation: Erythromycin ointment is legally mandated in many regions
to prevent ophthalmia neonatorum. This condition is caused by exposure to
Neisseria gonorrhoeae or Chlamydia trachomatis in the birth canal. If left untreated,
these infections can lead to permanent blindness in the infant. The ointment is
applied within the first hour of life as a prophylactic measure. It is a standard of care
for all newborns regardless of the delivery method.
4. While assessing a newborn, the nurse notices the infant’s arms extend and abduct,
followed by an embrace-like motion when startled. Which reflex is being
demonstrated?
A. Babinski reflex
B. Tonic neck reflex
C. Moro reflex
D. Stepping reflex
Correct Answer: C
Expert Explanation: The Moro reflex is also known as the startle reflex and is a
normal neurological finding. It is elicited by a sudden change in position or a loud
noise. The infant typically responds by extending the arms and then bringing them
back toward the body. This reflex should be symmetrical and is usually present until
, about four months of age. Asymmetry in this reflex could indicate a fractured
clavicle or brachial plexus injury.
5. Why is Vitamin K (Phytonadione) administered to a newborn shortly after birth?
A. To stimulate the production of red blood cells.
B. To assist with the digestion of breast milk or formula.
C. To prevent hemorrhagic disease of the newborn.
D. To boost the infant’s immune system against bacteria.
Correct Answer: C
Expert Explanation: Newborns are born with sterile intestines and lack the
bacteria necessary to synthesize Vitamin K. Vitamin K is essential for the synthesis
of several blood clotting factors in the liver. Without this injection, the infant is at a
significantly higher risk for spontaneous bleeding. The dose is typically given
intramuscularly in the vastus lateralis muscle shortly after birth. This intervention is
a vital safety measure to ensure the infant’s coagulation system functions properly.
6. A nurse is assessing a newborn 2 hours after birth. Which finding would be a
primary indicator of hypoglycemia?
A. Loud, vigorous crying
B. Jitteriness or tremors
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse evaluates a newborn at 1 minute of life and finds: Heart rate 110 bpm, slow
and irregular respirations, some flexion of extremities, grimace during suctioning, and
a pink body with blue hands and feet. What is the APGAR score?
A. 5
B. 4
C. 7
D. 6
Correct Answer: D
Expert Explanation: The heart rate over 100 beats per minute provides two points
for the score. Slow and irregular respiratory effort contributes one point to the
evaluation. Some flexion of the extremities is graded as one point for muscle tone. A
grimace during suctioning represents one point for reflex irritability. Finally, the
presence of acrocyanosis results in one point for color.
2. Which mechanism of heat loss is a nurse preventing when they place a newborn on
a pre-warmed scale with a protective cover?
A. Evaporation
,B. Convection
C. Radiation
D. Conduction
Correct Answer: D
Expert Explanation: Conduction is the transfer of heat from the body to a cooler
surface by direct contact. Placing a baby on a cold metal scale would quickly pull
heat away from the skin. Pre-warming the scale or using a cover creates a thermal
barrier to prevent this loss. This is a critical intervention in maintaining the
newborn’s neutral thermal environment. Nurses must always ensure that any
surface touching the infant is appropriately warmed.
3. A mother asks why her newborn is receiving Erythromycin ophthalmic ointment.
Which response by the nurse is most accurate?
A. It is a vitamin supplement to help with visual development.
B. It is used to treat an active eye infection the baby was born with.
C. It helps the baby’s eyes adjust to the bright lights of the nursery.
D. It prevents blindness caused by gonorrhea or chlamydia during birth.
Correct Answer: D
,Expert Explanation: Erythromycin ointment is legally mandated in many regions
to prevent ophthalmia neonatorum. This condition is caused by exposure to
Neisseria gonorrhoeae or Chlamydia trachomatis in the birth canal. If left untreated,
these infections can lead to permanent blindness in the infant. The ointment is
applied within the first hour of life as a prophylactic measure. It is a standard of care
for all newborns regardless of the delivery method.
4. While assessing a newborn, the nurse notices the infant’s arms extend and abduct,
followed by an embrace-like motion when startled. Which reflex is being
demonstrated?
A. Babinski reflex
B. Tonic neck reflex
C. Moro reflex
D. Stepping reflex
Correct Answer: C
Expert Explanation: The Moro reflex is also known as the startle reflex and is a
normal neurological finding. It is elicited by a sudden change in position or a loud
noise. The infant typically responds by extending the arms and then bringing them
back toward the body. This reflex should be symmetrical and is usually present until
, about four months of age. Asymmetry in this reflex could indicate a fractured
clavicle or brachial plexus injury.
5. Why is Vitamin K (Phytonadione) administered to a newborn shortly after birth?
A. To stimulate the production of red blood cells.
B. To assist with the digestion of breast milk or formula.
C. To prevent hemorrhagic disease of the newborn.
D. To boost the infant’s immune system against bacteria.
Correct Answer: C
Expert Explanation: Newborns are born with sterile intestines and lack the
bacteria necessary to synthesize Vitamin K. Vitamin K is essential for the synthesis
of several blood clotting factors in the liver. Without this injection, the infant is at a
significantly higher risk for spontaneous bleeding. The dose is typically given
intramuscularly in the vastus lateralis muscle shortly after birth. This intervention is
a vital safety measure to ensure the infant’s coagulation system functions properly.
6. A nurse is assessing a newborn 2 hours after birth. Which finding would be a
primary indicator of hypoglycemia?
A. Loud, vigorous crying
B. Jitteriness or tremors
