Maternity Nursing (OB Maternal &
Newborn) NCLEX Practice Quiz #3 |
75 Questions
1. Question
A newborn who has an asymmetrical Moro reflex response should
be further assessed for which of the following?
o A. Talipes equinovarus
o B. Fractured clavicle
o C. Congenital hypothyroidism
o D. Increased intracranial pressure
Correct Answer: B. Fractured clavicle
A fractured clavicle would prevent the normal Moro response of
symmetrical sequential extension and abduction of the arms
followed by flexion and adduction.
Option A: In talipes equinovarus (clubfoot) the foot is
turned medially, and in plantar flexion, with the heel
elevated. The feet are not involved with the Moro
reflex.
Option C: Hypothyroidism has no effect on the
primitive reflexes. Hypothyroidism means that the
thyroid gland can’t make enough thyroid hormones to
keep the body running normally.
Option D: The absence of the Moro reflex is the most
significant single indicator of central nervous system
status, but it is not a sign of increased intracranial
pressure.
2. 2. Question
During the first 4 hours after a male circumcision, assessing for
which of the following is the priority?
A. Infection
, B. Hemorrhage
C. Discomfort
D. Dehydration
Correct Answer: B. Hemorrhage
Hemorrhage is a potential risk following any surgical procedure.
Although the infant has been given vitamin K to facilitate clotting,
the prophylactic dose is often not sufficient to prevent bleeding.
Option A: Although infection is a possibility, signs will
not appear within 4 hours after the surgical procedure.
Option C: The primary discomfort of circumcision
occurs during the surgical procedure, not afterward.
Option D: Although feedings are withheld prior to the
circumcision, the chances of dehydration are minimal.
3. 3. Question
The mother asks the nurse. “What’s wrong with my son’s
breasts? Why are they so enlarged?” Which of the following
would be the best response by the nurse?
A. “The breast tissue is inflamed from the trauma
experienced with birth.”
B. “A decrease in material hormones present
before birth causes enlargement,”
C. “You should discuss this with your doctor. It could be
a malignancy.”
D. “The tissue has hypertrophied while the baby was in
the uterus.”
Correct Answer: B. “A decrease in material hormones
present before birth causes enlargement,”
The presence of excessive estrogen and progesterone in the
maternal-fetal blood followed by prompt withdrawal at birth
precipitates breast engorgement, which will spontaneously
resolve in 4 to 5 days after birth.
, Option A: The trauma of the birth process does not
cause inflammation of the newborn’s breast tissue.
Option C: Newborns do not have breast malignancy.
This reply by the nurse would cause the mother to
have undue anxiety.
Option D: Breast tissue does not hypertrophy in the
fetus or newborns.
4. 4. Question
Immediately after birth, the nurse notes the following on a male
newborn: respirations 78; apical heart rate 160 BPM, nostril-
flaring; mild intercostal retractions; and grunting at the end of
expiration. Which of the following should the nurse do?
A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares.
D. Recognize this as a normal first period of
reactivity.
Correct Answer: D. Recognize this as normal first period
of reactivity
The first 15 minutes to 1 hour after birth is the first period of
reactivity involving respiratory and circulatory adaptation to
extrauterine life. The data given reflect the normal changes
during this time period.
Option A: The infant’s assessment data reflect
normal adaptation. Thus, the physician does not need
to be notified.
Option B: Babies with heart or lung problems may
need to breathe increased amounts of oxygen to get
normal levels of oxygen in their blood. Oxygen therapy
provides babies with extra oxygen.
Option C: The data do not indicate the presence of
choking, gagging, or coughing, which are signs of
excessive secretions. Suctioning is not necessary.
5. 5. Question
, The nurse hears a mother telling a friend on the telephone about
umbilical cord care. Which of the following statements by the
mother indicates effective teaching?
A. “Daily soap and water cleansing is best.”
B. “Alcohol helps it dry and kills germs.”
C. “An antibiotic ointment applied daily prevents
infection.”
D. “He can have a tub bath each day.”
Correct Answer: B. “Alcohol helps it dry and kills germs”
Application of 70% isopropyl alcohol to the cord minimizes
microorganisms (germicidal) and promotes drying. The cord
should be kept dry until it falls off and the stump has healed.
Option A: Research now shows that the stump might
actually heal faster if left alone. If the stump becomes
dirty or sticky, clean it with plain water, after which
you dry it by holding a clean, absorbent cloth around it
or fanning it with a piece of paper.
Option C: Antibiotic ointment should only be used to
treat an infection, not as prophylaxis.
Option D: Infants should not be submerged in a tub
of water until the cord falls off and the stump has
completely healed.
6. 6. Question
A newborn weighing 3000 grams and feeding every 4 hours
needs 120 calories/kg of body weight every 24 hours for proper
growth and development. How many ounces of 20 cals/oz
formula should this newborn receive at each feeding to meet
nutritional needs?
