Maternity Nursing (OB Maternal &
Newborn) NCLEX Practice Quiz #3 | 75
Questions
1. 1. Question
A newborn who has an asymmetrical Moro reflex response should be
further assessed for which of the following?
o A. Talipes equinovarus
o B. Fractured clavicle
o C. Congenital hypothyroidism
o D. Increased intracranial pressure
Incorrect
Correct Answer: B. Fractured clavicle
A fractured clavicle would prevent the normal Moro response of
symmetrical sequential extension and abduction of the arms followed
by flexion and adduction.
Option A: In talipes equinovarus (clubfoot) the foot is turned
medially, and in plantar flexion, with the heel elevated. The feet
are not involved with the Moro reflex.
Option C: Hypothyroidism has no effect on the primitive
reflexes. Hypothyroidism means that the thyroid gland can’t
make enough thyroid hormones to keep the body running
normally.
Option D: The absence of the Moro reflex is the most significant
single indicator of central nervous system status, but it is not a
sign of increased intracranial pressure.
2. 2. Question
During the first 4 hours after a male circumcision, assessing for which
of the following is the priority?
A. Infection
, B. Hemorrhage
C. Discomfort
D. Dehydration
Incorrect
Correct Answer: B. Hemorrhage
Hemorrhage is a potential risk following any surgical procedure.
Although the infant has been given vitamin K to facilitate clotting, the
prophylactic dose is often not sufficient to prevent bleeding.
Option A: Although infection is a possibility, signs will not appear
within 4 hours after the surgical procedure.
Option C: The primary discomfort of circumcision occurs during
the surgical procedure, not afterward.
Option D: Although feedings are withheld prior to the
circumcision, the chances of dehydration are minimal.
3. 3. Question
The mother asks the nurse. “What’s wrong with my son’s breasts? Why
are they so enlarged?” Which of the following would be
the best response by the nurse?
A. “The breast tissue is inflamed from the trauma experienced with
birth.”
B. “A decrease in material hormones present before birth
causes enlargement,”
C. “You should discuss this with your doctor. It could be a
malignancy.”
D. “The tissue has hypertrophied while the baby was in the uterus.”
Incorrect
Correct Answer: B. “A decrease in material hormones present
before birth causes enlargement,”
The presence of excessive estrogen and progesterone in the maternal-
fetal blood followed by prompt withdrawal at birth precipitates breast
engorgement, which will spontaneously resolve in 4 to 5 days after
birth.
, Option A: The trauma of the birth process does not cause
inflammation of the newborn’s breast tissue.
Option C: Newborns do not have breast malignancy. This reply
by the nurse would cause the mother to have undue anxiety.
Option D: Breast tissue does not hypertrophy in the fetus or
newborns.
4. 4. Question
Immediately after birth, the nurse notes the following on a male
newborn: respirations 78; apical heart rate 160 BPM, nostril-flaring;
mild intercostal retractions; and grunting at the end of expiration.
Which of the following should the nurse do?
A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares.
D. Recognize this as a normal first period of reactivity.
Incorrect
Correct Answer: D. Recognize this as normal first period of
reactivity
The first 15 minutes to 1 hour after birth is the first period of reactivity
involving respiratory and circulatory adaptation to extrauterine life.
The data given reflect the normal changes during this time period.
Option A: The infant’s assessment data reflect normal
adaptation. Thus, the physician does not need to be notified.
Option B: Babies with heart or lung problems may need to
breathe increased amounts of oxygen to get normal levels of
oxygen in their blood. Oxygen therapy provides babies with extra
oxygen.
Option C: The data do not indicate the presence of choking,
gagging, or coughing, which are signs of excessive secretions.
Suctioning is not necessary.
5. 5. Question
The nurse hears a mother telling a friend on the telephone about
umbilical cord care. Which of the following statements by the mother
indicates effective teaching?
, A. “Daily soap and water cleansing is best.”
B. “Alcohol helps it dry and kills germs.”
C. “An antibiotic ointment applied daily prevents infection.”
D. “He can have a tub bath each day.”
Incorrect
Correct Answer: B. “Alcohol helps it dry and kills germs”
Application of 70% isopropyl alcohol to the cord minimizes
microorganisms (germicidal) and promotes drying. The cord should be
kept dry until it falls off and the stump has healed.
Option A: Research now shows that the stump might actually
heal faster if left alone. If the stump becomes dirty or sticky,
clean it with plain water, after which you dry it by holding a clean,
absorbent cloth around it or fanning it with a piece of paper.
Option C: Antibiotic ointment should only be used to treat an
infection, not as prophylaxis.
Option D: Infants should not be submerged in a tub of water
until the cord falls off and the stump has completely healed.
