MCN NEWBORN
Tachypnea and retractions
1. The nurse assisted with the delivery of a
newborn. Which nursing action is most
effective in preventing heat loss by
evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant
warmer
3. Drying the infant with a warm blanket
2. The mother of a newborn calls the clinic
and reports that when cleaning the
umbilical cord, she noticed that the cord
was moist and that discharge was
present. What is the most
appropriate nursing instruction for this
mother?
1. Bring the infant to the clinic.
2. This is a normal occurrence.
3. Increase the number of times that the
cord is cleaned per day.
4. Monitor the cord for another 24 to 48
hours and call the clinic if the discharge
continues.
1. Bring the infant to the clinic.
3. The nurse is assessing a newborn after
circumcision and notes that the
circumcised area is red with a small
amount of bloody drainage. Which nursing
action is most appropriate?
1. Apply gentle pressure.
2. Reinforce the dressing.
3. Document the findings.
4. Contact the health care provider (HCP).
3. Document the findings.
4. The nurse in a newborn nursery is
monitoring a preterm newborn for
respiratory distress syndrome. Which
assessment findings would alert the nurse
to the possibility of this syndrome?
1. Tachypnea and retractions
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. Presence of a barrel chest and
acrocyanosis
1.
5. The postpartum nurse is providing
instructions to the mother of a newborn
with hyperbilirubinemia who is being
breast-fed. The nurse should provide
which most appropriate instruction to the
mother?
1. Feed the newborn less frequently.
2. Continue to breast-feed every 2 to 4
hours.
3. Switch to bottle-feeding the infant for 2
weeks.
4. Stop breast-feeding and switch to
bottle-feeding permanently.
2. Continue to breast-feed every 2 to 4 hours.
6. The nurse is assessing a newborn who
was born to a mother who is addicted to
drugs. Which assessment finding would
the nurse expect to note during the
assessment of this newborn?
1. Lethargy
2. Sleepiness
3. Constant crying
4. Cuddles when being held
3. Constant crying
7. The nurse notes hypotonia, irritability, and
a poor sucking reflex in a full-term
newborn on admission to the nursery. The
nurse suspects fetal alcohol syndrome
and is aware that which additional sign
would be consistent with this syndrome?
1. Length of 19 inches
2. Abnormal palmar creases
3. Birth weight of 6 lb, 14 oz
4. Head circumference appropriate for
gestational age
2. Abnormal palmar creases
8. The nurse is preparing a plan of care for a
newborn with fetal alcohol syndrome. The
nurse should include
which priority intervention in the plan of
care?
1. Allow the newborn to establish own
sleep-rest pattern.
2. Maintain the newborn in a brightly
lighted area of the nursery.
3. Encourage frequent handling of the
 newborn by staff and parents.
4. Monitor the newborn's response to
feedings and weight gain pattern.
4. Monitor the newborn's response to feedings
and weight gain pattern.
9. The nurse administers erythromycin
ointment (0.5%) to the eyes of a newborn
and the mother asks the nurse why this is
performed. Which explanation is best for
the nurse to provide about neonatal eye
prophylaxis?
1. Protects the newborn's eyes from
possible infections acquired while
hospitalized.
2. Prevents cataracts in the newborn born
to a woman who is susceptible to rubella.
3. Minimizes the spread of
microorganisms to the newborn from
invasive procedures during labor.
4. Prevents an infection called ophthalmia
neonatorum from occurring after delivery
in a newborn born to a woman with an
untreated gonococcal infection.
4. Prevents an infection called ophthalmia
neonatorum from occurring after delivery in a
newborn born to a woman with an untreated
gonococcal infection.
10. The nurse is preparing to care for a
newborn receiving phototherapy. Which
interventions should be included in the
plan of care? Select all that apply.
1. Avoid stimulation.
2. Decrease fluid intake.
3. Expose all of the newborn's skin.
4. Monitor skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye
shields or patches.
o 4. Monitor skin temperature closely.
o 5. Reposition the newborn every 2
hours.
o 6. Cover the newborn's eyes with eye
shields or patches.
11. The nurse develops a plan of care for a
woman with human immunodeficiency
virus infection and her newborn. The
nurse should include which intervention in
the plan of care?
1. Monitoring the newborn's vital signs
routinely
2. Maintaining standard precautions at all
times while caring for the newborn
3. Initiating referral to evaluate for
blindness, deafness, learning problems, or
behavioral problems
4. Instructing the breast-feeding mother
regarding the treatment of the nipples with
nystatin ointment
2. Maintaining standard precautions at all
times while caring for the newborn
12. The nurse is planning care for a newborn
of a mother with diabetes mellitus. What is
the priority nursing consideration for this
newborn?
1. Developmental delays because of
excessive size
2. Maintaining safety because of low
blood glucose levels
3. Choking because of impaired suck and
swallow reflexes
4. Elevated body temperature because of
excess fat and glycogen
2. Maintaining safety because of low blood
glucose levels
13. Which statement reflects a new mother's
understanding of the teaching about the
prevention of newborn abduction?
