MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6
1. The nurse is discussing the neonatal blood
screening test with a new mother. The nurse
knows that more teaching is needed when the
mother states that which of the following diseases
is included in the screening test?
1. Hypothyroidism.
2. Sickle cell anemia.
3. Galactosemia.
4. Cerebral palsy.
2. The nursery nurse is careful to wear gloves
when admitting neonates into the nursery. Which
of the following is the scientific rationale for this
action?
1. Meconium is filled with enteric bacteria.
2. Amniotic fluid may contain harmful viruses.
3. The high alkalinity of fetal urine is caustic to the
skin.
4. The baby is high risk for infection and must be
protected.
3. A full-term newborn was just born. Which
nursing intervention is important for the nurse to
perform first?
1. Remove wet blankets.
2. Assess Apgar score.
3. Insert eye prophylaxis.
4. Elicit the Moro reflex.
4. To reduce the risk of hypoglycemia in a full-term
newborn weighing 2900 grams, what should the
nurse do?
1. Maintain the infant’s temperature above
97.7oF.
2. Feed the infant glucose water every 3 hours
until breastfeeding well.
3. Assess blood glucose levels every 3 hours for
the first twelve hours.
4. Encourage the mother to breastfeed every 4
hours.
5. A mother asks the nurse to tell her about the
responsiveness of neonates at birth. Which of the
following answers is appropriate?
1. “Babies have a poorly developed sense of smell
until they are 2 months old.”
2. “Babies can taste only salty and sour
substances at birth.”
3. “Babies are especially sensitive to being
touched and cuddled.”
4. “Babies are nearsighted with blurry vision until
they are about 3 months of age.”
6. A mother, 1 day postpartum from a 3-hour labor
and a spontaneous vaginal delivery, questions the
nurse because her baby’s face is “purple.” Upon
examination, the nurse notes petechiae over the
scalp, forehead, and cheeks of the baby. The
nurse’s response should be based on which of the
following?
1. Petechiae are indicative of severe bacterial
infections.
2. Rapid deliveries can injure the neonatal
presenting part.
3. Petechiae are characteristic of the normal
newborn rash.
4. The injuries are a sign that the child has been
abused.
7. A 2-day-old breastfeeding baby born via normal
spontaneous vaginal delivery has just been
weighed in the newborn nursery. The nurse
determines that the baby has lost 3.5% of the birth
weight. Which of the following nursing actions is
appropriate?
1. Do nothing because this is a normal weight
loss.
2. Notify the neonatalogist of the significant weight
loss.
3. Advise the mother to bottlefeed the baby at the
next feed.
4. Assess the baby for hypoglycemia with a
glucose monitor.
8. Four newborns are in the neonatal nursery.
Which of the babies should the nurse report to the
neonatalogist?
1. 16-hour-old baby who has yet to pass
meconium.
2. 16-hour-old baby whose blood glucose is 50
mg/dL.
3. 2-day-old baby who is breathing irregularly at
70 breaths per minute.
4. 2-day-old baby who is excreting a milky
discharge from both nipples.
9. The pediatrician has ordered vitamin K 0.5 mg
IM for a newly born baby. The medication is
available as 2 mg/mL. How many milliliters (mL)
should the nurse administer to the baby? ___ mL
10. A nurse is doing a newborn assessment on a
new admission to the nursery. Which of the
following actions should the nurse make when
evaluating the baby for developmental dysplasia
of the hip (DDH)? Select all that apply.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6
1. Grasp the baby’s thighs with the thumbs on the
inner thighs and forefingers on the outer thighs.
2. Gently adduct the baby’s thighs.
3. Palpate the trochanter to sense changes during
hip rotation.
4. Place the baby in a prone position.
5. Flex the baby’s hips and knees at 90o angles.
11. A nurse notes that a 6-hour-old neonate has
cyanotic hands and feet. Which of the following
actions by the nurse is appropriate?
1. Place child in isolette.
2. Administer oxygen.
3. Swaddle baby in blanket.
4. Apply pulse oximeter.
12. A couple is asking the nurse whether or not
their son should be circumcised. On which fact
should the nurse’s response be based?
1. Boys should be circumcised in order for them to
establish a positive self-image.
2. Boys should not be circumcised because there
is no medical rationale for the procedure.
3. Experts from the Centers for Disease Control
and Prevention argue that circumcision is
desirable.
4. A statement from the American Academy of
Pediatrics asserts that circumcision is optional.
13. A baby boy is to be circumcised by the
mother’s obstetrician. Which of the following
actions shows that the nurse is being a patient
advocate?
1. Before the procedure, the nurse prepares the
sterile field for the physician.
2. The nurse refuses to unclothe the baby until the
doctor orders something for pain.
3. The nurse holds the feeding immediately before
the circumcision.
4. After the procedure, the nurse monitors the site
for signs of bleeding.
14. Using the Neonatal Infant Pain Scale (NIPs),
a nurse is assessing the pain response of a
newborn who has just had a circumcision. A
change in which of the following signs/symptoms
is the nurse evaluating? Select all that apply.
