**The Maternal-Newborn & Pediatric Nursing
Mastery: NGN Comprehensive Assessment**
1. A nurse is caring for a newborn who is 12 hours old. Which finding requires immediate intervention?
A) Respiratory rate of 58 breaths/min with nasal flaring
B) Heart rate of 160 bpm during crying
C) Grunting and sternal retractions
D) Acrocyanosis of hands and feet
💫RATIONALE✔️✔️: Grunting and retractions indicate respiratory distress syndrome or sepsis;
acrocyanosis is normal in first 24 hours.
💫ANSWER✔️✔️: C) Grunting and sternal retractions
---
2. A nurse is assessing a 2-year-old child with suspected dehydration. Which finding is most indicative of
severe dehydration?
A) Capillary refill of 2 seconds
B) Sunken anterior fontanel
C) Tachycardia and dry mucous membranes
D) Blood pressure 90/60 mmHg
💫RATIONALE✔️✔️: Sunken fontanel, lethargy, and hypotension indicate severe dehydration (≥10% fluid
loss).
💫ANSWER✔️✔️: B) Sunken anterior fontanel
---
3. A nurse is administering vitamin K intramuscularly to a newborn. Which site is preferred?
A) Dorsogluteal
B) Deltoid
,C) Vastus lateralis
D) Ventrogluteal
💫RATIONALE✔️✔️: The vastus lateralis is the preferred IM site for infants due to adequate muscle mass.
💫ANSWER✔️✔️: C) Vastus lateralis
---
4. A client at 38 weeks of gestation has a biophysical profile (BPP) score of 6/10. Which finding is most
concerning?
A) One episode of fetal breathing in 30 minutes
B) Amniotic fluid index of 5 cm
C) Gross fetal movement of 3 body movements in 30 minutes
D) Non-reactive non-stress test with accelerations
💫RATIONALE✔️✔️: A non-reactive NST with a BPP of 6 indicates possible fetal compromise; requires
further evaluation.
💫ANSWER✔️✔️: D) Non-reactive non-stress test with accelerations
---
5. A nurse is caring for a child with suspected bacterial meningitis. Which finding is most specific for
meningitis?
A) Photophobia
B) Kernig's sign
C) Fever
D) Bulging fontanel in an infant
💫RATIONALE✔️✔️: Kernig's sign (pain with knee extension after hip flexion) is a classic meningeal sign.
💫ANSWER✔️✔️: B) Kernig's sign
---
6. A nurse is assessing a newborn with suspected neonatal abstinence syndrome (NAS). Which finding is
expected?
A) Hypoactive reflexes
,B) Prolonged sleep periods
C) High-pitched cry and irritability
D) Bradycardia
💫RATIONALE✔️✔️: NAS causes CNS hyperirritability: high-pitched cry, jitteriness, poor feeding, and
hypertonia.
💫ANSWER✔️✔️: C) High-pitched cry and irritability
---
7. A client in active labor has a prolapsed umbilical cord. Which action should the nurse take first?
A) Prepare for immediate cesarean section
B) Apply warm saline-soaked gauze to the cord
C) Elevate the presenting part off the cord manually
D) Place the client in Trendelenburg position
💫RATIONALE✔️✔️: Manual elevation of the presenting part relieves cord compression; Trendelenburg
also helps but manual is first.
💫ANSWER✔️✔️: C) Elevate the presenting part off the cord manually
---
8. A nurse is teaching a postpartum client about signs of postpartum depression. Which statement
indicates understanding?
A) "Baby blues last up to 6 months after delivery"
B) "Feeling sad for a few days is normal and will pass"
C) "I should call my provider if I have thoughts of harming the baby"
D) "Postpartum depression only occurs in first-time mothers"
💫RATIONALE✔️✔️: Intrusive thoughts of harm require immediate evaluation; baby blues last 1-2 weeks.
💫ANSWER✔️✔️: C) "I should call my provider if I have thoughts of harming the baby"
---
9. A nurse is caring for a child with acute epiglottitis. Which intervention is most important?
, A) Obtain a throat culture
B) Prepare for tracheostomy
C) Maintain a patent airway and do not examine the throat
D) Administer oral antibiotics
💫RATIONALE✔️✔️: Epiglottitis can cause complete airway obstruction; avoid throat exams and prepare
for intubation.
💫ANSWER✔️✔️: C) Maintain a patent airway and do not examine the throat
---
10. A client at 32 weeks of gestation is receiving magnesium sulfate for preeclampsia. Which finding
indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Respiratory rate 14 breaths/min
C) Urinary output 25 mL/hr
D) Serum magnesium 8 mg/dL
💫RATIONALE✔️✔️: Urine output <30 mL/hr indicates renal impairment and risk of magnesium toxicity.
💫ANSWER✔️✔️: C) Urinary output 25 mL/hr
---
11. A nurse is assessing a 4-month-old infant. Which developmental milestone is expected?
A) Rolls from back to front
B) Sits without support
C) Pincer grasp
D) Transfers object from hand to hand
💫RATIONALE✔️✔️: Rolling over (back to front) typically occurs at 4-5 months; sitting without support at
6-8 months.