1. "I will place my baby's crib close to the
door."
2. "Some health care personnel won't
have name badges."
3. "It's OK to allow the unlicensed
assistive personnel to carry my newborn
to the nursery."
4. "I will ask the nurse to attend to my
infant if I am napping and my husband is
not here."
4. "I will ask the nurse to attend to my infant if
I am napping and my husband is not here."
14. The nurse prepares to administer a
vitamin K injection to a newborn, and the
mother asks the nurse why her infant
needs the injection. What best response
should the nurse provide?
1. "Your newborn needs vitamin K to
develop immunity."
2. "The vitamin K will protect your
newborn from being jaundiced."
3. "Newborns have sterile bowels, and
 vitamin K promotes the growth of bacteria
in the bowel."
4. "Newborns are deficient in vitamin K,
and this injection prevents your newborn
from bleeding."
4. "Newborns are deficient in vitamin K, and
this injection prevents your newborn from
bleeding."
15. The nurse is monitoring a client who is
receiving oxytocin (Pitocin) to induce
labor. Which assessment finding would
cause the nurse
to immediately discontinue the oxytocin
infusion?
1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Early decelerations of the fetal heart
rate
3. Uterine hyperstimulation
16. A pregnant client is receiving magnesium
sulfate for the management of
preeclampsia. The nurse determines that
the client is experiencing toxicity from the
medication if which finding is noted on
assessment?
1. Proteinuria of 3+
2. Respirations of 10 breaths/minute
3. Presence of deep tendon reflexes
4. Serum magnesium level of 6 mEq/L
2. Respirations of 10 breaths/minute
17. The nurse is monitoring a client in preterm
labor who is receiving intravenous
magnesium sulfate. The nurse should
monitor for which adverse effects of this
medication? Select all that apply.
1. Flushing
2. Hypertension
3. Increased urine output
4. Depressed respirations
5. Extreme muscle weakness
6. Hyperactive deep tendon reflexes
o 1. Flushing
o 4. Depressed respirations
o 5. Extreme muscle weakness
18. The nursing instructor asks a nursing
student to describe the procedure for
administering erythromycin ointment to
the eyes of a newborn. Which student
statement indicates that further teaching
is needed?
1. "I will flush the eyes after instilling the
ointment."
2. "I will clean the newborn's eyes before
instilling ointment."
3. "I need to administer the eye ointment
within 1 hour after delivery."
4. "I will instill the eye ointment into each
of the newborn's conjunctival sacs."
1. "I will flush the eyes after instilling the
ointment."
19. A client in preterm labor (31 weeks) who
is dilated to 4 cm has been started on
magnesium sulfate and contractions have
stopped. If the client's labor can be
inhibited for the next 48 hours, the nurse
anticipates a prescription for which
medication?
1. Nalbuphine (Nubain)
2. Betamethasone (Celestone)
3. Rho(D) immune globulin (RhoGAM)
4. Dinoprostone (Cervidil vaginal insert)
2. Betamethasone (Celestone)
20. Methylergonovine (Methergine) is
prescribed for a woman to treat
postpartum hemorrhage. Before
administration of methylergonovine, what
is the priority nursing assessment?
1. Uterine tone
2. Blood pressure
3. Amount of lochia
4. Deep tendon reflexes
2. Blood pressure
21. The nurse is preparing to administer
beractant (Survanta) to a premature infant
who has respiratory distress syndrome.
The nurse plans to administer the
medication by which route?
1. Intradermal
2. Intratracheal
3. Subcutaneous
4. Intramuscular
2. Intratracheal
22. An opioid analgesic is administered to a
client in labor. The nurse assigned to care
for the client ensures that which
medication is readily available if
respiratory depression occurs?
1. Naloxone
2. Morphine sulfate
3. Betamethasone (Celestone)
4. Meperidine hydrochloride
(Demerol)
1. Naloxone
23. Rho(D) immune globulin (RhoGAM) is
prescribed for a client after delivery and
the nurse provides information to the
client about the purpose of the
medication. The nurse determines that the
woman understands the purpose if the
woman states that it will protect her next
baby from which condition?
1. Having Rh-positive blood
2. Developing a rubella infection
3. Developing physiological jaundice
4. Being affected by Rh incompatibility
4. Being affected by Rh incompatibility
24. Methylergonovine (Methergine) is
prescribed for a client with postpartum
hemorrhage. Before administering the
medication, the nurse contacts the health
care provider who prescribed the
medication if which condition is
documented in the client's medical
history?
1. Hypotension
2. Hypothyroidism
3. Diabetes mellitus
4. Peripheral vascular disease
4. Peripheral vascular disease
25. A client who is positive for human
immunodeficiency virus (HIV) delivers a
newborn infant. The nurse provides
instructions to help the client regarding
care of her infant. Which client statement
indicates the need for further
instruction?
1. "I will be sure to wash my hands before
and after bathroom use."
2. "I need to breast-feed, especially for the
first 6 weeks postpartum."
3. "Support groups are available to assist
me with understanding my diagnosis of
HIV."