1. Heart rate.
2. Blood pressure.
3. Temperature.
4. Facial expression.
5. Breathing pattern.
15. A nurse is teaching a mother how to care for
her 3-day-old son’s circumcised penis. Which of
the following actions demonstrates that the
mother has learned the information?
1. The mother cleanses the glans with a cotton
swab dipped in hydrogen peroxide.
2. The mother covers the glans with antifungal
ointment after rinsing off any discharge.
3. The mother squeezes soapy water from the
wash cloth over the glans.
4. The mother replaces the dry sterile dressing
before putting on the diaper.
16. Please put an “X” on the site where the nurse
should administer vitamin K 0.5 mg IM to the
neonate.
17. The nurse is teaching a mother regarding the
baby’s sutures and fontanelles. Please put an “X”
on the fontanelle that will close at 6 to 8 weeks of
age.
18. A neonate is being admitted to the well-baby
nursery. Which of the following findings should be
reported to the neonatalogist?
1. Umbilical cord with three vessels.
2. Diamond-shaped anterior fontanelle.
3. Cryptorchidism.
4. Cafe au lait spot.
19. A female African American baby has been
admitted into the nursery. Which of the following
physiological findings would the nurse assess as
normal? Select all that apply.
1. Purple-colored patches on the buttocks and
torso.
2. Bilateral whitish discharge from the breasts.
3. Bloody discharge from the vagina.
4. Sharply demarcated dark red area on the face.
5. Deep hair-covered dimple at the base of the
spine.
20. The nurse is assessing a newborn on
admission to the newborn nursery. Which of the
following findings should the nurse report to the
neonatalogist?
1. Intracostal retractions.
2. Caput succedaneum.
3. Epstein’s pearls.
4. Harlequin sign.
21. Four babies have just been admitted into the
neonatal nursery. Which of the babies should the
nurse assess first?
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1. Baby with respirations 42, oxygen saturation
96%.
2. Baby with Apgar 9/9, weight 4660 grams.
3. Baby with temperature 97.8oF, length 21
inches.
4. Baby with glucose 55 mg/dL, heart rate 121.
22. A neonate is in the active alert behavioral
state. Which of the following would the nurse
expect to see?
1. Baby is showing signs of hunger and frustration.
2. Baby is starting to whimper and cry.
3. Baby is wide awake and attending to a picture.
4. Baby is asleep and breathing rhythmically.
23. A mother asks whether or not she should be
concerned that her baby never opens his mouth
to breathe when his nose is so small. Which of the
following is the nurse’s best response?
1. “The baby does rarely open his mouth but you
can see that he isn’t in any distress.”
2. “Babies usually breathe in and out through their
noses so they can feed without choking.”
3. “Everything about babies is small. It truly is
amazing how everything works so well.”
4. “You are right. I will report the baby’s small
nasal openings to the paediatrician right away.”
24. The nursery charge nurse is assessing a 1-
day-old female on morning rounds. Which of the
following findings should be reported to the
neonatalogist as soon as possible?
1. Blood in the diaper.
2. Grunting during expiration.
3. Deep red coloring on one side of the body with
pale pink on the other side.
4. Lacy and mottled appearance over the entire
chest and abdomen.
25. A mother calls the nurse to her room because
“My baby’s eyes are bleeding.” The nurse notes
bright red hemorrhages in the sclerae of both of
the baby’s eyes. Which of the following actions by
the nurse is appropriate at this time?
1. Notify the pediatrician immediately and report
the finding.
2. Notify the social worker about the probable
maternal abuse.
3. Reassure the mother that the trauma resulted
from pressure changes at birth and the
hemorrhages will slowly disappear.
4. Obtain an ophthalmoscope from the nursery to
evaluate the red reflex and condition of the retina
in each eye.
26. Which of the following full-term babies
requires immediate intervention?
1. Baby with seesaw breathing.
2. Baby with irregular breathing with 10-second
apnea spells.
3. Baby with coordinated thoracic and abdominal
breathing.
4. Baby with respiratory rate of 52.
27. Which of the following drawings is consistent
with a baby who was in the frank breech position
in utero?
28. The following four babies are in the neonatal
nursery. Which of the babies should be seen by
the neonatalogist?
1. 1-day-old, HR 110 beats per minute in deep
sleep.
2. 2-day-old, T 97.7oF, slightly jaundiced.
3. 3-day-old, breastfeeding every 4 hours, jittery.
4. 4-day-old, crying, papular rash on an
erythematous base.
29. In which of the following situations would it be
appropriate for the father to place the baby in the
en face position?
1. The baby is asleep with little to no eye
movement, regular breathing.
2. The baby is asleep with rapid eye movement,
irregular breathing.
3. The baby is awake, looking intently at an object,
irregular breathing.
4. The baby is awake, placing hands in the mouth,
irregular breathing.
30. Four newborns were admitted into the
neonatal nursery 1 hour ago. They are all sleeping
in overhead warmers. Which of the babies should
the nurse ask the neonatologist to evaluate?
1. The neonate with a temperature of 97.9oF and
weight of 3000 grams.
