NCLEX-maternity and newborn LATEST EXAM STUDY GUIDE ACTUAL
EXAM QUESTIONS AND WELL ELABORATED ANSWERS (MOST TESTED
QUESTIONS WITH VERIFIED ANSWERS) LATEST UPDATES 2025
|ALREADY GRADED A+ (REVISED EXAM)
Which safety measures should be implemented at delivery and when
working in the newborn nursery? Select all that apply. - CORRECT
ANSWER 1. Adhere to standard precautions during delivery and in the
nursery
2. The parents should be instructed to not release their newborn infant
to anyone wearing improper identification.
3. The mother should be fingerprinted and the infant should be
footprints on the identification card before removing the infant from
the delivery room
The nurse is bathing a neonate and notices small dark tufts of fine hair
on the neonate's lower back. Based on this observation, the nurse
should take which action? - CORRECT ANSWER Arrange to notify the
health care provider of this physical finding
,The nurse is reviewing the procedure for vitamin K injection in the
newborn with a nursing student. Which information should the nurse
provide to the student? - CORRECT ANSWER Inject into the skin that
has been cleansed thoroughly with alcohol
Which nursing interventions should be implemented for a newborn
receiving phototherapy? Select all that apply. - CORRECT ANSWER 1.
Monitor the temperature frequently
2. Protect the eyes with an opaque mask
3. Monitor the number and consistency of stools
A newborn has just been circumcised. Which postcircumcision
interventions should the nurse implement? Select all that apply. -
CORRECT ANSWER 1. Observe for bleeding
2. Note the time and amount of the first void after the circumcision
3. Apply fresh petrolatum around the glans after each diaper change
The nurse is performing an initial assessment on a newborn. After
completing the assessment, the nurse reviews the objective
assessment data to identify any area that does not meet normal
newborn criteria. Which assessment observations are considered
acceptable criteria for the newborn? Select all that apply - CORRECT
ANSWER 1. Heart rate of 136 beats per minute
2. Two arteries and one vein in the umbilical cord
The nurse is monitoring a newborn for signs of increased intracranial
pressure (ICP). On assessment of the fontanels, the nurse notes that
the anterior fontanel bulges when the newborn is sleeping. On the
basis of this finding, the nurse should take which initial action? -
CORRECT ANSWER Notify the health care provider
The nurse is monitoring a newborn infant who was circumcised. The
nurse notes that the infant has a temperature of 100.6° F and that the
dressing at the circumcised area is saturated with a foul-smelling
drainage. Which should be the priority nursing action? - CORRECT
ANSWER Contact the health care provider
,The nurse explains to a mother that her newborn infant is being
admitted to the neonatal intensive care unit with a probable diagnosis
of fetal alcohol syndrome (FAS). The nurse explains the expected
effects of FAS to the mother and tells the mother which information? -
CORRECT ANSWER Withdrawal symptoms include tremors, crying,
seizures and abnormal reflexes
A client is to be discharged with her newborn baby. Which statement
made by the client indicates there is a need for further teaching
regarding care of her baby? - CORRECT ANSWER I have a car seat
that i will put in the front seat to keep my baby safe
A nurse is providing teaching for a client who has a new prescription
for combined oral contraceptives, which of the following findings
should the nurse include as an adverse effect of this medication
A) Depression
B) Polyuria
C) Hypotension
D) Urticaria - CORRECT ANSWER A) Depression
A nurse is providing teaching to a client who is at 40 weeks of
gestation and has a new prescription for misoprostol. Which of the
following instructions should the nurse include in the teaching?
A) I can administer oxytocin 4 hours after the insertion of the
medication
B) You will need a full bladder prior to the insertion of the medication
C) Remain in a side lying position for 15 minutes after the medication
is inserted
D) An antacid will be given 20 minutes prior to the insertion of the
medication - CORRECT ANSWER A) I can administer oxytocin 4 hours
after the insertion of the medication
A nurse is caring for a prenatal client who has parvovirus B19 (fifth
disease). Which of the following actions should the nurse take?
A) Administer antiviral medication
B) Schedule an ultrasound examination
, C) Administer Haemophilus influenza type B vaccine
D) Schedule an indirect coombs test - CORRECT ANSWER B)
Schedule an ultrasound examination
To monitor the fetus during pregnancy to detect the possible
development of fetal hydrops. The virus can cause miscarriage, IUGR,
fetal anemia, or stillbirth. There is no antiviral medication available.
A nurse is caring for a client who is at 14 weeks of gestation and has a
suspected placental abruption. Which of the following laboratory tests
should the nurse expect the provider to prescribe?
A) Kleihauer-Betke test
B) Progesterone serum level
C) Lecithin/sphingomyelin ratio
D) Maternal Alpha-fetoprotein - CORRECT ANSWER A) Kleihauer-
Betke test
To determine if their is fetal blood in maternal circulation
A nurse is admitting a client who is in labor. The client admits to
recent cocaine use. For which of the following complications should
the nurse assess?
A) Abruptio placenta
B) Placenta previa
C) Preeclampsia
D) Maternal bradycardia - CORRECT ANSWER A) Abruptio placenta
A nurse is assessing a client who has severe preeclampsia. Which of
the following manifestations should the nurse expect?
A) 2+ dtr
B) Proteinuria of 200 mg in a 24 hr specimen
C) Polyuria
D) Blurred vision - CORRECT ANSWER D) Blurred vision
A nurse is teaching a newly licensed nurse about collecting a
specimen for the universal newborn screening. Which of the following
statements should the nurse include in the teaching?
