NURS 230 Maternal Exam 2: 100% Verified Questions &
Answers
Question 1
The nurse is assessing a newborn who has just been delivered. Which of the following is the
priority physiological change?
• a. Successful feeding.
• b. Thermoregulation.
• c. Extra-uterine circulatory shift.
• d. Spontaneous respirations.
Correct Answer: d
Rationale: The most critical physiological adaptation immediately following birth is the
establishment of spontaneous respirations to ensure proper oxygenation and transition to
extra-uterine life.
Question 2
The nurse is caring for a newborn who was delivered 24 hours ago and is due to have an initial
bath. Which of the following interventions should the nurse include when bathing the
newborn?
• a. Place a hat on the newborn during bathing.
• b. Utilize a cleanser with a neutral pH during bathing.
• c. Make sure the newborn is placed in hot water.
• d. Use warm 0.9% sodium chloride (normal saline) during bathing.
Correct Answer: b
Rationale: Standard practice for newborn bathing involves using tap water and a minimal
amount of a pH-neutral or slightly acidic cleanser to avoid harming the infant's delicate skin.
,Question 3
The nurse is caring for a newborn who was born 30 minutes ago. The nurse recognizes which
of the following as a probable sign of respiratory distress?
• a. Chest retractions.
• b. Respirations (R) of 58.
• c. Short periods of apnea lasting 8 to 10 seconds.
• d. Blue hands and feet.
Correct Answer: a
Rationale: Key indicators of Respiratory Distress Syndrome in a newborn include grunting,
nasal flaring, and chest retractions. Apneic periods under 15 seconds and blue hands/feet
(acrocyanosis) are normal findings initially.
Question 4
The nurse is caring for a newborn immediately following birth. After ensuring a patent airway,
which of the following is the priority nursing action?
• a. Dry the skin.
• b. Administer eye prophylaxis.
• c. Administer vitamin K.
• d. Place an identification bracelet.
Correct Answer: a
Rationale: Preventing heat loss is critical. If a newborn becomes cold stressed, their oxygen and
energy demands spike, leading to hypoglycemia and potential respiratory distress. Drying the
skin immediately is the priority action to prevent evaporative heat loss.
Question 5
The nurse is assessing a newborn who has just been admitted to the nursery. Which of the
following findings requires further assessment by the nurse?
• a. An edematous area on the occiput of the scalp.
, • b. Head is 1/4 the total body length.
• c. Transient rash with macules and papules.
• d. Irregular shape of blue-grey pigmentation over the sacral area.
Correct Answer: a
Rationale: An edematous area on the occiput of the scalp requires close follow-up and
assessment to differentiate between a benign caput succedaneum and a more serious
cephalhematoma or subdural hematoma. The other findings (head-to-body ratio, erythema
toxicum, and Mongolian spots) are common, benign newborn variations.
Question 6
The nurse is caring for a newborn 4 hours after birth. Which of the following actions should
the nurse include in the plan of care to prevent jaundice?
• a. Begin phototherapy.
• b. Monitor with a transcutaneous bilirubinometry (TcB) monitor.
• c. Initiate early feeding.
• d. Prepare for an exchange blood transfusion.
Correct Answer: c
Rationale: Initiating early feeding promotes bowel elimination (excreting meconium, which is
rich in bilirubin), helping prevent hyperbilirubinemia.
Question 7
A nurse is providing postpartum care to a mother with diabetes and her newborn. One and
one-half hours post-delivery, the nurse observed tremors of the newborn's extremities. The
blood glucose level is obtained from a heel stick and the results are 50 mg/dL. Which of the
following actions should the nurse take next?
• a. Feed the newborn breastmilk or formula.
• b. Place the newborn skin-to-skin with mother.
• c. Recheck the blood glucose level.
Answers
Question 1
The nurse is assessing a newborn who has just been delivered. Which of the following is the
priority physiological change?
• a. Successful feeding.
• b. Thermoregulation.
• c. Extra-uterine circulatory shift.
• d. Spontaneous respirations.
Correct Answer: d
Rationale: The most critical physiological adaptation immediately following birth is the
establishment of spontaneous respirations to ensure proper oxygenation and transition to
extra-uterine life.
Question 2
The nurse is caring for a newborn who was delivered 24 hours ago and is due to have an initial
bath. Which of the following interventions should the nurse include when bathing the
newborn?
• a. Place a hat on the newborn during bathing.
• b. Utilize a cleanser with a neutral pH during bathing.
• c. Make sure the newborn is placed in hot water.
• d. Use warm 0.9% sodium chloride (normal saline) during bathing.
Correct Answer: b
Rationale: Standard practice for newborn bathing involves using tap water and a minimal
amount of a pH-neutral or slightly acidic cleanser to avoid harming the infant's delicate skin.
,Question 3
The nurse is caring for a newborn who was born 30 minutes ago. The nurse recognizes which
of the following as a probable sign of respiratory distress?
• a. Chest retractions.
• b. Respirations (R) of 58.
• c. Short periods of apnea lasting 8 to 10 seconds.
• d. Blue hands and feet.
Correct Answer: a
Rationale: Key indicators of Respiratory Distress Syndrome in a newborn include grunting,
nasal flaring, and chest retractions. Apneic periods under 15 seconds and blue hands/feet
(acrocyanosis) are normal findings initially.
Question 4
The nurse is caring for a newborn immediately following birth. After ensuring a patent airway,
which of the following is the priority nursing action?
• a. Dry the skin.
• b. Administer eye prophylaxis.
• c. Administer vitamin K.
• d. Place an identification bracelet.
Correct Answer: a
Rationale: Preventing heat loss is critical. If a newborn becomes cold stressed, their oxygen and
energy demands spike, leading to hypoglycemia and potential respiratory distress. Drying the
skin immediately is the priority action to prevent evaporative heat loss.
Question 5
The nurse is assessing a newborn who has just been admitted to the nursery. Which of the
following findings requires further assessment by the nurse?
• a. An edematous area on the occiput of the scalp.
, • b. Head is 1/4 the total body length.
• c. Transient rash with macules and papules.
• d. Irregular shape of blue-grey pigmentation over the sacral area.
Correct Answer: a
Rationale: An edematous area on the occiput of the scalp requires close follow-up and
assessment to differentiate between a benign caput succedaneum and a more serious
cephalhematoma or subdural hematoma. The other findings (head-to-body ratio, erythema
toxicum, and Mongolian spots) are common, benign newborn variations.
Question 6
The nurse is caring for a newborn 4 hours after birth. Which of the following actions should
the nurse include in the plan of care to prevent jaundice?
• a. Begin phototherapy.
• b. Monitor with a transcutaneous bilirubinometry (TcB) monitor.
• c. Initiate early feeding.
• d. Prepare for an exchange blood transfusion.
Correct Answer: c
Rationale: Initiating early feeding promotes bowel elimination (excreting meconium, which is
rich in bilirubin), helping prevent hyperbilirubinemia.
Question 7
A nurse is providing postpartum care to a mother with diabetes and her newborn. One and
one-half hours post-delivery, the nurse observed tremors of the newborn's extremities. The
blood glucose level is obtained from a heel stick and the results are 50 mg/dL. Which of the
following actions should the nurse take next?
• a. Feed the newborn breastmilk or formula.
• b. Place the newborn skin-to-skin with mother.
• c. Recheck the blood glucose level.