2. The neonate with white spots on the bridge of
the nose.
3. The neonate with raised white specks on the
gums.
4. The neonate with respirations of 72 and heart
rate of 166.
31. A neonate is admitted to the nursery. The
nurse makes the following assessments: weight
3845 grams, head circumference 35 cm, chest
circumference 33 cm, positive Ortolani sign, and
presence of supernumerary nipples. Which of the
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6
assessments should be reported to the health
care practitioner?
1. Birth weight.
2. Head and chest circumferences.
3. Ortolani sign.
4. Supernumerary nipples.
32. The nurse is about to elicit the Moro reflex.
Which of the following responses should the nurse
expect to see?
1. When the cheek of the baby is touched, the
newborn turns toward the side that is touched.
2. When the lateral aspect of the sole of the baby’s
foot is stroked, the toes extend and fan outward.
3. When the baby is suddenly lowered or startled,
the neonate’s arms straighten outward and the
knees flex.
4. When the newborn is supine and the head is
turned to one side, the arm on that same side
extends.
33. To check for the presence of Epstein’s pearls,
the nurse should assess which part of the
neonate’s body?
1. Feet.
2. Hands.
3. Back.
4. Mouth.
34. The nurse is assessing a neonate in the
newborn nursery. Which of the following findings
in a newborn should be reported to the
neonatalogist?
1. The eyes cross and uncross when they are
open.
2. The ears are positioned in alignment with the
inner and outer canthus of the eyes.
3. Axillae and femoral folds of the baby are
covered with a white cheesy substance.
4. The nostrils flare whenever the baby inhales.
35. A 40-week-gestation neonate is in the first
period of reactivity. Which of the following actions
should the nurse take at this time?
1. Encourage the parents to bond with their baby.
2. Notify the neonatalogist of the finding.
3. Perform the gestational age assessment.
4. Place the baby under the overhead warmer.
36. The nurse notes that a newborn, who is 5
minutes old, exhibits the following characteristics:
heart rate 108 bpm, respiratory rate 29 rpm with
lusty cry, pink body with bluish hands and feet,
some flexion. What does the nurse determine the
baby’s Apgar score is?
1. 6
2. 7
3. 8
4. 9
37. A neonate, who is being admitted into the well-
baby nursery, is exhibiting each of the following
assessment findings. Which of the findings must
the nurse report to the primary health care
provider?
1. Harlequin sign.
2. Extension of the toes when the lateral aspect of
the sole is stroked.
3. Elbow moves past the midline when the scarf
sign is assessed.
4. Telangiectatic nevi.
38. The mother notes that her baby has a “bulge”
on the back of one side of the head. She calls the
nurse into the room to ask what the bulge is. The
nurse notes that the bulge covers the right parietal
bone but does not cross the suture lines. The
nurse explains to the mother that the bulge results
from which of the following?
1. Molding of the baby’s skull so that the baby
could fit through her pelvis.
2. Swelling of the tissues of the baby’s head from
the pressure of her pushing.
3. The position that the baby took in her pelvis
during the last trimester of her pregnancy.
4. Small blood vessels that broke under the baby’s
scalp during birth.
39. A nurse is providing discharge teaching to the
parents of a newborn. Which of the following
should be included when teaching the parents
how to care for the baby’s umbilical cord?
1. Cleanse it with hydrogen peroxide if it starts to
smell.
2. Remove it with sterile tweezers at one week of
age.
3. Call the doctor if greenish drainage appears.
4. Cover it with sterile dressings until it falls off.
40. A mother asks the nurse which powder she
should purchase to use on the baby’s skin. What
should the nurse’s response be?
1. “Any powder made especially for babies should
be fine.”
2. “It is recommended that powder not be put on
babies.”
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6
3. “There is no real difference except that many
babies are allergic to cornstarch so it should not
be used.”
4. “As long as you only put it on the buttocks area,
you can use any brand of baby powder that you
like.”
41. The nurse is teaching the parents of a 1-day-
old baby how to give a sponge bath. Which of the
following actions should be included?
1. Clean the eyes from outer canthus to inner
canthus.
2. Cleanse the ear canals with a cotton swab.
3. Assemble all supplies before beginning the
bath.
4. Check temperature of the bath water with
fingertips.
42. The nurse is teaching the parents of a female
baby how to change the baby’s diapers. Which of
the following should be included in the teaching?
1. Always wipe the perineum from front to back.
2. Remove any vernix caseosa from the labial
folds.
3. Put powder on the buttocks every time the baby
stools.
4. Weigh every diaper in order to assess for
hydration.
43. The nurse has provided anticipatory guidance
to a couple that has just delivered a baby. Which
of the following is an appropriate short-term goal
for the care of their new baby?
1. The baby will have a bath with soap every
morning.
2. During a supervised play period, the baby will
be placed on the tummy every day.
3. The baby will be given a pacifier after each
feeding.
4. For the first month of life, the baby will sleep on
its side in a crib next to the parents.
44. A nurse is advising a mother of a neonate
being discharged from the hospital regarding car
seat safety. Which of the following should be
included in the teaching plan?