4. "My newborn infant should be on
antiviral medications for the first 6 weeks
after delivery."
2. "I need to breast-feed, especially for the
first 6 weeks postpartum."
26. The nurse is performing an initial
assessment on a newborn infant. When
assessing the infant's head, the nurse
notes that the ears are low-set. Which
nursing action is most appropriate?
1. Document the findings.
2. Arrange for hearing testing.
3. Notify the health care provider.
4. Cover the ears with gauze pads.
3. Notify the health care provider.
27. The nurse is providing instructions to a
new mother regarding cord care for a
newborn infant. Which statement, if made
by the mother, indicates a need
for further instructions?
1. "The cord will fall off in 1 to 2 weeks."
2. "Alcohol may be used to clean the
cord."
3. "I should cleanse the cord two or three
times a day."
4. "I need to fold the diaper above the
cord to prevent infection."
4. "I need to fold the diaper above the cord to
prevent infection."
28. The nursery room nurse is assessing a
newborn infant who was born to a mother
who abuses alcohol. Which assessment
finding should the nurse expect to note?
1. Lethargy
2. Irritability
3. Higher-than-normal birth weight
4. A greater-than-normal appetite when
feeding
2. Irritability
29. The postpartum nurse teaches a mother
how to give a bath to the newborn infant
and observes the mother performing the
procedure. Which observation indicates
 a lack of understanding of the
instructions?
1. The mother bathes the newborn infant
after a feeding.
2. The mother states that she would
gather all supplies before the bath is
started.
3. The mother states that she would never
leave the newborn infant in the tub of
water alone.
4. The mother fills a clean basin or sink
with 2 to 3 inches of water and then
checks the temperature with her wrist.
1. The mother bathes the newborn infant after
a feeding.
30. A newborn infant of a mother who has
human immunodeficiency virus (HIV)
infection is tested for the presence of HIV
antibodies. An enzyme-linked
immunosorbent assay (ELISA) is
performed, and the results are positive.
Which is the correct interpretation of these
results?
1. Positive for HIV
2. Indicates the presence of maternal
infection
3. Indicates that the newborn will develop
AIDS later in life
4. Positive for acquired immunodeficiency
syndrome (AIDS)
2. Indicates the presence of maternal infection
31. A nurse employed in a neonatal intensive
care nursery receives a telephone call
from the delivery room and is told that a
newborn with spina bifida
(myelomeningocele type) will be
transported to the nursery. The maternity
nurse prepares for the arrival of the
newborn and places which priority item at
the newborn's bedside?
1. A rectal thermometer
2. A blood pressure cuff
3. A specific gravity urinometer
4. A bottle of sterile normal saline
4. A bottle of sterile normal saline
32. The nurse has provided instructions about
measures to clean the penis to a mother
of a male newborn who is not
circumcised. Which statement, if made by
the mother, indicates an understanding of
how to clean the newborn's penis?
1. "I should retract the foreskin and clean
the penis every time I change the diaper."
2. "I need to retract the foreskin and clean
the penis every time I give my infant a
bath."
3. "I need to avoid pulling back the
foreskin to clean the penis because this
may cause adhesions."
4. "I should gently retract the foreskin as
far as it will go on the penis and then pull
the skin back over the penis after
cleaning."
3. "I need to avoid pulling back the foreskin to
clean the penis because this may cause
adhesions."
33. The nurse is preparing to instruct a client
in how to bathe a newborn. Which
statement should the nurse include in the
instruction?
1. "Begin with the eyes and face."
2. "Begin with the feet and work upward."
3. "Do the back side first, and then the
front side."
4. "Start with the chest, move to the face,
and then finish the rest of the body."
1. "Begin with the eyes and face."
34. The nurse is preparing to administer an
injection of vitamin K to a newborn. Which
injection site should the nurse select?
1. The gluteal muscle
2. The lower aspect of the rectus femoris
muscle
3. The medial aspect of the upper third of
the vastus lateralis muscle
4. The lateral aspect of the middle third of
the vastus lateralis muscle
4. The lateral aspect of the middle third of the
vastus lateralis muscle
35. The nurse is assessing the reflexes of a
newborn infant. In eliciting the Moro reflex,
the nurse should perform which action?
1. Make a loud, abrupt noise to startle the
newborn.
2. Stimulate the ball of the foot of the
newborn by firm pressure.
 3. Stimulate the perioral cavity of the
newborn infant with a finger.
4. Stimulate the pads of the newborn
infant's hands by firm pressure.
1. Make a loud, abrupt noise to startle the
newborn.
36. A 4-day-old newborn is receiving
phototherapy at home for a bilirubin level
of 14 mg/dL. The nurse should plan to
include which instruction in the teaching
plan of care during the home visit to the
mother of the newborn?
