CMS Maternal Newborn Practice A Questions and
Answers Rated A
A nurse is collecting data from a client who is at - Apgar score: heart rate, respiratory rate, muscle
36 weeks of gestation during a prenatal tone, reflex irritability and skin color
examination. Which of the following findings - Newborn Hearing Screen should be completed
should the nurse report to the provider? - before the newborn is discharged from the
ANSWERS - Blurred vision - indication of hospital
preeclampsia - Critical Congenital Heart Disease screen should
Expected findings: non pitting ankle edema, 10 be completed 24- 28 hours following birth and
fetal movements in 2 hr, leg cramps before the newborn is discharged from the
hospital
A nurse is caring or a newborn who is receiving
phototherapy. Which of the following actions A nurse is assisting in the care of a newborn
should the nurse take? - ANSWERS - immediately following birth. Which of the
Place an opaque mask over the newborn's eyes following images should the nurse identify as an
- to prevent damage to the retinas indication that the newborn has a
myelomeningocele? - ANSWERS - Occurs
- Should remove mask for feedings when the neural tube fails to close, and the
DO NOT apply a thin layer of lotion to the meninges and spinal cord herniate
newborn's skin Occurs in the lumbar area and may be covered
by a thin membranous sac
- Exstrophy of the bladder; occurs from abnormal
A nurse is caring for a client who is at 11 weeks development of the abdominal wall, symphysis
of gestation and reports frequent vomiting. Which pubis and bladder ; visible in the suprapubic area
of the following findings should the nurse identify and requires surgical intervention soon after birth
as an indication that the client has hyperemesis - Omphalocel: occurs when abdominal organs
gravidarum? - ANSWERS - Ketonuria herniate through the umbilical ring at the base of
the umbilical cord
Occurs due to the breakdown of fat secondary to - Cephalohematoma; collection of blood between
malnutrition or starvation the skull bone and its covering, the periosteum. A
Tachycardia and tachypnea due to dehydration cephalohematoma does not cross the suture
lines of the newborn's skull and will
spontaneously resolve in 2-8 weeks
A nurse is caring for a newborn who has a high-
pitched cry and does not respond to consoling
efforts. Which of the following neonatal data A nurse is collecting data from a newborn who is
collection tools should the nurse expect to 8hr old. Which of the following findings should the
complete? - ANSWERS - Neonatal nurse report to the provider? - ANSWERS -
Abstinence Scoring System: exhibiting opioid Apical heart rate of 90/min while crying - normal
withdrawal range 110 - 160 for a newborn, heart rate of 80-
100/min while asleep and up to 180/min while
Additional manifestations: restlessness, tremors, crying
increased muscle tone, and an exaggerated - Apneic episode of 20 seconds or less - normal;
Moro reflex newborns respirations are normally shallow and
irregular
, CMS Maternal Newborn Practice A Questions and
Answers Rated A
- Positive moro reflex present from birth up to 8 glucose of less than 95 mg/dL.
weeks
- Vernix in the skin folds - normal
A nurse is reinforcing teaching about risk factors
for respiratory distress syndrome (RDS) in
A nurse is caring for a client 6 hr after a vaginal newborns with a group of clients who are
birth who is going to breastfeed her newborn. pregnant. Which of the following risk factors
The client reports perineal pain of 6 on a scale should the nurse include?
from 0 to 10. The nurse also notes mild perineal a. cord compression
edema and ecchymosis, with a fundus that is 2 b. chronic hypertension
cm above the umbilicus with deviation to the c. alcohol use during pregnancy
right. Which of the following actions is the nurse's d. prematurity - ANSWERS - d. prematurity
priority?
a. administer analgesics A newborn who is premature has inadequate
b. apply an ice pack to the perineum surfactant production, which can lead to RDS.
c. assist the client with breastfeeding Alcohol syndrome can result in fetal alcohol
d. help the client ambulate to the toilet - syndrome, developmental delay, and birth
ANSWERS - d. help the client ambulate to defects. Cord compression can result in fetal
the toilet anoxia.
The greatest risk for this client is postpartum
hemorrhage from uterine atony. Therefore, the A nurse is caring for a client who is planning to
priority intervention by the nurse is to assist the become pregnant. The client asks the nurse why
client to urinate and completely empty the folic acid supplements are necessary. The nurse
bladder, which will allow the uterus to contract. should inform the client that the purpose of the
folic acid supplement is to do which of the
following?
A nurse is reinforcing teaching with a client who a. facilitate the storage of iron in the fetus liver
is at 20 wks of gestation and has gestational b. prevent certain kinds of birth defects
diabetes mellitus. Which of the following c. inhibit premature labor
information should the nurse include in the d. aid in the absorption of other important
teaching? nutrients - ANSWERS - b. prevent certain
a. exercise before meals kinds of birth defects
b. consume at least 2,000 cal/day
c. avoid consuming an evening snack
d. maintain a fasting blood glucose of 110 to 120 A nurse is reinforcing discharge teaching about
mg/dL - ANSWERS - b. consume at least methods to prevent engorgement during lactation
2,000 cal/day suppression with a client who is bottle-feeding
her newborn. Which of the following statements
This will ensure adequate glucose intake and should the nurse identify as an indication that the
prevent hypoglycemia. Exercise should be done client understands the instructions?
after meals to prevent hypoglycemia. Should a. "I will massage my breasts while I take a
have an evening snack to prevent hypoglycemia shower."