1. Put the car seat facing forward only after the
baby reaches twenty pounds.
2. The baby’s car seat should be placed facing the
rear in the front seat of the car.
3. A fist should fit between the straps of the seat
and the baby’s body.
4. Seat belt adjusters should always be used to
support infant car seats.
45. A nurse is providing anticipatory guidance to a
couple regarding the baby’s immunization
schedule. Which of the following statements by
the parents shows that further teaching by the
nurse is needed?
1. The first hepatitis B injection is given by 1 month
of age.
2. The first polio injection will be given at 2 months
of age.
3. The MMR (measles, mumps, and rubella)
immunization should be administered before the
first birthday.
4. Three DTaP (diphtheria, tetanus, and acellular
pertussis) shots will be given during the first year
of life.
46. A nurse is advising a couple of a newborn
regarding when they should call their pediatrician.
Which of the following responses show that the
teaching was effective? Select all that apply.
1. If the baby repeatedly refuses to feed.
2. If the baby’s breathing is irregular.
3. If the baby has no tears when he cries.
4. If the baby is repeatedly difficult to awaken.
5. If the baby’s temperature is above 100.4oF.
47. A nurse is providing anticipatory guidance to a
couple before they take home their newborn.
Which of the following should be included?
1. If their baby is sleeping soundly, they should not
awaken the baby for a feeding.
2. If they take their baby outside, they should put
sunscreen on the baby.
3. They should purchase liquid acetaminophen to
be used when ordered by the pediatrician.
4. They should notify their pediatrician when the
umbilical cord falls off.
48. A mucousy baby is being left with the parents
for the first time after delivery. Which of the
following should the nurse teach the parents
regarding use of the bulb syringe?
1. Suction the nostrils before suctioning the
mouth.
2. Make sure to suction the back of the throat.
3. Insert the syringe before compressing the bulb.
4. Dispose of the drainage in a tissue or a cloth.
49. Please put an “X” on the site where the nurse
should perform a heel stick on the neonate.
50. A nurse must give vitamin K 0.5 mg IM to a
newly born baby. Which of the following needles
could the nurse safely choose for the injection?
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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1. 5⁄8 inch, 18 gauge.
2. 5⁄8 inch, 25 gauge.
3. 1 inch, 18 gauge.
4. 1 inch, 25 gauge.
51. A nurse is practicing the procedures for
conducting cardiopulmonary resuscitation (CPR)
in the neonate. Which site should the nurse use to
assess the pulse of a baby?
1. Carotid.
2. Radial.
3. Brachial.
4. Pedal.
52. A baby has just been admitted into the
neonatal nursery. Before taking the newborn’s
vital signs, the nurse should warm his or her
hands and the stethoscope in order to prevent
heat loss resulting from which of the following?
1. Evaporation.
2. Conduction.
3. Radiation.
4. Convection.
53. The nurse is developing a teaching plan for
parents who are taking home their 2-day-old
breastfed baby. Which of the following should the
nurse include in the plan?
1. Wash hands well before picking up the baby.
2. Refrain from having visitors for the first month.
3. Wear a mask to prevent transmission of a cold.
4. Sterilize the breast pump supplies for the first
month.
54. It is time for a baby, who is in the drowsy
behavioral state, to breastfeed. Which of the
following techniques could the mother use to
arouse the baby? Select all that apply.
1. Swaddle or tightly bundle the baby.
2. Hand express milk onto the baby’s lips.
3. Talk with the baby while making eye contact.
4. Remove the baby’s shirt and change the diaper.
5. Play pat-a-cake with the baby.
55. A bottlefeeding mother is providing a return
demonstration of how to burp the baby. Which of
the following would indicate that further teaching
is needed?
1. The woman gently strokes and pats her baby’s
back.
2. The woman positions the baby face down on
her lap.
3. The woman waits to burp the baby until the
baby’s feeding is complete.
4. The woman states that a small amount of
regurgitated formula is acceptable.
56. A breastfeeding baby is born with a tight
frenulum. Which of the following is an important
assessment for the nurse to make?
1. Integrity of the baby’s uvula.
2. Presence of maternal nipple damage.
3. Presence of neonatal tongue injury.
4. The baby’s breathing pattern.
57. A mother is told that she should bottlefeed her
child for medical reasons. Which of the following
maternal disease states are consistent with the
recommendation?
Select all that apply.
1. Untreated, active tuberculosis.
2. Hepatitis B surface antigen positive.
3. Human immunodeficiency virus positive.
4. Chorioamnionitis.
5. Mastitis
58. A nurse has brought a 2-hour-old baby to a
mother from the nursery. The nurse is going to
assist the mother with the first breastfeeding
experience. Which of the following actions should
the nurse perform first?
1. Compare mother’s and baby’s identification
bracelets.
2. Help the mother into a comfortable position.
3. Teach the mother about a proper breast latch.
4. Tickle the baby’s lips with the mother’s nipple.
59. Which short-term goal is appropriate for a full-
term, breastfeeding neonate?
