A nurse is testing the reflexes of a newborn to assess neurologic maturity. What reflexes is the
nurse assessing when she quickly and gently turns the newborn's head to one side?
a. moro
b. babinski
c. rooting
d. tonic neck - ANSWER - d. tonic neck
To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side
when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same
side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3
to 4 months.
A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse
expect?
a. symmetric rib cage
b. lanugo abundant on the back
c. dry, wrinkled skin
d. vernix over the entire body - ANSWER - a. symmetric rib cage
A newborn who is born at 39 weeks of gestation is full-term and should have normal, smooth skin with
good turgor and the presence of subcutaneous fat pockets. A postmature newborn, greater than 42
weeks of gestation, will have dry, cracked skin with a wrinkled appearance.
pg. 1
,A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that
does not cross the suture line. What pieces of info should the nurse provide to the mother when she
inquires about the finding?
a. this will resolve within 3-6 wks without treatment
b. this will resolve on its own within 3-4 days
c. this is expected at birth so you don't need to worry about it
d. the provider might drain this area with a syringe - ANSWER - a. this will resolve within 3-6 wks without
treatment
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding
should the nurse monitor to identify a cervical laceration?
a. a gush of rubra lochia when the nurse massages the uterus
b. continuous lochia flow and flaccid uterus
c. slow trickle of bright vaginal bleeding and a firm fundus
d. report of increasing pain and pressure in the perineal area - ANSWER - c. slow trickle of bright vaginal
bleeding and a firm fundus
The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm
fundus to identify a cervical laceration.
A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should
the nurse seek clarification?
a. initiate bedrest with HOB elevated
b. initiate high-fiber diet for client
c. monitor clients wt wkly
d. monitor client's I&O - ANSWER - c. monitor clients wt wkly
The nurse should weigh the client daily to monitor for fluid overload.
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her
newborn. What instructions should the nurse include in the teaching?
a. stand under hot shower with your breasts exposed
pg. 2
,b. place ice packs on your breasts
c. limit fluid intake to 1 L per day
d. wear a loose-fitting, comfortable bra - ANSWER - b. place ice packs on your breasts
The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off
schedule, to decrease swelling of the breast tissue as the body produces milk.
A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the
newborn within 1-2 hr of delivery?
a. poractant alpha
b. rotavirus immunization
c. naloxone
d. erythromycin ophthalmic ointment - ANSWER - d. erythromycin ophthalmic ointment
Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent
gonorrheal or chlamydial infections that the newborn can contract during birth.
A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh? - ANSWER - 1.8
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client
becomes frightened when she has a gush of dark red blood from her vagina. What following statements
should the nurse make?
a. blood pools in the vagina when you are lying a bed
b. the amount of blood flow will increase during the first few days after giving birth
c. you might have retained placental fragments in your uterus
d. you might have a damaged blood vessel - ANSWER - a. blood pools in the vagina when you are lying a
bed
In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow
out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a
trickle of bright red lochia.
pg. 3
, A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What meds
should the nurse plan to administer?
a. misoprostol
b. betamethasone
c. poractant alfa
d. methylergonovine - ANSWER - b. betamethasone
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse
how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will
be used to confirm her pregnancy?
a. urine test for presence of HCG
b. urine test for the presence of HCS
c. blood test for presence of estrogen
d. blood test for the amount of circulating progesterone - ANSWER - a. urine test for presence of HCG
A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify
as a positive sign of pregnancy?
a. palpable fetal movement
b. amenorrhea
c. chadwick's sign
d. positive pregnancy test - ANSWER - a. palpable fetal movement
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect?
a. renal agenesis
b. atrial septal defect
c. spina bifida
d. hydrocephalus - ANSWER - a. renal agenesis
pg. 4
nurse assessing when she quickly and gently turns the newborn's head to one side?
a. moro
b. babinski
c. rooting
d. tonic neck - ANSWER - d. tonic neck
To elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side
when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same
side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3
to 4 months.