1. Applying lotions to exposed newborn
skin
2. Assessing skin integrity and fluid status
of the newborn
3. Having minimal contact with the
newborn to prevent stimulation
4. Advising the mother to limit the
newborn's oral intake during phototherapy
2. Assessing skin integrity and fluid status of
the newborn
37. The nurse is performing Apgar scoring for
a newborn immediately after birth. The
nurse notes that the heart rate is less than
100, respiratory effort is irregular, and
muscle tone shows some extremity
flexion. The newborn grimaces when
suctioned with a bulb syringe, and the skin
color indicates some cyanosis of the
extremities. The nurse
should most appropriately document
which Apgar score for the newborn?
1. 3
2. 5
3. 7
4. 10
2. 5
38. The nurse in the newborn nursery is
performing admission vital signs on a
newborn infant. The nurse notes that the
respiratory rate of the newborn is 50
breaths per minute. Which action should
the nurse take?
1. Document the findings.
2. Contact the health care provider.
3. Apply an oxygen mask to the newborn
infant.
4. Cover the newborn infant with blankets
and reassess the respiratory rate in 15
minutes.
1. Document the findings.
39. Methylergonovine (Methergine) has been
prescribed for a woman who is at risk for
postpartum bleeding in the immediate
postpartum period. The nurse preparing to
administer the medication ensures that
which priority item is at the bedside?
1. Peripads
2. Tape measure
3. Reflex hammer
4. Blood pressure cuff
4. Blood pressure cuff
40. Butorphanol tartrate (Stadol) is prescribed
for a woman in labor, and the woman asks
the nurse about the purpose of the
medication. The nurse should make
which most appropriate response?
1. "The medication provides pain relief
during labor."
2. "The medication will help prevent any
nausea and vomiting."
3. "The medication will assist in increasing
the contractions."
4. "The medication prevents respiratory
depression in the newborn infant."
1. "The medication provides pain relief during
labor."
41. The nurse in the labor room measures the
Apgar score in a newborn infant and notes
that the score is 4. Which action by the
nurse has highest priority?
1. Initiate an intravenous (IV) line on the
newborn infant.
2. Place the newborn infant on a
cardiorespiratory monitor.
3. Place the newborn infant in the radiant
warmer incubator.
4. Administer oxygen via resuscitation bag
to the newborn infant.
4. Administer oxygen via resuscitation bag to
the newborn infant.
42. The nurse in the delivery room is
performing an initial assessment on a
 newborn infant. When examining the
umbilical cord, the nurse should expect to
observe which finding?
1. One artery
2. Two veins
3. Two arteries
4. One artery and one vein
3. Two arteries
43. The home care nurse is visiting a mother
1 week after she gave birth to an infant
who is at risk for developing neonatal
congenital syphilis. After teaching the
mother about the signs and symptoms of
this disorder, the nurse instructs the
mother to monitor the infant for which
finding?
1. Loose stools
2. High-pitched cry
3. Vigorous feeding habits
4. A copper-colored skin rash
4. A copper-colored skin rash
44. The nurse in the newborn nursery is
preparing to complete an initial
assessment on a newborn infant who was
just admitted to the nursery. The nurse
should place a warm blanket on the
examining table to prevent heat loss in the
infant caused by which method?
1. Radiation
2. Convection
3. Conduction
4. Evaporation
3. Conduction
45. The nurse in the delivery room is
performing an assessment on a newborn
to determine the Apgar score. The nurse
notes an Apgar score of 6. On the basis of
this score, what should the nurse
determine?
1. The newborn requires vigorous
resuscitation.
2. The newborn is adjusting well to
extrauterine life.
3. The newborn requires some
resuscitative interventions.
4. The newborn is having some difficulty
adjusting to extrauterine life.
3. The newborn requires some resuscitative
interventions.
46. A nurse is teaching the mother of a
newborn infant measures to maintain the
infant's health. The nurse identifies which
as an example of primary prevention
activities for the infant?
1. Selective placement of the infant
2. Periodic well-baby examinations
3. Phenylketonuria (PKU) testing at birth
4. Administration of an antibiotic for an
umbilical cord staphylococcal infection
2. Periodic well-baby examinations
47. The nurse is preparing to bathe a 1-day-
old newborn. Which action should the
nurse avoid when performing the
procedure?
1. Immersing the newborn in water
2. Supporting the newborn's body during
the bath
3. Ensuring that the water temperature is
warm
4. Ensuring that the water temperature
does not exceed 100° F
1. Immersing the newborn in water
48. On delivery of a newborn, the nurse
performs an initial assessment. When
should the nurse plan to determine the
Apgar score?
1. At 1 minute after birth and 5 minutes
after birth
2. Immediately at birth, 3 minutes after
birth, and 10 minutes after birth
3. At 1 minute after birth, 5 minutes after
birth, and 10 minutes after birth
4. At 1 minute after birth, after the cord is
cut, and after the mother delivers the
placenta
1. At 1 minute after birth and 5 minutes after
birth
49. The nurse is performing Apgar scoring for
a newborn infant immediately after birth.
The nurse notes that the heart rate is
greater than 100 beats/min, the
respiratory effort is good, muscle tone is
active, the newborn infant sneezes when
suctioned by the bulb syringe, and the
 skin color is pink. On the basis of these
findings, the nurse should document
which Apgar score?