1. The baby will regain birth weight by 4 weeks of
age.
2. The baby will sleep through the night by 4
weeks of age.
3. The baby will stool every 3 to 4 hours by 1 week
of age.
4. The baby will urinate 6 to 10 times per day by 1
week of age.
60. A mother is attempting to latch her newborn
baby to the breast. Which of the following actions
are important for the mother to perform in order to
achieve effective breastfeeding? Select all that
apply.
1. Place the baby on his or her back in the
mother’s lap.
2. Wait until the baby opens his or her mouth wide.
3. Hold the baby at the level of the mother’s
breasts.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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4. Point the baby’s nose to the mother’s nipple.
5. Wait until the baby’s tongue is pointed toward
the roof of his or her mouth.
61. The nurse is evaluating the effectiveness of an
intervention when assisting a woman whose baby
has been latched to the nipple only rather than to
the nipple and the areola. Which response would
indicate that further intervention is needed?
1. The client states that the pain has decreased.
2. The nurse hears the baby swallow after each
suck.
3. The baby’s jaws move up and down once every
second.
4. The baby’s cheeks move in and out with each
suck.
62. The parents and their full-term, breastfed
neonate were discharged from the hospital.
Which behavior 2 days later indicates a positive
response by the parents to the nurse’s discharge
teaching?
1. The parents weigh their baby’s diapers.
2. The parents measure the baby’s intake.
3. The parents give one bottle of formula every
day.
4. The parents take the baby to see the
pediatrician.
63. The nurse does not hear the baby swallow
when suckling even though the baby appears to
be latched properly to the breast. Which of the
following situations may be the reason for this
observation?
1. The mother reports a pain level of 4 on a 5-point
scale.
2. The baby has been suckling for over 10
minutes.
3. The mother uses the cross-cradle hold while
feeding.
4. The baby lies with the chin touching the under
part of the breast.
64. The nurse is concerned that a bottlefed baby
may become obese because of which activity by
the mother?
1. She encourages the baby to finish the bottle at
each feed.
2. She feeds the baby every 3 to 4 hours.
3. She feeds the baby a soy-based formula.
4. She burps the baby every 1⁄2 to 1 ounce.
65. A 2-day-old, exclusively breastfed baby is to
be discharged home. Under what conditions
should the nurse teach the parents to call the
pediatrician?
1. If the baby feeds 8 to 12 times each day.
2. If the baby urinates 6 to 10 times each day.
3. If the baby has stools that are watery and bright
yellow.
4. If the baby has eyes and skin that are tinged
yellow
66. A nurse who is caring for a mother/newborn
dyad on the maternity unit has identified the
following nursing diagnosis: Effective
breastfeeding. Which of the following would
warrant this diagnosis?
1. Baby’s lips are flanged when latched.
2. Baby feeds every 4 hours.
3. Baby lost 12% of weight since birth.
4. Baby’s tongue stays behind the gum line.
67. A newborn was born weighing 3278 grams.
On day 2 of life, the baby weighed 3042 grams.
What percent of weight loss did the baby
experience? _______ %
68. A mother is preparing to breastfeed her baby.
Which of the following actions would encourage
the baby to open the mouth wide for feeding?
1. Holding the baby in the en face position.
2. Pushing down on the baby’s lower jaw.
3. Tickling the baby’s lips with the nipple.
4. Giving the baby a trial bottle of formula.
69. A breastfeeding mother mentions to the nurse
that she has heard that babies sleep better at
night if they are given a small amount of rice
cereal in the evening. Which of the following
comments by the nurse is appropriate?
1. “That is correct. The rice cereal takes longer for
them to digest so they sleep better and longer.”
2. “It is recommended that babies receive only
breast milk for the first 4 to 6 months of their lives.”
3. “It is too early for rice cereal, but I would
recommend giving the baby a bottle of formula at
night.”
4. “A better recommendation is to give apple
sauce at 3 months of age and apple juice 1 month
later.”
70. On admission to the maternity unit, it is
learned that a mother has smoked 2 packs of
cigarettes per day and expects to continue to
smoke after discharge. The mother also states
that she expects to breastfeed her baby. The
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6
nurse’s response should be based on which of the
following?
1. Breastfeeding is contraindicated if the mother
smokes cigarettes.
2. Breastfeeding is protective for the baby and
should be encouraged.
3. A 2-pack-a-day smoker should be reported to
child protective services for child abuse.
4. A mother who admits to smoking cigarettes may
also be abusing illicit substances.
71. A breastfeeding mother who is 2 weeks
postpartum is informed by her pediatrician that her
4-year-old has chickenpox (varicella). The mother
calls the nursery nurse because she is concerned
about having the baby in contact with the sick
sibling. The mother had chickenpox as a child.
Which of the following responses by the nurse is
appropriate?
1. “The baby received passive immunity through
the placenta, plus the breast milk will also be
protective.”
2. “The baby should stay with relatives until the ill
sibling recovers from the episode of chickenpox.”
3. “Chickenpox is transmitted by contact route so
careful hand washing should prevent
transmission.”
