Maternity Newborn Exam Study Guide Questions And
Answers Verified 100% Correct
A nursing instructor is observing a nursing student caring for a newborn with a diagnosis
of bladder exstrophy. The nursing student provides appropriate care to the infant by
which action?
1. Covering the bladder with Tegaderm
2. Covering the bladder with a dry, sterile dressing
3. Covering the bladder with a sterile, nonadhering moist dressing
4. Applying sterile water soaks and a dry, sterile dressing to the mucosa - ANSWER3
Rationale:
The priority nursing intervention right after birth of a neonate with exstrophy of the
bladder is to prevent infection of the sac. Infection of the sac can result if the sac leaks.
This can be prevented by keeping the sac moist and covered. It is also imperative that
the covering be of a nonadhering type.
The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of
subdural hematoma after a difficult vaginal delivery. Which intervention implemented by
the nurse indicates an understanding of a subdural hematoma?
1. Checking the urine for blood
2. Monitoring urinary output patterns
3. Observing for contractures of the extremities
4. Testing for equality of extremities when stimulating reflexes - ANSWER4
Rationale:
,A subdural hematoma can cause pressure on a specific area of the cerebral tissue.
Especially if actively bleeding, this can cause changes in the stimuli responses in the
extremities on the opposite side of the body. Options 1 and 2 are incorrect. An infant,
after delivery, normally is incontinent of urine. Blood in the urine would indicate
abdominal trauma. Option 3 is incorrect because contractures do not occur this soon
after delivery.
*Checking newborn reflexes is a basic assessment for determining neurological
complications in this age group.*
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate
admitted to the newborn nursery. The nurse determines that which additional sign would
be consistent with fetal alcohol syndrome (FAS)?
1. Length 19 inches
2. Birth weight 6 pounds 14 ounces
3. Microcephaly and increased respiratory effort
4. Head circumference appropriate for gestational age - ANSWER3
Rationale:
Features associated with FAS include craniofacial abnormalities, cleft lip or palate,
abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies,
and increased respiratory effort during the transition to extrauterine life also are noted
frequently in the neonate with FAS.
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one
day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action
is appropriate related to this finding?
1. Increase oral fluids.
2. Document the finding.
3. Notify the primary health care provider.
4. Assess blood pressure readings every 4 hours for the next 24 hours. - ANSWER2
Rationale:
, During the first week after giving birth, transient episodes of bradycardia are common in
the mother. The woman's pulse may be as low as 40 to 50 beats/min the first 1 to 2
days after delivery. It is not necessary to notify the primary health care provider.
Increasing oral fluids, notifying the primary health care provider and performing
numerous blood pressure screenings are not necessary.
An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of
99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is
hyperactive to environmental stimuli. The nurse determines that these behaviors may
be consistent with what problem?
1. Sepsis
2. Hypercalcemia
3. Drug withdrawal
4. Intraventricular hemorrhage - ANSWER3
Rationale:
Drug withdrawal causes a hyperactive response in the infant because of the increased
central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased
use of calories). This response and the signs and symptoms of drug withdrawal seem to
be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular
hemorrhage are characterized by symptoms of CNS depression.
The nurse is planning for the nursery room admission of a large-for-gestational-age
(LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for
which diagnostic test?
1. Serum insulin level
2. Heel stick blood glucose
3. Rh and ABO blood typing
4. Indirect and direct bilirubin levels - ANSWER2
Rationale:
After birth, the most common problem in the LGA infant is hypoglycemia, especially if
the mother has diabetes mellitus. At delivery when the umbilical cord is clamped and
cut, the maternal blood glucose supply is lost. The newborn continues to produce large
Answers Verified 100% Correct
A nursing instructor is observing a nursing student caring for a newborn with a diagnosis
of bladder exstrophy. The nursing student provides appropriate care to the infant by
which action?
1. Covering the bladder with Tegaderm
2. Covering the bladder with a dry, sterile dressing
3. Covering the bladder with a sterile, nonadhering moist dressing
4. Applying sterile water soaks and a dry, sterile dressing to the mucosa - ANSWER3
Rationale:
The priority nursing intervention right after birth of a neonate with exstrophy of the
bladder is to prevent infection of the sac. Infection of the sac can result if the sac leaks.
This can be prevented by keeping the sac moist and covered. It is also imperative that
the covering be of a nonadhering type.
The nurse is collecting data on a newborn admitted to the nursery with a diagnosis of
subdural hematoma after a difficult vaginal delivery. Which intervention implemented by
the nurse indicates an understanding of a subdural hematoma?
1. Checking the urine for blood
2. Monitoring urinary output patterns
3. Observing for contractures of the extremities
4. Testing for equality of extremities when stimulating reflexes - ANSWER4
Rationale:
,A subdural hematoma can cause pressure on a specific area of the cerebral tissue.
Especially if actively bleeding, this can cause changes in the stimuli responses in the
extremities on the opposite side of the body. Options 1 and 2 are incorrect. An infant,
after delivery, normally is incontinent of urine. Blood in the urine would indicate
abdominal trauma. Option 3 is incorrect because contractures do not occur this soon
after delivery.
*Checking newborn reflexes is a basic assessment for determining neurological
complications in this age group.*
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term neonate
admitted to the newborn nursery. The nurse determines that which additional sign would
be consistent with fetal alcohol syndrome (FAS)?
1. Length 19 inches
2. Birth weight 6 pounds 14 ounces
3. Microcephaly and increased respiratory effort
4. Head circumference appropriate for gestational age - ANSWER3
Rationale:
Features associated with FAS include craniofacial abnormalities, cleft lip or palate,
abnormal palmar creases, and irregular hair distribution. Microcephaly, limb anomalies,
and increased respiratory effort during the transition to extrauterine life also are noted
frequently in the neonate with FAS.
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one
day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action
is appropriate related to this finding?
1. Increase oral fluids.
2. Document the finding.
3. Notify the primary health care provider.
4. Assess blood pressure readings every 4 hours for the next 24 hours. - ANSWER2
Rationale:
, During the first week after giving birth, transient episodes of bradycardia are common in
the mother. The woman's pulse may be as low as 40 to 50 beats/min the first 1 to 2
days after delivery. It is not necessary to notify the primary health care provider.
Increasing oral fluids, notifying the primary health care provider and performing
numerous blood pressure screenings are not necessary.
An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of
99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is
hyperactive to environmental stimuli. The nurse determines that these behaviors may
be consistent with what problem?
1. Sepsis
2. Hypercalcemia
3. Drug withdrawal
4. Intraventricular hemorrhage - ANSWER3
Rationale:
Drug withdrawal causes a hyperactive response in the infant because of the increased
central nervous system (CNS) stimulation (tachypnea, elevated temperature, increased
use of calories). This response and the signs and symptoms of drug withdrawal seem to
be most apparent at around 1 week of age. Hypercalcemia, sepsis, and intraventricular
hemorrhage are characterized by symptoms of CNS depression.
The nurse is planning for the nursery room admission of a large-for-gestational-age
(LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for
which diagnostic test?
1. Serum insulin level
2. Heel stick blood glucose
3. Rh and ABO blood typing
4. Indirect and direct bilirubin levels - ANSWER2
Rationale:
After birth, the most common problem in the LGA infant is hypoglycemia, especially if
the mother has diabetes mellitus. At delivery when the umbilical cord is clamped and
cut, the maternal blood glucose supply is lost. The newborn continues to produce large