during the night. Should maintain a fasting blood b. "I should wear an underwire bra during the
Answers Rated A
A nurse is collecting data from a client who is at - Apgar score: heart rate, respiratory rate, muscle
36 weeks of gestation during a prenatal tone, reflex irritability and skin color
examination. Which of the following findings - Newborn Hearing Screen should be completed
should the nurse report to the provider? - before the newborn is discharged from the
ANSWERS - Blurred vision - indication of hospital
preeclampsia - Critical Congenital Heart Disease screen should
Expected findings: non pitting ankle edema, 10 be completed 24- 28 hours following birth and
fetal movements in 2 hr, leg cramps before the newborn is discharged from the
hospital
A nurse is caring or a newborn who is receiving
phototherapy. Which of the following actions A nurse is assisting in the care of a newborn
should the nurse take? - ANSWERS - immediately following birth. Which of the
Place an opaque mask over the newborn's eyes following images should the nurse identify as an
- to prevent damage to the retinas indication that the newborn has a
myelomeningocele? - ANSWERS - Occurs
- Should remove mask for feedings when the neural tube fails to close, and the
DO NOT apply a thin layer of lotion to the meninges and spinal cord herniate
newborn's skin Occurs in the lumbar area and may be covered
by a thin membranous sac
- Exstrophy of the bladder; occurs from abnormal
A nurse is caring for a client who is at 11 weeks development of the abdominal wall, symphysis
of gestation and reports frequent vomiting. Which pubis and bladder ; visible in the suprapubic area
of the following findings should the nurse identify and requires surgical intervention soon after birth
as an indication that the client has hyperemesis - Omphalocel: occurs when abdominal organs
gravidarum? - ANSWERS - Ketonuria herniate through the umbilical ring at the base of
the umbilical cord
Occurs due to the breakdown of fat secondary to - Cephalohematoma; collection of blood between
malnutrition or starvation the skull bone and its covering, the periosteum. A
Tachycardia and tachypnea due to dehydration cephalohematoma does not cross the suture
lines of the newborn's skull and will
spontaneously resolve in 2-8 weeks
A nurse is caring for a newborn who has a high-
pitched cry and does not respond to consoling
efforts. Which of the following neonatal data A nurse is collecting data from a newborn who is
collection tools should the nurse expect to 8hr old. Which of the following findings should the
complete? - ANSWERS - Neonatal nurse report to the provider? - ANSWERS -
Abstinence Scoring System: exhibiting opioid Apical heart rate of 90/min while crying - normal
withdrawal range 110 - 160 for a newborn, heart rate of 80-
100/min while asleep and up to 180/min while
Additional manifestations: restlessness, tremors, crying
increased muscle tone, and an exaggerated - Apneic episode of 20 seconds or less - normal;
Moro reflex newborns respirations are normally shallow and
irregular
, CMS Maternal Newborn Practice A Questions and
Answers Rated A
- Positive moro reflex present from birth up to 8 glucose of less than 95 mg/dL.
weeks
- Vernix in the skin folds - normal
A nurse is reinforcing teaching about risk factors
for respiratory distress syndrome (RDS) in
A nurse is caring for a client 6 hr after a vaginal newborns with a group of clients who are
birth who is going to breastfeed her newborn. pregnant. Which of the following risk factors
The client reports perineal pain of 6 on a scale should the nurse include?
from 0 to 10. The nurse also notes mild perineal a. cord compression
edema and ecchymosis, with a fundus that is 2 b. chronic hypertension
cm above the umbilicus with deviation to the c. alcohol use during pregnancy
right. Which of the following actions is the nurse's d. prematurity - ANSWERS - d. prematurity
priority?
a. administer analgesics A newborn who is premature has inadequate
b. apply an ice pack to the perineum surfactant production, which can lead to RDS.
c. assist the client with breastfeeding Alcohol syndrome can result in fetal alcohol
d. help the client ambulate to the toilet - syndrome, developmental delay, and birth
ANSWERS - d. help the client ambulate to defects. Cord compression can result in fetal
the toilet anoxia.
The greatest risk for this client is postpartum
hemorrhage from uterine atony. Therefore, the A nurse is caring for a client who is planning to
priority intervention by the nurse is to assist the become pregnant. The client asks the nurse why
client to urinate and completely empty the folic acid supplements are necessary. The nurse
bladder, which will allow the uterus to contract. should inform the client that the purpose of the
folic acid supplement is to do which of the
following?
A nurse is reinforcing teaching with a client who a. facilitate the storage of iron in the fetus liver
is at 20 wks of gestation and has gestational b. prevent certain kinds of birth defects
diabetes mellitus. Which of the following c. inhibit premature labor
information should the nurse include in the d. aid in the absorption of other important
teaching? nutrients - ANSWERS - b. prevent certain
a. exercise before meals kinds of birth defects
b. consume at least 2,000 cal/day
c. avoid consuming an evening snack
d. maintain a fasting blood glucose of 110 to 120 A nurse is reinforcing discharge teaching about
mg/dL - ANSWERS - b. consume at least methods to prevent engorgement during lactation
2,000 cal/day suppression with a client who is bottle-feeding
her newborn. Which of the following statements
This will ensure adequate glucose intake and should the nurse identify as an indication that the
prevent hypoglycemia. Exercise should be done client understands the instructions?
after meals to prevent hypoglycemia. Should a. "I will massage my breasts while I take a
have an evening snack to prevent hypoglycemia shower."
during the night. Should maintain a fasting blood b. "I should wear an underwire bra during the