4. “Because chickenpox is a spirochetal illness,
both the child and baby should receive the
appropriate medications.”
72. A client is preparing to breastfeed her newborn
son in the cross-cradle position. Which of the
following actions should the woman make?
1. Place a pillow in her lap.
2. Position the head of the baby in her elbow.
3. Put the baby on his back.
4. Move the breast toward the mouth of the baby.
73. A mother, who gave birth 5 minutes ago,
states that she would like to breastfeed. The
baby’s Apgar score is 9/9. Which of the following
actions should the nurse perform first?
1. Assist the woman to breastfeed.
2. Assess the baby’s blood pressures.
3. Administer the ophthalmic prophylaxis.
4. Take the baby’s rectal temperature.
74. A 4-day-old breastfeeding neonate whose
birth weight was 2678 grams has lost 100 grams
since the cesarean birth. Which of the following
actions should the nurse take?
1. Nothing because this is an acceptable weight
loss.
2. Advise the mother to supplement feedings with
formula.
3. Notify the neonatalogist of the excessive weight
loss.
4. Give the baby dextrose water between breast
feedings.
75. A 2-day-postpartum breastfeeding client is
complaining of pain during feedings. Which of the
following may be causing the pain?
1. The neonate’s frenulum is attached to the tip of
the tongue.
2. The baby’s tongue forms a trough around the
breast during the feedings.
3. The newborn’s feeds last for 30 minutes every
2 hours.
4. The baby is latched to the nipple and to about
1 inch of the mother’s areola.
76. A newly delivered mother states, “I have not
had any alcohol since I decided to become
pregnant. I have decided not to breastfeed
because I would really like to go out and have a
good time for a change.” Which of the following is
the best response by the nurse?
1. “I understand that being good for so many
months can become very frustrating.”
2. “Even if you bottlefeed the baby, you will have
to refrain from drinking alcohol for at least the next
six weeks to protect your own health.”
3. “Alcohol can be consumed at any time while
you are breastfeeding.”
4. “You may drink alcohol while breastfeeding,
although it is best to wait until the alcohol has
been metabolized before you feed again.”
77. A physician writes in a breastfeeding mother’s
chart, “Ampicillin 500 mg q 6 h PO. Baby should
be bottlefed until medication is discontinued.”
What should be the nurse’s next action?
1. Follow the order as written.
2. Call the doctor and question the order.
3. Follow the antibiotic order but ignore the order
to bottlefeed the baby.
4. Refer to a text to see whether the antibiotic is
safe while breastfeeding.
78. Four pregnant women advise the nurse that
they wish to breastfeed their babies. Which of the
mothers should be advised to bottlefeed her
child?
1. The woman with a neoplasm requiring
chemotherapy.
2. The woman with cholecystitis requiring surgery.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 6
3. The woman with a concussion.
4. The woman with thrombosis.
79. A woman states that she is going to bottlefeed
her baby because, “I hate milk and I know that to
make good breast milk I will have to drink milk.”
The nurse’s response about producing high-
quality breast milk should be based on which of
the following?
1. The mother must drink at least 3 glasses of milk
per day in order to absorb sufficient quantities of
calcium.
2. The mother should consume at least 1 glass of
milk per day but should also consume other dairy
products like cheese.
3. The mother can consume a variety of good
calcium sources like broccoli and fish with bones
as well as dairy products.
4. The mother must monitor her protein intake
more than her calcium intake because the baby
needs the protein for growth.
80. A client asks whether or not there are any
foods that she must avoid eating while
breastfeeding. Which of the following responses
by the nurse is appropriate?
1. “No, there are no foods that are strictly
contraindicated while breastfeeding.”
2. “Yes, the same foods that were dangerous to
eat during pregnancy should be avoided.”
3. “Yes, foods like onions, cauliflower, broccoli,
and cabbage make babies very colicky.”
4. “Yes, spices from hot and spicy foods get into
the milk and can bother your baby.”
81. A woman who has just delivered has decided
to bottlefeed her full-term baby.
Which of the following should be included in the
patient teaching?
1. The baby’s stools will appear bright yellow and
will usually be loose.
2. The bottle nipples should be enlarged to ease
the baby’s suckling.
3. It is best to heat the baby’s bottle in the
microwave before feeding.
4. It is important to hold the bottle to keep the
nipple filled with formula.
82. Please choose the picture of the breastfeeding
baby that shows correct position and latch on.
83. A full-term neonate, Apgar 9/9, has just been
admitted to the nursery after a cesarean delivery,
fetal position LMA, under epidural anesthesia.
Which of the following physiological findings
would the nurse expect to see?
1. Soft pulmonary rales.
2. Absent bowel sounds.
3. Depressed Moro reflex.
4. Positive Ortolani sign.
84. A full-term neonate has brown adipose fat
tissue (BAT) stores that were deposited during the
latter part of the third trimester. What does the
nurse understand is the function of BAT stores?
1. To promote melanin production in the neonatal
period.
2. To provide heat production when the baby is
hypothermic.
3. To protect the bony structures of the body from
injury.
4. To provide calories for neonatal growth
between feedings.
