PN MATERNAL NEWBORN 2024
Question 1 Exhibit 1
A nurse is caring for a newborn who is 4 hr old.
Nurses’ Notes
Newborn is lying in bassinet, lightly swaddled.
Newborn is noted to be jittery with a weak cry when disturbed.
Extremities are mottled with acrocyanosis
Respirations are rapid and unlabored
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sampleAction 2: administer p
Potential Condition: Congenital Syphilis
Parameter 1: Sking integrity
Parameter 2: Respiratory status
Question 1 Exhibit 2
A nurse is caring for a newborn who is 4 hr old.
Medical History
Gravida 2 para 2
Spontaneous vaginal birth at 41 weeks of gestation.
,Maternal history positive for syphilis in the first semester, which was treated with penicillin. No
reoccurrence during the pregnancy.
Client reports intermittent cannabis use during pregnancy.
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
Newborn vita signs:
Axillary temperature 36oC (96.8oF)
Heart rate 132/min
Respiratory rate 72/min
Weight 4,366 g (9 lb to 10 oz)
Action 1: Collect urine sample
Action 2: Obtain a capillary blood sample
Potential condition: Congenital syphilis
Parameter to monitor 1: Respiratory
states Parameter to monitor 2: Skin
integrity
Question 1 Exhibit 3
A nurse is caring for a newborn who is 4 hr
old.
Vital Signs
monitor to assess the client’s progress.
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should
, Action 1: Obtain a capillary blood sample
Action 2: Place the newborn under a phototherapy
lamp
Potential condition: Congenital syphilis
Parameter to monitor: Respiratory states
Parameter to monitor: skin integrity
Question 1 Exhibit 4
A nurse is caring for a newborn who is 4 hr old.
Diagnostic Results
Maternal Laboratory Result:
Blood type: A+
Rapid plasma regain (RRR)/Venereal Disease Research Laboratories (VDRL): negative
Urine drug screen: Positive for cannabis, negative for opiates, cocaine, amphetamines, and barbiturates.
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse
should monitor to assess the client’s progress.
Action 1: Obtain a capillary blo
Potential condition:
Parameter to monitor: Respira
Question 2 Exhibit 1
, A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses’ Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute
score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed
meconium stool since birth.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
Question 2 Exhibit 2
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination
Fontanels soft and flat
Head molded with caput succedaneum
Eyes symmetric, no discharge, sclera yellow
Mucous membranes dry
Abdomen soft and rounded, bowel sounds present x 4 quadrants.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
Question 1 Exhibit 1
A nurse is caring for a newborn who is 4 hr old.
Nurses’ Notes
Newborn is lying in bassinet, lightly swaddled.
Newborn is noted to be jittery with a weak cry when disturbed.
Extremities are mottled with acrocyanosis
Respirations are rapid and unlabored
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sampleAction 2: administer p
Potential Condition: Congenital Syphilis
Parameter 1: Sking integrity
Parameter 2: Respiratory status
Question 1 Exhibit 2
A nurse is caring for a newborn who is 4 hr old.
Medical History
Gravida 2 para 2
Spontaneous vaginal birth at 41 weeks of gestation.
,Maternal history positive for syphilis in the first semester, which was treated with penicillin. No
reoccurrence during the pregnancy.
Client reports intermittent cannabis use during pregnancy.
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should monitor to assess the client’s progress.
Newborn vita signs:
Axillary temperature 36oC (96.8oF)
Heart rate 132/min
Respiratory rate 72/min
Weight 4,366 g (9 lb to 10 oz)
Action 1: Collect urine sample
Action 2: Obtain a capillary blood sample
Potential condition: Congenital syphilis
Parameter to monitor 1: Respiratory
states Parameter to monitor 2: Skin
integrity
Question 1 Exhibit 3
A nurse is caring for a newborn who is 4 hr
old.
Vital Signs
monitor to assess the client’s progress.
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the
nurse should
, Action 1: Obtain a capillary blood sample
Action 2: Place the newborn under a phototherapy
lamp
Potential condition: Congenital syphilis
Parameter to monitor: Respiratory states
Parameter to monitor: skin integrity
Question 1 Exhibit 4
A nurse is caring for a newborn who is 4 hr old.
Diagnostic Results
Maternal Laboratory Result:
Blood type: A+
Rapid plasma regain (RRR)/Venereal Disease Research Laboratories (VDRL): negative
Urine drug screen: Positive for cannabis, negative for opiates, cocaine, amphetamines, and barbiturates.
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse
should monitor to assess the client’s progress.
Action 1: Obtain a capillary blo
Potential condition:
Parameter to monitor: Respira
Question 2 Exhibit 1
, A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses’ Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute
score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed
meconium stool since birth.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
Question 2 Exhibit 2
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination
Fontanels soft and flat
Head molded with caput succedaneum
Eyes symmetric, no discharge, sclera yellow
Mucous membranes dry
Abdomen soft and rounded, bowel sounds present x 4 quadrants.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