6. 6. Question
A newborn weighing 3000 grams and feeding every 4 hours needs 120
calories/kg of body weight every 24 hours for proper growth and
development. How many ounces of 20 cals/oz formula should this
newborn receive at each feeding to meet nutritional needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
Incorrect
Correct Answer: B. 3 ounces
To determine the amount of formula needed, do the following
mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day
feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60
calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3
Newborn) NCLEX Practice Quiz #3 | 75
Questions
1. 1. Question
A newborn who has an asymmetrical Moro reflex response should be
further assessed for which of the following?
o A. Talipes equinovarus
o B. Fractured clavicle
o C. Congenital hypothyroidism
o D. Increased intracranial pressure
Incorrect
Correct Answer: B. Fractured clavicle
A fractured clavicle would prevent the normal Moro response of
symmetrical sequential extension and abduction of the arms followed
by flexion and adduction.
Option A: In talipes equinovarus (clubfoot) the foot is turned
medially, and in plantar flexion, with the heel elevated. The feet
are not involved with the Moro reflex.
Option C: Hypothyroidism has no effect on the primitive
reflexes. Hypothyroidism means that the thyroid gland can’t
make enough thyroid hormones to keep the body running
normally.
Option D: The absence of the Moro reflex is the most significant
single indicator of central nervous system status, but it is not a
sign of increased intracranial pressure.
2. 2. Question
During the first 4 hours after a male circumcision, assessing for which
of the following is the priority?
A. Infection
, B. Hemorrhage
C. Discomfort
D. Dehydration
Incorrect
Correct Answer: B. Hemorrhage
Hemorrhage is a potential risk following any surgical procedure.
Although the infant has been given vitamin K to facilitate clotting, the
prophylactic dose is often not sufficient to prevent bleeding.
Option A: Although infection is a possibility, signs will not appear
within 4 hours after the surgical procedure.
Option C: The primary discomfort of circumcision occurs during
the surgical procedure, not afterward.
Option D: Although feedings are withheld prior to the
circumcision, the chances of dehydration are minimal.
3. 3. Question
The mother asks the nurse. “What’s wrong with my son’s breasts? Why
are they so enlarged?” Which of the following would be
the best response by the nurse?
A. “The breast tissue is inflamed from the trauma experienced with
birth.”
B. “A decrease in material hormones present before birth
causes enlargement,”
C. “You should discuss this with your doctor. It could be a
malignancy.”
D. “The tissue has hypertrophied while the baby was in the uterus.”
Incorrect
Correct Answer: B. “A decrease in material hormones present
before birth causes enlargement,”
The presence of excessive estrogen and progesterone in the maternal-
fetal blood followed by prompt withdrawal at birth precipitates breast
engorgement, which will spontaneously resolve in 4 to 5 days after
birth.
, Option A: The trauma of the birth process does not cause
inflammation of the newborn’s breast tissue.
Option C: Newborns do not have breast malignancy. This reply
by the nurse would cause the mother to have undue anxiety.
Option D: Breast tissue does not hypertrophy in the fetus or
newborns.
4. 4. Question
Immediately after birth, the nurse notes the following on a male
newborn: respirations 78; apical heart rate 160 BPM, nostril-flaring;
mild intercostal retractions; and grunting at the end of expiration.
Which of the following should the nurse do?
A. Call the assessment data to the physician’s attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infant’s mouth and nares.
D. Recognize this as a normal first period of reactivity.
Incorrect
Correct Answer: D. Recognize this as normal first period of
reactivity
The first 15 minutes to 1 hour after birth is the first period of reactivity
involving respiratory and circulatory adaptation to extrauterine life.
The data given reflect the normal changes during this time period.
Option A: The infant’s assessment data reflect normal
adaptation. Thus, the physician does not need to be notified.
Option B: Babies with heart or lung problems may need to
breathe increased amounts of oxygen to get normal levels of
oxygen in their blood. Oxygen therapy provides babies with extra
oxygen.
Option C: The data do not indicate the presence of choking,
gagging, or coughing, which are signs of excessive secretions.
Suctioning is not necessary.
5. 5. Question
The nurse hears a mother telling a friend on the telephone about
umbilical cord care. Which of the following statements by the mother
indicates effective teaching?
, A. “Daily soap and water cleansing is best.”
B. “Alcohol helps it dry and kills germs.”
C. “An antibiotic ointment applied daily prevents infection.”
D. “He can have a tub bath each day.”
Incorrect
Correct Answer: B. “Alcohol helps it dry and kills germs”
Application of 70% isopropyl alcohol to the cord minimizes
microorganisms (germicidal) and promotes drying. The cord should be
kept dry until it falls off and the stump has healed.
Option A: Research now shows that the stump might actually
heal faster if left alone. If the stump becomes dirty or sticky,
clean it with plain water, after which you dry it by holding a clean,
absorbent cloth around it or fanning it with a piece of paper.
Option C: Antibiotic ointment should only be used to treat an
infection, not as prophylaxis.
Option D: Infants should not be submerged in a tub of water
until the cord falls off and the stump has completely healed.
6. 6. Question
A newborn weighing 3000 grams and feeding every 4 hours needs 120
calories/kg of body weight every 24 hours for proper growth and
development. How many ounces of 20 cals/oz formula should this
newborn receive at each feeding to meet nutritional needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
Incorrect
Correct Answer: B. 3 ounces
To determine the amount of formula needed, do the following
mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day
feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60
calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3