85. A neonate has an elevated bilirubin and is
slightly jaundiced on day 3 of life. What is the
probable reason for these changes?
1. Hemolysis of neonatal red blood cells by the
maternal antibodies.
2. Physiological destruction of fetal red blood cells
during the extrauterine period.
3. Pathological liver function resulting from
hypoxemia during the birthing process.
4. Delayed meconium excretion resulting in the
production of direct bilirubin.
86. The pediatrician writes the following order for
a term newborn: Vitamin K 1 mg IM. Which of the
following responses provides a rationale for this
order?
1. During the neonatal period, babies absorb fat-
soluble vitamins poorly.
2. Breast milk and formula contain insufficient
quantities of vitamin K.
3. The neonatal gut is sterile.
4. Vitamin K prevents hemolytic jaundice.
87. A nurse takes a Spanish-speaking Mexican
woman her baby to breastfeed. The woman
refuses to feed and makes motions like she wants
to bottlefeed. Which of the following is a likely
explanation for the woman’s behavior?
1. She has decided not to breastfeed.
2. She thinks she must give formula before the
breast.
3. She believes that colostrum is bad for the baby.
4. She thinks that she should bottlefeed.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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88. The nurse enters a Latin woman’s postpartum
room and notes that her neonate is wearing a hat
and is covered in three blankets. The room
temperature is 70oF. The nurse’s action should be
based on which of the following?
1. Overdressing babies is common in some
cultures and should be ignored.
2. The mother has dressed the baby appropriately
for the room temperature.
3. The nurse should drop the room temperature
since the baby is overdressed.
4. Overheating is dangerous for neonates and the
extra clothing should be removed.
89. The nurse observes a healthy woman of
African descent expressing breast milk into her
baby’s eyes. Which of the following responses by
the nurse is appropriate at this time?
1. Report the abusive behavior to the social
worker.
2. Advise the mother that her action is potentially
dangerous.
3. Observe the mother for other signs of irrational
behavior.
4. Ask the woman about other cultural traditions.
90. The nurse informs the parents of a breastfed
baby that the American Academy of Pediatrics
advises that babies be supplemented with which
of the following vitamins?
1. Vitamin A.
2. Vitamin B12.
3. Vitamin C.
4. Vitamin D.
91. A 2-day-old neonate received a vitamin K
injection at birth. Which of the following
signs/symptoms in the baby would indicate that
the treatment was effective?
1. Skin color is pink.
2. Vital signs are normal.
3. Glucose levels are stable.
4. Blood clots after heel sticks.
92. A nurse is about to administer the ophthalmic
preparation to a newly born neonate. Which of the
following is the correct statement regarding the
medication?
1. It is administered to prevent the development of
neonatal cataracts.
2. The medicine should be placed in the lower
conjunctiva from the inner to outer canthus.
3. The medicine must be administered
immediately upon delivery of the baby.
4. It is administered to neonates whose mothers
test positive for gonorrhea during pregnancy.
93. A mother questions why the ophthalmic
medication is given to the baby. Which of the
following responses by the nurse would be
appropriate to make at this time?
1. “I am required by law to give the medicine.”
2. “The medicine helps to prevent eye infections.”
3. “The medicine promotes neonatal health.”
4. “All babies receive the medicine at delivery.”
94. A neonate is to receive the hepatitis B vaccine
in the neonatal nursery. Which of the following
must the nurse have available before
administering the injection?
1. Hepatitis B immune globulin in a second
syringe.
2. Sterile water to dilute the vaccine before
injecting.
3. Epinephrine in case of severe allergic
reactions.
4. Oral syringe since the vaccine is given by
mouth.
95. A certified nursing assistant (CNA) is working
with a registered nurse (RN) in the neonatal
nursery. Which of the following actions should the
RN perform rather than delegating it to the CNA?
1. Bathe and weigh a 1-hour-old baby.
2. Take the apical heart rate and respirations of a
4-hour-old baby.
3. Obtain a stool sample from a 1-day-old baby.
4. Provide discharge teaching to the mother of a
4-day-old baby.
96. Four babies with the following conditions are
in the well-baby nursery. The baby with which of
the conditions is high risk for physiological
jaundice?
1. Cephalhematoma.
2. Caput succedaneum.
3. Harlequin coloring.
4. Mongolian spotting.
97. A full-term baby’s bilirubin level is 15 on day 3.
Which of the following neonatal behaviors would
the nurse expect to see?
1. Excessive crying.
2. Increased appetite.
3. Lethargy.
4. Hyperreflexia.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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98. The nursing management of a neonate with
physiological jaundice should be directed toward
which client care goal?
1. The baby shows no signs of kernicterus.
2. The baby does not develop erythroblastosis
fetalis.
3. The baby has a bilirubin of 16 mg/dL on the day
of discharge.
4. The baby spends at least 20 hours per day
under phototherapy.
99. A 2-day-old baby’s blood values are: blood
type—O_ (negative). direct Coombs—(negative).
hematocrit—50%. Bilirubin—1.5 mg/dL. The
mother’s blood type is A_. What should the nurse
do?