1. 3
2. 5
3. 7
4. 10
4. 10
50. The nurse in the newborn nursery is
determining admission vital signs for a
newborn infant. The nurse documents that
the heart rate is within normal range if
which heart rate is noted on assessment?
1. 80 beats/min
2. 90 beats/min
3. 130 beats/min
4. 180 beats/min
3. 130 beats/min
51. The nurse is performing an assessment of
a newborn admitted to the nursery after
birth. On assessment of the newborn's
head, what should the nurse anticipate to
be the most likely finding?
1. A depressed anterior fontanel
2. A soft and flat anterior fontanel
3. An anterior fontanel measuring 1 cm
4. An anterior fontanel measuring 7 cm
2. A soft and flat anterior fontanel
52. The nurse is reviewing the record of a
newborn infant in the nursery and notes
that the health care provider has
documented the presence of a
cephalohematoma. Based on this
documentation, what should the nurse
expect to note on assessment of the
infant?
1. A suture split greater than 1 cm
2. A hard, rigid, immobile suture line
3. Swelling of the soft tissues of the head
and scalp
4. Edema resulting from bleeding below
the periosteum of the cranium
4. Edema resulting from bleeding below the
periosteum of the cranium
53. The nurse is admitting a newborn infant to
the nursery and notes that the health care
provider has documented that the
newborn has an omphalocele. While
performing an assessment, where should
the nurse document the location of the
viscera in this condition?
1. Inside the abdominal cavity and under
the skin
2. Inside the abdominal cavity and under
the dermis
3. Outside the abdominal cavity and not
covered with a sac
4. Outside the abdominal cavity but inside
a translucent sac covered with peritoneum
and amniotic membrane
4. Outside the abdominal cavity but inside a
translucent sac covered with peritoneum and
amniotic membrane
54. The mother of a 1-month-old infant is
bottle-feeding her infant and asks the
nurse about the stomach capacity of an
infant. What should the nurse tell the
client is the stomach capacity of a 1-
month-old infant?
1. 10 to 20 mL
2. 30 to 90 mL
3. 75 to 100 mL
4. 90 to 150 mL
4. 90 to 150 mL
55. A newborn infant is diagnosed with
gastroesophageal reflux (GER), and the
infant's mother asks the nurse to explain
the diagnosis. On what description should
the nurse plan to base the response?
1. Gastric contents regurgitate back into
the esophagus.
2. The esophagus terminates before it
reaches the stomach.
3. Abdominal contents herniate through
an opening of the diaphragm.
4. A portion of the stomach protrudes
through the esophageal hiatus of the
diaphragm.
1. Gastric contents regurgitate back into the
esophagus.
56. The nurse is assessing a newborn infant
with a diagnosis of hiatal hernia. Which
findings would the nurse most specifically
expect to note in the infant?
 1. Excessive oral secretions
2. Bowel sounds heard over the chest
3. Hiccups and spitting up after a meal
4. Coughing, wheezing, and short periods
of apnea
4. Coughing, wheezing, and short periods of
apnea
57. An infant is born to a mother with hepatitis
B. Which prophylactic measure would be
indicated for the infant?
1. Hepatitis B vaccine given within 24
hours after birth
2. Immune globulin (IG) given as soon as
possible after delivery
3. Hepatitis B immune globulin (HBIG)
given within 14 days after birth
4. Hepatitis B immune globulin (HBIG)
and hepatitis B vaccine given within 12
hours after birth
4. Hepatitis B immune globulin (HBIG) and
hepatitis B vaccine given within 12 hours after
birth
58. The nurse is caring for a newborn. Blood
samples for serum chemistries are drawn,
and the total calcium level is reported as
8.0 mg/dL. How should the nurse interpret
this laboratory value?
1. A normal value
2. Lower than normal
3. Higher than normal
4. Requiring health care provider
notification
1. A normal value
59. The nurse is caring for a term newborn.
Which assessment finding would alert the
nurse to suspect the potential for jaundice
in this infant?
1. Presence of a cephalhematoma
2. Infant blood type of O negative
3. Birth weight of 8 pounds 6 ounces
4. A negative direct Coombs' test result
1. Presence of a cephalhematoma
60. The nurse is performing an admission
assessment on a newborn infant with the
diagnosis of subdural hematoma after a
difficult vaginal delivery. Which
assessment technique would assist to
support the newborn's diagnosis?
1. Monitoring the urine for blood
2. Monitoring the urinary output pattern
3. Testing for contractures of the
extremities
4. Stimulating for reflex responses in the
extremities
4. Stimulating for reflex responses in the
extremities
61. Which medication should the nurse plan
to administer to a newborn by the
intramuscular (IM) route?
1. Erythromycin
2. Tetracycline 1%
3. Phytonadione (Vitamin K)
4. Measles-mumps-rubella vaccination
3. Phytonadione (Vitamin K)
62. The nurse in a newborn nursery is
performing an assessment of an infant.
What procedure should the nurse use to
measure the infant's head circumference?
1. Wrap the tape measure around the
infant's head, and measure just below the
eyebrows.