A. 2 ounces
B. 3 ounces
Newborn) NCLEX Practice Quiz #3 |
75 Questions
1. Question
A newborn who has an asymmetrical Moro reflex response should
be further assessed for which of the following?
o A. Talipes equinovarus
o B. Fractured clavicle
o C. Congenital hypothyroidism
o D. Increased intracranial pressure
Correct Answer: B. Fractured clavicle
A fractured clavicle would prevent the normal Moro response of
symmetrical sequential extension and abduction of the arms
followed by flexion and adduction.
Option A: In talipes equinovarus (clubfoot) the foot is
turned medially, and in plantar flexion, with the heel
elevated. The feet are not involved with the Moro
reflex.
Option C: Hypothyroidism has no effect on the
primitive reflexes. Hypothyroidism means that the
thyroid gland can’t make enough thyroid hormones to
keep the body running normally.
Option D: The absence of the Moro reflex is the most
significant single indicator of central nervous system
status, but it is not a sign of increased intracranial
pressure.
2. 2. Question
During the first 4 hours after a male circumcision, assessing for
which of the following is the priority?
A. Infection
, B. Hemorrhage
C. Discomfort
D. Dehydration
Correct Answer: B. Hemorrhage
Hemorrhage is a potential risk following any surgical procedure.
Although the infant has been given vitamin K to facilitate clotting,
the prophylactic dose is often not sufficient to prevent bleeding.
Option A: Although infection is a possibility, signs will
not appear within 4 hours after the surgical procedure.
Option C: The primary discomfort of circumcision
occurs during the surgical procedure, not afterward.
Option D: Although feedings are withheld prior to the
circumcision, the chances of dehydration are minimal.
3. 3. Question
The mother asks the nurse. “What’s wrong with my son’s
breasts? Why are they so enlarged?” Which of the following
would be the best response by the nurse?
A. “The breast tissue is inflamed from the trauma
experienced with birth.”
B. “A decrease in material hormones present
before birth causes enlargement,”
C. “You should discuss this with your doctor. It could be
a malignancy.”
D. “The tissue has hypertrophied while the baby was in
the uterus.”
Correct Answer: B. “A decrease in material hormones
present before birth causes enlargement,”
The presence of excessive estrogen and progesterone in the
maternal-fetal blood followed by prompt withdrawal at birth
precipitates breast engorgement, which will spontaneously
resolve in 4 to 5 days after birth.
, Option A: The trauma of the birth process does not
cause inflammation of the newborn’s breast tissue.
Option C: Newborns do not have breast malignancy.
This reply by the nurse would cause the mother to
have undue anxiety.
Option D: Breast tissue does not hypertrophy in the
fetus or newborns.
4. 4. Question
Immediately after birth, the nurse notes the following on a male
newborn: respirations 78; apical heart rate 160 BPM, nostril-
flaring; mild intercostal retractions; and grunting at the end of
expiration. Which of the following should the nurse do?
A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares.
D. Recognize this as a normal first period of
reactivity.
Correct Answer: D. Recognize this as normal first period
of reactivity
The first 15 minutes to 1 hour after birth is the first period of
reactivity involving respiratory and circulatory adaptation to
extrauterine life. The data given reflect the normal changes
during this time period.
Option A: The infant’s assessment data reflect
normal adaptation. Thus, the physician does not need
to be notified.
Option B: Babies with heart or lung problems may
need to breathe increased amounts of oxygen to get
normal levels of oxygen in their blood. Oxygen therapy
provides babies with extra oxygen.
Option C: The data do not indicate the presence of
choking, gagging, or coughing, which are signs of
excessive secretions. Suctioning is not necessary.
5. 5. Question
, The nurse hears a mother telling a friend on the telephone about
umbilical cord care. Which of the following statements by the
mother indicates effective teaching?
A. “Daily soap and water cleansing is best.”
B. “Alcohol helps it dry and kills germs.”
C. “An antibiotic ointment applied daily prevents
infection.”
D. “He can have a tub bath each day.”
Correct Answer: B. “Alcohol helps it dry and kills germs”
Application of 70% isopropyl alcohol to the cord minimizes
microorganisms (germicidal) and promotes drying. The cord
should be kept dry until it falls off and the stump has healed.
Option A: Research now shows that the stump might
actually heal faster if left alone. If the stump becomes
dirty or sticky, clean it with plain water, after which
you dry it by holding a clean, absorbent cloth around it
or fanning it with a piece of paper.
Option C: Antibiotic ointment should only be used to
treat an infection, not as prophylaxis.
Option D: Infants should not be submerged in a tub
of water until the cord falls off and the stump has
completely healed.
6. 6. Question
A newborn weighing 3000 grams and feeding every 4 hours
needs 120 calories/kg of body weight every 24 hours for proper
growth and development. How many ounces of 20 cals/oz
formula should this newborn receive at each feeding to meet
nutritional needs?
A. 2 ounces
B. 3 ounces