1. Do nothing because the results are within
normal limits.
2. Assess the baby for opisthotonic posturing.
3. Administer RhoGAM to the mother per doctor’s
order.
4. Call the doctor for an order to place the baby
under bili-lights.
100. A 4-day-old baby born via cesarean section
is slightly jaundiced. The laboratory reports a
bilirubin assessment of 6.0 mg/dL. Which of the
following would the nurse expect the
neonatalogist to order for the baby at this time?
1. To be placed under phototherapy.
2. To be discharged home with the parents.
3. To be prepared for a replacement transfusion.
4. To be fed glucose water between routine feeds.
101. A nurse is assessing the bonding of the
father with his newborn baby. Which of the
following actions by the father would be of concern
to the nurse?
1. He holds the baby in the en face position.
2. He calls the baby by a full name rather than a
nickname.
3. He tells the mother to pick up the crying baby.
4. He falls asleep in the chair with the baby on his
chest.
102. The nurse is conducting a state-mandated
evaluation of a neonate’s hearing. Infants are
assessed for deficits because hearing-impaired
babies are high risk for which of the following?
1. Delayed speech development.
2. Otitis externa.
3. Poor parental bonding.
4. Choanal atresia.
103. A baby has just been circumcised. If bleeding
occurs, which of the following actions should be
taken first?
1. Put the baby’s diapers on as tightly as possible.
2. Apply light pressure to the area with sterile
gauze.
3. Call the physician who performed the surgery.
4. Assess the baby’s heart rate and oxygen
saturation.
104. A nurse reads that the neonatal mortality rate
in the United States for a given year was 5. The
nurse interprets that information as:
1. 5 babies less than 28 days old per 1000 live
births died.
2. 5 babies less than 1 year old per 1000 live births
died.
3. 5 babies less than 28 days old per 100,000
births died.
4. 5 babies less than 1 year old per 100,000 births
died.
105. A mother tells the nurse that, because of
family history, she is afraid her baby son will
develop colic. Which of the following colic
management strategies should the parents be
taught? Select all that apply.
1. Small, frequent feedings.
2. Prone sleep positioning.
3. Tightly swaddling the baby.
4. Rocking the baby while holding him face down
on the forearm.
5. Maintaining a home environment that is
cigarette smoke–free.
106. A nurse, when providing discharge teaching
to parents, emphasizes actions to prevent
plagiocephaly and to promote gross motor
development in their full-term newborn. Which of
the following actions should the nurse advise the
parents to take?
1. Breastfeed the baby frequently.
2. Make sure the baby receives vaccinations at
recommended intervals.
3. Change the diapers regularly.
4. Minimize supine positioning during supervised
play periods.
107. A mother and her 2-day-old baby are
preparing for discharge. Which of the following
situations would require the baby’s discharge to
be cancelled?
1. The parents only own a car seat that faces the
rear of the car.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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2. The baby’s bilirubin is 19 mg/dL. 3. Pro-life advocate.

3. The baby’s blood glucose is 59 mg/dL.
4. There is a large bluish spot on the left buttock
of the baby.
108. A mother confides to a nurse that she has no
crib at home for her baby. The mother asks the
nurse which of the following places would be best
for the baby to sleep. Of the following choices,
which location should the nurse suggest?
1. In bed with his 5-year-old brother.
2. In a waterbed with his mother and father.
3. In a large empty dresser drawer.
4. In the living room on a pull-out sofa.
4. Visitor of the same race.
113. Which of the following behaviors should
nurses know are characteristic of infant
abductors? Select all that apply.
1. Act on the spur of the moment.
2. Create a diversion on the unit.
3. Ask questions about the routine of the unit.
4. Choose rooms near stairwells.
5. Wear over-sized clothing.

109. A baby is just delivered. Which of the

following physiological changes is of highest
priority?
1. Thermoregulation.
2. Spontaneous respirations.
3. Extrauterine circulatory shift.
4. Successful feeding.

110. A breastfeeding mother refuses to place her

unclothed baby face down on her chest because,
“Babies are always supposed to be put on their
backs. Babies who are on their stomachs die from
SIDS.” The nurse’s action should be based on
which of the following?
1. Skin-to-skin contact facilitates breastfeeding
and helps to maintain neonatal temperature.
2. The risk of SIDS increases whenever
unsupervised babies are placed in the supine
position.
3. SIDS rarely occurs before the completion of the
neonatal period.
4. Back-to-sleep guidelines have been modified
for breastfeeding babies.

111. The nursing diagnosis—risk for suffocation—

is included in a standard care plan in the neonatal
nursery. Which of the following outcome goals
should be included in relation to this diagnosis?
1. Baby is placed supine for sleep.
2. Baby is breastfed in the side-lying position.
3. Baby is swaddled when in the open crib.
4. Baby is strapped when seated in a car seat.

112. It has just been discovered that a newborn is

missing from the maternity unit. The nursing staff
should be watchful for which of the following
individuals?
1. A middle-aged male.
2. An underweight female.