2. Place the tape measure under the
infant's head, wrap around the occiput,
and measure just above the eyebrows.
3. Place the tape measure under the
infant's head at the base of the skull, and
wrap around to the front just below the
eyes.
4. Place the tape measure at the back of
the infant's head, wrap around across the
ears, and measure across the infant's
mouth.
2. Place the tape measure under the infant's
head, wrap around the occiput, and measure
just above the eyebrows.
63. The nurse is developing a plan of care for
a preterm newborn infant. The nurse
develops measures to provide skin care,
knowing that the preterm newborn infant's
skin appears in what way?
1. Thin and gelatinous, with increased
subcutaneous fat
2. Thin and gelatinous, with increased
amounts of brown fat
 3. Reddened, translucent, and gelatinous,
with decreased amounts of subcutaneous
fat
4. With fine downy hair on thin epidermal
and dermal layers, with increased amount
of brown fat
3. Reddened, translucent, and gelatinous, with
decreased amounts of subcutaneous fat
64. The nurse in the labor room is performing
an initial assessment on a newborn infant.
On assessment of the head, the nurse
notes that the ears are low set. Which
nursing action would be most
appropriate?
1. Document the findings.
2. Arrange for hearing testing.
3. Cover the ears with gauze pads.
4. Notify the health care provider (HCP).
4. Notify the health care provider (HCP).
65. The nurse is caring for a post-term, small-
for-gestational age (SGA) newborn infant
immediately after admission to the
nursery. What should the nurse monitor
as the priority?
1. Urinary output
2. Total bilirubin levels
3. Blood glucose levels
4. Hemoglobin and hematocrit levels
3. Blood glucose levels
66. An initial assessment on a large-for-
gestational age (LGA) newborn infant is
being done. Which physical assessment
technique should the nurse assist in
performing to assess for evidence of birth
trauma?
1. Palpate the clavicles for a fracture.
2. Auscultate the heart for a cardiac
defect.
3. Blanch the skin for evidence of
jaundice.
4. Perform Ortolani's maneuver for hip
dislocation.
1. Palpate the clavicles for a fracture.
67. The nurse in the newborn nursery is
assessing a neonate who was born of a
mother addicted to cocaine. Which would
the nurse expect to note in the neonate?
1. Tremors
2. Bradycardia
3. Flaccid muscles
4. Extreme lethargy
1. Tremors
68. An infant returns to the nursing unit
following surgery for a diagnosis of
esophageal atresia with
tracheoesophageal fistula (TEF). The
infant is receiving intravenous fluids and a
gastrostomy tube is in place. Following
assessment, the nurse positions the infant
and performs which action?
1. Elevates the gastrostomy tube
2. Tapes the gastrostomy tube to the bed
linens
3. Attaches the gastrostomy tube to low
suction
4. Connects the gastrostomy to the
feeding pump
1. Elevates the gastrostomy tube
69. Which would be considered a normal
finding in a newborn less than 12 hours
old?
1. Grunting respirations
2. Heart rate of 190 beats/min
3. Bluish discoloration of the hands and
feet
4. A yellow discoloration of the sclera and
body
3. Bluish discoloration of the hands and feet
70. The nurse weighing a term newborn
during the initial newborn assessment
determines the infant's weight to be 4325
g. The nurse determines that this infant
may be at risk for which
complications? Select all that apply.
1. Retinopathy
2. Hypoglycemia
3. Fractured clavicle
4. Hyperbilirubinemia
5. Congenital heart defect
6. Necrotizing enterocolitis
o 2. Hypoglycemia
o 3. Fractured clavicle
o 5. Congenital heart defect
71. A newborn is delivered via spontaneous
vaginal delivery. On reception of the
crying newborn, the nurse's priority is to
perform which action?
1. Determine Apgar score.
2. Auscultate the heart rate.
3. Thoroughly dry the newborn.
4. Take the newborn's rectal temperature.
3. Thoroughly dry the newborn.
72. The staff nurse in a neonatal intensive
care unit is aware that red electrical
outlets denote emergency power and will
function in the event of an outage. There
are only two red outlets in the room of a 4-
day-old male newborn being treated for
physiological jaundice and to rule out
sepsis from group B streptococcal
exposure. Which pieces of equipment
requiring power would the nurse select to
be plugged into the red outlets in case of
a power outage? Select all that apply.
1. Call bell
2. Feeding pump
3. Vital sign machine
4. Phototherapy lights
5. Intravenous (IV) pump
o 4. Phototherapy lights
o 5. Intravenous (IV) pump
73. Which would be considered a normal
finding in a newborn less than 12 hours
old?
1. Grunting respirations
2. Heart rate of 190 beats/minute
3. Bluish discoloration of the hands and
feet
4. A yellow discoloration of the sclera and
body
3. Bluish discoloration of the hands and feet
74. Which would be considered abnormal
findings in a newborn less than 12 hours
old? Select all that apply.
