NUR 230 – Exam 4 High-Risk Student ID: __________________ Page ___
GALEN COLLEGE OF NURSING
DEPARTMENT OF NURSING EDUCATION
COURSE: NUR 230 – Maternal-Newborn Nursing
EXAM: Exam 4: High-Risk Conditions & Newborn Complications VERSION:
Comprehensive (50 Questions)
TOTAL POINTS: 50 (1 point each)
TIME ALLOWED: 75 minutes
STUDENT NAME: _______________________________________
STUDENT ID: _______________________________________
DATE: _______________________________________ INSTRUCTOR:
_______________________________________
DIRECTIONS:
1. Use a #2 pencil or blue/black ink pen.
2. Select the BEST answer for each question.
3. Mark your answers on the separate answer sheet provided.
4. Do not write on the exam booklet (unless permitted).
5. After completion, return both exam booklet and answer sheet. 6.
Cellular phones, smartwatches, and other electronic devices
must be turned off and stored out of sight.
--------------------------------------------------------------------
ACADEMIC HONESTY STATEMENT:
By signing below, I affirm that I will neither give nor receive any
unauthorized aid on this examination.
STUDENT SIGNATURE: _______________________________________
FOR FACULTY USE ONLY:
SCORE: ________ / 50 PERCENTAGE: ________ %
,NUR 230 – Exam 4 High-Risk Student ID: __________________ Page ___
INSTRUCTOR INITIALS: ___________
NUR 230 – Maternal-Newborn Nursing
Exam 4: High-Risk Conditions & Newborn Complications
Question 1
A nurse is assessing a newborn at 1 minute of life. The newborn has a heart rate of 110 bpm, is
crying vigorously, has active movement, has blue hands and feet, but a pink trunk. What is the
APGAR score?
A. 7
B. 8
C. 9
D. 10
Answer: C. 9
Rationale:
• Heart rate >100 bpm = 2
• Respiratory effort (crying vigorously) = 2
• Muscle tone (active movement) = 2
• Reflex irritability (vigorous cry) = 2
• Color (pink trunk, blue extremities = acrocyanosis) = 1
Total = 9. Acrocyanosis is normal in the first minutes; a perfect 10 requires completely
pink body and extremities.
Question 2
A newborn at 24 hours of life has a total serum bilirubin of 14 mg/dL. The mother is type O
negative, and the newborn is type A positive. Which intervention does the nurse anticipate? A.
Exchange transfusion
B. Phototherapy
C. Increased oral feedings only
D. Administration of vitamin K
Answer: B. Phototherapy
Rationale: This is likely ABO incompatibility with early, rapid rise in bilirubin. Phototherapy is
indicated to prevent bilirubin neurotoxicity. Exchange transfusion is reserved for levels
approaching exchange range (e.g., >20-25 mg/dL depending on weight and age).
Question 3
A nurse is caring for a patient with preeclampsia who is receiving a magnesium sulfate infusion.
Which assessment finding is most indicative of magnesium toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate 14 breaths/min
, NUR 230 – Exam 4 High-Risk Student ID: __________________ Page ___
Rationale:
C. Urine output 20 mL in 2 hours
D. Serum magnesium level 6 mg/dL
Answer: C. Urine output 20 mL in 2 hours
Oliguria (<30 mL/hr) is a sign of magnesium toxicity because magnesium is excreted
renally. Urine output of 10 mL/hr (20 mL/2 hr) is dangerously low. Normal DTRs (2+) and RR 14
are fine; therapeutic level is 4-8 mg/dL, but toxicity occurs with levels >8-10 mg/dL, often
accompanied by absent DTRs and respiratory depression.
Question 4
A patient with gestational diabetes mellitus (GDM) at 38 weeks gives birth to a 4,500 g
newborn. Which newborn complication is the priority to assess?
A. Hypercalcemia
B. Hypoglycemia
C. Hyperbilirubinemia
D. Polycythemia
Answer: B. Hypoglycemia
Rationale: Macrosomic infants of diabetic mothers have fetal hyperinsulinemia, which leads to
neonatal hypoglycemia within 1-2 hours after birth due to continued high insulin levels after
cord clamping. Blood glucose should be checked immediately and serially.
Question 5
A nurse is assessing a 2-hour-old newborn born at 35 weeks gestation. Which finding should be
reported to the healthcare provider immediately? A. Axillary temperature 97.8°F (36.6°C)
B. Respiratory rate 60 breaths/min with grunting
C. Heart rate 150 bpm while sleeping
D. Occasional acrocyanosis
Answer: B. Respiratory rate 60 breaths/min with grunting
Rationale: Grunting is a sign of respiratory distress (e.g., respiratory distress syndrome,
transient tachypnea, or pneumonia). RR 60 is tachypneic (normal 30-60 but grunting indicates
work of breathing). Preterm infants are at high risk for RDS due to surfactant deficiency.
Question 6
The nurse is teaching a patient with chronic hypertension who is 32 weeks pregnant about
signs of worsening preeclampsia. Which symptom should the patient report immediately?