💫ANSWER✔️✔️: A) Rolls from back to front
---
Mastery: NGN Comprehensive Assessment**
1. A nurse is caring for a newborn who is 12 hours old. Which finding requires immediate intervention?
A) Respiratory rate of 58 breaths/min with nasal flaring
B) Heart rate of 160 bpm during crying
C) Grunting and sternal retractions
D) Acrocyanosis of hands and feet
💫RATIONALE✔️✔️: Grunting and retractions indicate respiratory distress syndrome or sepsis;
acrocyanosis is normal in first 24 hours.
💫ANSWER✔️✔️: C) Grunting and sternal retractions
---
2. A nurse is assessing a 2-year-old child with suspected dehydration. Which finding is most indicative of
severe dehydration?
A) Capillary refill of 2 seconds
B) Sunken anterior fontanel
C) Tachycardia and dry mucous membranes
D) Blood pressure 90/60 mmHg
💫RATIONALE✔️✔️: Sunken fontanel, lethargy, and hypotension indicate severe dehydration (≥10% fluid
loss).
💫ANSWER✔️✔️: B) Sunken anterior fontanel
---
3. A nurse is administering vitamin K intramuscularly to a newborn. Which site is preferred?
A) Dorsogluteal
B) Deltoid
,C) Vastus lateralis
D) Ventrogluteal
💫RATIONALE✔️✔️: The vastus lateralis is the preferred IM site for infants due to adequate muscle mass.
💫ANSWER✔️✔️: C) Vastus lateralis
---
4. A client at 38 weeks of gestation has a biophysical profile (BPP) score of 6/10. Which finding is most
concerning?
A) One episode of fetal breathing in 30 minutes
B) Amniotic fluid index of 5 cm
C) Gross fetal movement of 3 body movements in 30 minutes
D) Non-reactive non-stress test with accelerations
💫RATIONALE✔️✔️: A non-reactive NST with a BPP of 6 indicates possible fetal compromise; requires
further evaluation.
💫ANSWER✔️✔️: D) Non-reactive non-stress test with accelerations
---
5. A nurse is caring for a child with suspected bacterial meningitis. Which finding is most specific for
meningitis?
A) Photophobia
B) Kernig's sign
C) Fever
D) Bulging fontanel in an infant
💫RATIONALE✔️✔️: Kernig's sign (pain with knee extension after hip flexion) is a classic meningeal sign.
💫ANSWER✔️✔️: B) Kernig's sign
---
6. A nurse is assessing a newborn with suspected neonatal abstinence syndrome (NAS). Which finding is
expected?
A) Hypoactive reflexes
,B) Prolonged sleep periods
C) High-pitched cry and irritability
D) Bradycardia
💫RATIONALE✔️✔️: NAS causes CNS hyperirritability: high-pitched cry, jitteriness, poor feeding, and
hypertonia.
💫ANSWER✔️✔️: C) High-pitched cry and irritability
---
7. A client in active labor has a prolapsed umbilical cord. Which action should the nurse take first?
A) Prepare for immediate cesarean section
B) Apply warm saline-soaked gauze to the cord
C) Elevate the presenting part off the cord manually
D) Place the client in Trendelenburg position
💫RATIONALE✔️✔️: Manual elevation of the presenting part relieves cord compression; Trendelenburg
also helps but manual is first.
💫ANSWER✔️✔️: C) Elevate the presenting part off the cord manually
---
8. A nurse is teaching a postpartum client about signs of postpartum depression. Which statement
indicates understanding?
A) "Baby blues last up to 6 months after delivery"
B) "Feeling sad for a few days is normal and will pass"
C) "I should call my provider if I have thoughts of harming the baby"
D) "Postpartum depression only occurs in first-time mothers"
💫RATIONALE✔️✔️: Intrusive thoughts of harm require immediate evaluation; baby blues last 1-2 weeks.
💫ANSWER✔️✔️: C) "I should call my provider if I have thoughts of harming the baby"
---
9. A nurse is caring for a child with acute epiglottitis. Which intervention is most important?
, A) Obtain a throat culture
B) Prepare for tracheostomy
C) Maintain a patent airway and do not examine the throat
D) Administer oral antibiotics
💫RATIONALE✔️✔️: Epiglottitis can cause complete airway obstruction; avoid throat exams and prepare
for intubation.
💫ANSWER✔️✔️: C) Maintain a patent airway and do not examine the throat
---
10. A client at 32 weeks of gestation is receiving magnesium sulfate for preeclampsia. Which finding
indicates magnesium toxicity?
A) Deep tendon reflexes 2+
B) Respiratory rate 14 breaths/min
C) Urinary output 25 mL/hr
D) Serum magnesium 8 mg/dL
💫RATIONALE✔️✔️: Urine output <30 mL/hr indicates renal impairment and risk of magnesium toxicity.
💫ANSWER✔️✔️: C) Urinary output 25 mL/hr
---
11. A nurse is assessing a 4-month-old infant. Which developmental milestone is expected?
A) Rolls from back to front
B) Sits without support
C) Pincer grasp
D) Transfers object from hand to hand
💫RATIONALE✔️✔️: Rolling over (back to front) typically occurs at 4-5 months; sitting without support at
6-8 months.
💫ANSWER✔️✔️: A) Rolls from back to front
---