1. Grunting respirations
2. Presence of vernix caseosa
3. Heart rate of 190 beats/minute
4. Anterior fontanelle measuring 5.0 cm
5. Bluish discoloration of hands and feet
6. A yellow discoloration of the sclera and
body
o 1. Grunting respirations
o 3. Heart rate of 190 beats/minute
o 6. A yellow discoloration of the sclera
and body
75. A nurse performs an assessment of a
pregnant woman who is receiving
intravenous magnesium sulfate for
management of preeclampsia and notes
that the woman's deep tendon reflexes
are absent. On the basis of this finding,
the nurse should make which
interpretation?
1. The infusion rate needs to be
increased.
2. The magnesium sulfate is effective.
3. The woman is experiencing cerebral
edema.
4. The woman is experiencing magnesium
excess.
4. The woman is experiencing magnesium
excess.
76. Methylergonovine (Methergine) is
prescribed for a woman with postpartum
hemorrhage caused by uterine atony.
Before administering the medication, the
nurse should check which most
important client parameter?
1. Lochial flow
2. Urine output
3. Temperature
4. Blood pressure
4. Blood pressure
77. A nurse is monitoring a newborn infant
who has been 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 is
the priority nursing action?
1. Reinforce the dressing.
2. Document the findings.
3. Contact the health care provider.
4. Swab the drainage and send the
sample to the laboratory for culture.
3. Contact the health care provider.
78. A nurse is preparing to care for a newborn
who has respiratory distress syndrome.
Which initial action should the nurse plan
to best facilitate bonding between the
newborn and the parents?
 1. Encourage the parents to touch their
newborn.
2. Identify specific caregiving tasks that
may be assumed by the parents.
3. Explain the equipment that is used and
how it functions to assist their newborn.
4. Give the parents pamphlets that will
help them understand their newborn's
condition.
1. Encourage the parents to touch their
newborn.
79. Butorphanol tartrate is prescribed for a
client in labor. The nurse understands that
this medication is prescribed to achieve
which outcome?
1. Providing pain relief
2. Promoting fetal lung maturity
3. Increasing uterine contractions
4. Decreasing uterine contractions
1. Providing pain relief
80. A client experiencing preterm labor at the
29th week of gestation has been admitted
to the hospital. The client has a
prescription to receive betamethasone.
The nurse understands that the
medication has which action?
1. Stops the uterine contractions
2. Prevents spontaneous delivery
3. Promotes maturation of the fetal lungs
4. Accelerates the growth rate of the fetus
3. Promotes maturation of the fetal lungs
81. A client with preeclampsia is receiving
magnesium sulfate. The nurse should
assess the client closely for which sign of
magnesium toxicity?
1. Proteinuria
2. Presence of deep tendon reflexes
3. Respiratory rate of 10 breaths/min
4. Serum magnesium level of 5 mEq/L
3. Respiratory rate of 10 breaths/min
82. A nurse has a routine prescription to instill
erythromycin ointment into the eyes of a
newborn. The nurse plans to explain to
the parents that which is the purpose of
the medication?
1. Help the newborn to see more clearly.
2. Ensure the sterility of the conjunctiva in
the newborn.
3. Guard against infection acquired during
intrauterine life.
4. Protect the newborn from contracting
an eye infection during birth.
4. Protect the newborn from contracting an
eye infection during birth.
83. A nurse has a routine prescription to
administer an injection of phytonadione
(vitamin K) to the newborn. Before giving
the medication, the nurse explains to the
mother that this medication has which
function?
1. Stimulating the liver to produce vitamin
K
2. Preventing clotting abnormalities in the
newborn
3. Preventing vitamin deficiency of fat-
soluble vitamins
4. Supplementing the infant, because
breast milk and formula are low in vitamin
K
2. Preventing clotting abnormalities in the
newborn
84. A client in preterm labor is being started
on intravenous magnesium sulfate to stop
the contractions. The nurse should checks
to ensure that which medication is
available as an antidote if needed?
1. Vitamin K
2. Magnesium oxide
3. Calcium gluconate
4. Aluminum hydroxide
3. Calcium gluconate
85. A nurse gave an intramuscular dose of
methylergonovine (Methergine) to a client
following delivery of an infant. The nurse
determines that this medication had the
intended effect if which finding is noted?
1. Decreased pulse rate
2. Increased urine output
3. Improved uterine tone
4. Increased blood pressure
3. Improved uterine tone
86. The nurse is preparing to listen to the
apical heart rate of a newborn. The nurse
performs the procedure and should note
that the heart rate is normal if which rate
is noted?
1. A heart rate of 100 beats/min
2. A heart rate of 140 beats/min
3. A heart rate of 180 beats/min
4. A heart rate of 190 beats/min
2. A heart rate of 140 beats/min
87. The nurse is preparing to check the
respirations of a newborn who was just
delivered. The nurse performs the
procedure and should determine that the
respiratory rate is normal if which
respiratory rate is noted?
1. A respiratory rate of 20 breaths/min
2. A respiratory rate of 40 breaths/min
3. A respiratory rate of 70 breaths/min
4. A respiratory rate of 80 breaths/min
2. A respiratory rate of 40 breaths/min
88. The nurse is performing an assessment
on a newborn. The nurse is preparing to
measure the head circumference of the
newborn. Which procedure should the
nurse use to perform this procedure?