A nurse is assessing a newborn who was born at 39 wks gestation. What finding should the nurse
expect?
a. symmetric rib cage
b. lanugo abundant on the back
c. dry, wrinkled skin
d. vernix over the entire body - ANSWER - a. symmetric rib cage
A newborn who is born at 39 weeks of gestation is full-term and should have normal, smooth skin with
good turgor and the presence of subcutaneous fat pockets. A postmature newborn, greater than 42
weeks of gestation, will have dry, cracked skin with a wrinkled appearance.
pg. 1
,A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous, bluish discoloration that
does not cross the suture line. What pieces of info should the nurse provide to the mother when she
inquires about the finding?
a. this will resolve within 3-6 wks without treatment
b. this will resolve on its own within 3-4 days
c. this is expected at birth so you don't need to worry about it
d. the provider might drain this area with a syringe - ANSWER - a. this will resolve within 3-6 wks without
treatment
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For what finding
should the nurse monitor to identify a cervical laceration?
a. a gush of rubra lochia when the nurse massages the uterus
b. continuous lochia flow and flaccid uterus
c. slow trickle of bright vaginal bleeding and a firm fundus
d. report of increasing pain and pressure in the perineal area - ANSWER - c. slow trickle of bright vaginal
bleeding and a firm fundus
The nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding,and a firm
fundus to identify a cervical laceration.
A nurse is planning care for a client who is postpartum and has cardiac disease. For what script should
the nurse seek clarification?
a. initiate bedrest with HOB elevated
b. initiate high-fiber diet for client
c. monitor clients wt wkly
d. monitor client's I&O - ANSWER - c. monitor clients wt wkly
The nurse should weigh the client daily to monitor for fluid overload.
A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her
newborn. What instructions should the nurse include in the teaching?
a. stand under hot shower with your breasts exposed
pg. 2
,b. place ice packs on your breasts
c. limit fluid intake to 1 L per day
d. wear a loose-fitting, comfortable bra - ANSWER - b. place ice packs on your breasts
The nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off
schedule, to decrease swelling of the breast tissue as the body produces milk.
A nurse is caring for a newborn directly after birth. What medications should the nurse administer to the
newborn within 1-2 hr of delivery?
a. poractant alpha
b. rotavirus immunization
c. naloxone
d. erythromycin ophthalmic ointment - ANSWER - d. erythromycin ophthalmic ointment
Every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent
gonorrheal or chlamydial infections that the newborn can contract during birth.
A nurse is caring for a newborn who weighs 4lb. How many kg does the newborn weigh? - ANSWER - 1.8
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client
becomes frightened when she has a gush of dark red blood from her vagina. What following statements
should the nurse make?
a. blood pools in the vagina when you are lying a bed
b. the amount of blood flow will increase during the first few days after giving birth
c. you might have retained placental fragments in your uterus
d. you might have a damaged blood vessel - ANSWER - a. blood pools in the vagina when you are lying a
bed
In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow
out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a
trickle of bright red lochia.
pg. 3
, A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What meds
should the nurse plan to administer?
a. misoprostol
b. betamethasone
c. poractant alfa
d. methylergonovine - ANSWER - b. betamethasone
A nurse at a prenatal clinic is caring for a client who suspects she may be pregnant and asks the nurse
how the provider will confirm her pregnancy. The nurse should inform the client that what lab test will
be used to confirm her pregnancy?
a. urine test for presence of HCG
b. urine test for the presence of HCS
c. blood test for presence of estrogen
d. blood test for the amount of circulating progesterone - ANSWER - a. urine test for presence of HCG
A nurse is caring for a client who believes she may be pregnant. What finding should the nurse identify
as a positive sign of pregnancy?
a. palpable fetal movement
b. amenorrhea
c. chadwick's sign
d. positive pregnancy test - ANSWER - a. palpable fetal movement
A nurse is caring for a client who has oligohydraminios. What fetal anomalies should the nurse expect?
a. renal agenesis
b. atrial septal defect
c. spina bifida
d. hydrocephalus - ANSWER - a. renal agenesis
pg. 4