A) Obtain informed consent
EXAM QUESTIONS AND WELL ELABORATED ANSWERS (MOST TESTED
QUESTIONS WITH VERIFIED ANSWERS) LATEST UPDATES 2025
|ALREADY GRADED A+ (REVISED EXAM)
Which safety measures should be implemented at delivery and when
working in the newborn nursery? Select all that apply. - CORRECT
ANSWER 1. Adhere to standard precautions during delivery and in the
nursery
2. The parents should be instructed to not release their newborn infant
to anyone wearing improper identification.
3. The mother should be fingerprinted and the infant should be
footprints on the identification card before removing the infant from
the delivery room
The nurse is bathing a neonate and notices small dark tufts of fine hair
on the neonate's lower back. Based on this observation, the nurse
should take which action? - CORRECT ANSWER Arrange to notify the
health care provider of this physical finding
,The nurse is reviewing the procedure for vitamin K injection in the
newborn with a nursing student. Which information should the nurse
provide to the student? - CORRECT ANSWER Inject into the skin that
has been cleansed thoroughly with alcohol
Which nursing interventions should be implemented for a newborn
receiving phototherapy? Select all that apply. - CORRECT ANSWER 1.
Monitor the temperature frequently
2. Protect the eyes with an opaque mask
3. Monitor the number and consistency of stools
A newborn has just been circumcised. Which postcircumcision
interventions should the nurse implement? Select all that apply. -
CORRECT ANSWER 1. Observe for bleeding
2. Note the time and amount of the first void after the circumcision
3. Apply fresh petrolatum around the glans after each diaper change
The nurse is performing an initial assessment on a newborn. After
completing the assessment, the nurse reviews the objective
assessment data to identify any area that does not meet normal
newborn criteria. Which assessment observations are considered
acceptable criteria for the newborn? Select all that apply - CORRECT
ANSWER 1. Heart rate of 136 beats per minute
2. Two arteries and one vein in the umbilical cord
The nurse is monitoring a newborn for signs of increased intracranial
pressure (ICP). On assessment of the fontanels, the nurse notes that
the anterior fontanel bulges when the newborn is sleeping. On the
basis of this finding, the nurse should take which initial action? -
CORRECT ANSWER Notify the health care provider
The nurse is monitoring a newborn infant who was circumcised. The
nurse notes that the infant has a temperature of 100.6° F and that the
dressing at the circumcised area is saturated with a foul-smelling
drainage. Which should be the priority nursing action? - CORRECT
ANSWER Contact the health care provider
,The nurse explains to a mother that her newborn infant is being
admitted to the neonatal intensive care unit with a probable diagnosis
of fetal alcohol syndrome (FAS). The nurse explains the expected
effects of FAS to the mother and tells the mother which information? -
CORRECT ANSWER Withdrawal symptoms include tremors, crying,
seizures and abnormal reflexes
A client is to be discharged with her newborn baby. Which statement
made by the client indicates there is a need for further teaching
regarding care of her baby? - CORRECT ANSWER I have a car seat
that i will put in the front seat to keep my baby safe
A nurse is providing teaching for a client who has a new prescription
for combined oral contraceptives, which of the following findings
should the nurse include as an adverse effect of this medication
A) Depression
B) Polyuria
C) Hypotension
D) Urticaria - CORRECT ANSWER A) Depression
A nurse is providing teaching to a client who is at 40 weeks of
gestation and has a new prescription for misoprostol. Which of the
following instructions should the nurse include in the teaching?
A) I can administer oxytocin 4 hours after the insertion of the
medication
B) You will need a full bladder prior to the insertion of the medication
C) Remain in a side lying position for 15 minutes after the medication
is inserted
D) An antacid will be given 20 minutes prior to the insertion of the
medication - CORRECT ANSWER A) I can administer oxytocin 4 hours
after the insertion of the medication
A nurse is caring for a prenatal client who has parvovirus B19 (fifth
disease). Which of the following actions should the nurse take?
A) Administer antiviral medication
B) Schedule an ultrasound examination
, C) Administer Haemophilus influenza type B vaccine
D) Schedule an indirect coombs test - CORRECT ANSWER B)
Schedule an ultrasound examination
To monitor the fetus during pregnancy to detect the possible
development of fetal hydrops. The virus can cause miscarriage, IUGR,
fetal anemia, or stillbirth. There is no antiviral medication available.
A nurse is caring for a client who is at 14 weeks of gestation and has a
suspected placental abruption. Which of the following laboratory tests
should the nurse expect the provider to prescribe?
A) Kleihauer-Betke test
B) Progesterone serum level
C) Lecithin/sphingomyelin ratio
D) Maternal Alpha-fetoprotein - CORRECT ANSWER A) Kleihauer-
Betke test
To determine if their is fetal blood in maternal circulation
A nurse is admitting a client who is in labor. The client admits to
recent cocaine use. For which of the following complications should
the nurse assess?
A) Abruptio placenta
B) Placenta previa
C) Preeclampsia
D) Maternal bradycardia - CORRECT ANSWER A) Abruptio placenta
A nurse is assessing a client who has severe preeclampsia. Which of
the following manifestations should the nurse expect?
A) 2+ dtr
B) Proteinuria of 200 mg in a 24 hr specimen
C) Polyuria
D) Blurred vision - CORRECT ANSWER D) Blurred vision
A nurse is teaching a newly licensed nurse about collecting a
specimen for the universal newborn screening. Which of the following
statements should the nurse include in the teaching?
A) Obtain informed consent