A. Mild ankle edema
B. Epigastric pain or right upper quadrant pain
C. Weight gain of 1 lb in one week
D. Intermittent Braxton-Hicks contractions
Answer: B. Epigastric pain or right upper quadrant pain
GALEN COLLEGE OF NURSING
DEPARTMENT OF NURSING EDUCATION
COURSE: NUR 230 – Maternal-Newborn Nursing
EXAM: Exam 4: High-Risk Conditions & Newborn Complications VERSION:
Comprehensive (50 Questions)
TOTAL POINTS: 50 (1 point each)
TIME ALLOWED: 75 minutes
STUDENT NAME: _______________________________________
STUDENT ID: _______________________________________
DATE: _______________________________________ INSTRUCTOR:
_______________________________________
DIRECTIONS:
1. Use a #2 pencil or blue/black ink pen.
2. Select the BEST answer for each question.
3. Mark your answers on the separate answer sheet provided.
4. Do not write on the exam booklet (unless permitted).
5. After completion, return both exam booklet and answer sheet. 6.
Cellular phones, smartwatches, and other electronic devices
must be turned off and stored out of sight.
--------------------------------------------------------------------
ACADEMIC HONESTY STATEMENT:
By signing below, I affirm that I will neither give nor receive any
unauthorized aid on this examination.
STUDENT SIGNATURE: _______________________________________
FOR FACULTY USE ONLY:
SCORE: ________ / 50 PERCENTAGE: ________ %
,NUR 230 – Exam 4 High-Risk Student ID: __________________ Page ___
INSTRUCTOR INITIALS: ___________
NUR 230 – Maternal-Newborn Nursing
Exam 4: High-Risk Conditions & Newborn Complications
Question 1
A nurse is assessing a newborn at 1 minute of life. The newborn has a heart rate of 110 bpm, is
crying vigorously, has active movement, has blue hands and feet, but a pink trunk. What is the
APGAR score?
A. 7
B. 8
C. 9
D. 10
Answer: C. 9
Rationale:
• Heart rate >100 bpm = 2
• Respiratory effort (crying vigorously) = 2
• Muscle tone (active movement) = 2
• Reflex irritability (vigorous cry) = 2
• Color (pink trunk, blue extremities = acrocyanosis) = 1
Total = 9. Acrocyanosis is normal in the first minutes; a perfect 10 requires completely
pink body and extremities.
Question 2
A newborn at 24 hours of life has a total serum bilirubin of 14 mg/dL. The mother is type O
negative, and the newborn is type A positive. Which intervention does the nurse anticipate? A.
Exchange transfusion
B. Phototherapy
C. Increased oral feedings only
D. Administration of vitamin K
Answer: B. Phototherapy
Rationale: This is likely ABO incompatibility with early, rapid rise in bilirubin. Phototherapy is
indicated to prevent bilirubin neurotoxicity. Exchange transfusion is reserved for levels
approaching exchange range (e.g., >20-25 mg/dL depending on weight and age).
Question 3
A nurse is caring for a patient with preeclampsia who is receiving a magnesium sulfate infusion.
Which assessment finding is most indicative of magnesium toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate 14 breaths/min
, NUR 230 – Exam 4 High-Risk Student ID: __________________ Page ___
Rationale:
C. Urine output 20 mL in 2 hours
D. Serum magnesium level 6 mg/dL
Answer: C. Urine output 20 mL in 2 hours
Oliguria (<30 mL/hr) is a sign of magnesium toxicity because magnesium is excreted
renally. Urine output of 10 mL/hr (20 mL/2 hr) is dangerously low. Normal DTRs (2+) and RR 14
are fine; therapeutic level is 4-8 mg/dL, but toxicity occurs with levels >8-10 mg/dL, often
accompanied by absent DTRs and respiratory depression.
Question 4
A patient with gestational diabetes mellitus (GDM) at 38 weeks gives birth to a 4,500 g
newborn. Which newborn complication is the priority to assess?
A. Hypercalcemia
B. Hypoglycemia
C. Hyperbilirubinemia
D. Polycythemia
Answer: B. Hypoglycemia
Rationale: Macrosomic infants of diabetic mothers have fetal hyperinsulinemia, which leads to
neonatal hypoglycemia within 1-2 hours after birth due to continued high insulin levels after
cord clamping. Blood glucose should be checked immediately and serially.
Question 5
A nurse is assessing a 2-hour-old newborn born at 35 weeks gestation. Which finding should be
reported to the healthcare provider immediately? A. Axillary temperature 97.8°F (36.6°C)
B. Respiratory rate 60 breaths/min with grunting
C. Heart rate 150 bpm while sleeping
D. Occasional acrocyanosis
Answer: B. Respiratory rate 60 breaths/min with grunting
Rationale: Grunting is a sign of respiratory distress (e.g., respiratory distress syndrome,
transient tachypnea, or pneumonia). RR 60 is tachypneic (normal 30-60 but grunting indicates
work of breathing). Preterm infants are at high risk for RDS due to surfactant deficiency.
Question 6
The nurse is teaching a patient with chronic hypertension who is 32 weeks pregnant about
signs of worsening preeclampsia. Which symptom should the patient report immediately?
A. Mild ankle edema
B. Epigastric pain or right upper quadrant pain
C. Weight gain of 1 lb in one week
D. Intermittent Braxton-Hicks contractions
Answer: B. Epigastric pain or right upper quadrant pain