1. Wrap the paper tape around the
newborn's head, and measure just above
the eyebrows.
2. Place the paper tape under the
newborn's head, wrap around the occiput,
and measure just above the eyes.
3. Place the paper tape at the back of the
head, wrap across the ears, and measure
across the newborn's mouth.
4. Place the paper tape under the
newborn's head at the base of the skull,
and wrap around to the front, just above
the eyes.
2. Place the paper tape under the newborn's
head, wrap around the occiput, and measure
just above the eyes.
89. The nurse is checking the reflexes of a
newborn. Which action should the nurse
perform in eliciting the Moro reflex?
1. Clap hands or slap the mattress.
2. Stimulate the perioral cavity with a
finger.
3. Stimulate the ball of the infant's foot
with firm pressure.
4. Stimulate the pads of the infant's hands
with firm pressure.
1. Clap hands or slap the mattress.
90. The nurse is planning to administer an
intramuscular injection of vitamin K to a
newborn. To administer the injection
which site should the nurse should select?
1. The gluteal muscle
2. The lower aspect of the rectus femoris
muscle
3. The medial aspect of the upper third of
the vastus lateralis muscle
4. The lateral aspect of the middle third of
the vastus lateralis muscle
4. The lateral aspect of the middle third of the
vastus lateralis muscle
91. The nurse is preparing to assist in
administering neonatal resuscitation with
a ventilation bag and mask because the
newborn is apneic, gasping, and has a
heart rate below 100 beats/min. The nurse
should understand that how many
ventilations per minute should be
delivered to this neonate?
1. 20 to 40 breaths/min
2. 40 to 60 breaths/min
3. 70 to 80 breaths/min
4. 80 to 100 breaths/min
2. 40 to 60 breaths/min
92. The nurse is performing an initial
assessment on a newborn. On
assessment of the newborn's head, the
nurse notes that the ears are low set.
Which nursing action is most
appropriate initially?
1. Document the findings.
2. Arrange for hearing testing.
3. Cover the ears with gauze pads.
4. Notify the health care provider (HCP).
4. Notify the health care provider (HCP).
93. A nurse has provided instructions to a
client on how to bathe her newborn. The
nurse demonstrates the procedure to the
client and on the following day asks the
 client to perform the procedure. Which
observation, if made by the nurse,
indicates that the client is performing the
procedure correctly?
1. The client begins to wash the newborn
by starting with the eyes and face.
2. The client cleans the newborn's ears
and then moves to the eyes and the face.
3. The client washes the arms, chest, and
back, followed by the neck, arms, and
face.
4. The client washes the entire newborn's
body and then washes the eyes, face, and
scalp.
1. The client begins to wash the newborn by
starting with the eyes and face.
94. A nurse is providing instructions to a client
regarding cord care for her newborn.
Which statement made by the client
indicates a need for further teaching?
1. "The cord will fall off in 1 to 2 weeks."
2. "I should clean the cord two or three
times a day."
3. "Alcohol may be used if prescribed to
clean the cord."
4. "I need to fold the diaper above the
cord to prevent infection."
4. "I need to fold the diaper above the cord to
prevent infection."
95. The nurse is providing instructions to the
mother of a breast-fed newborn who has
hyperbilirubinemia. Which instruction
should the nurse provide to the mother?
1. Increase the frequency of the breast-
feeding.
2. Stop the breast-feedings and switch to
bottle-feeding permanently.
3. Provide bottled water feedings between
the breast-feeding sessions.
4. Switch to bottle-feeding the baby during
the period of high bilirubin levels, and feed
less frequently.
1. Increase the frequency of the breast-
feeding.
96. A nurse is monitoring a newborn that was
born to a client who abuses alcohol.
Which finding should the nurse expect to
note when assessing this newborn?
1. Lethargy
2. Irritability
3. Higher than normal birth weight
4. A greater than normal appetite when
feeding
2. Irritability
97. A nurse is monitoring a preterm newborn
for respiratory distress syndrome (RDS).
Which finding in the newborn should alert
the nurse to the possibility of this
syndrome?
1. Tachypnea and retractions
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. The presence of a barrel chest, with
acrocyanosis
1. Tachypnea and retractions
98. The nurse is checking a newborn's 1-
minute Apgar score based on the
following assessment. The heart rate is
160 beats/min; he has positive respiratory
effort with a vigorous cry; his muscle tone
is active and well-flexed; he has a strong
gag reflex and cries with stimulus to the
soles of his feet; his body is pink, with his
hands and feet cyanotic. Which is the
newborn's 1-minute Apgar score?
1. 7
2. 9
3. 8
4. 10
2. 9
99. Which are modes of heat loss in the
newborn? Select all that apply.
1. Radiation
2. Urination
3. Convection
4. Conduction
5. Evaporation
o 1. Radiation
o 3. Convection
o 4. Conduction
o 5. Evaporation