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Section 1: Newborn Assessment & Normal Findings (Questions 1–40)
Question 1: Which term should the nurse use to describe the fine, downy hair that covers the forehead, ears, and
body of the newborn?
A) Petechiae
B) Lanugo
C) Acrocyanosis
D) Vernix caseosa
Answer: B
Lanugo is the fine, downy hair that covers the newborn's body, particularly the forehead, ears, and shoulders. It is
most prominent in preterm infants and typically sheds during the first few weeks of life. Vernix caseosa is the white,
cheesy protective substance; acrocyanosis is the bluish discoloration of hands and feet; petechiae are tiny red or
purple spots from capillary bleeding.
Question 2: The nurse is assessing the vital signs of a newborn. Which of the following would be an expected heart
rate if the newborn is crying?
A) 80 bpm
B) 110 bpm
C) 150 bpm
D) 180 bpm
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,Answer: D
The normal resting heart rate for a newborn is 110-160 bpm. However, when crying, the heart rate can increase to
180 bpm or higher. A heart rate below 100 bpm requires immediate assessment and intervention.
Question 3: Which is the nurse's first action when conducting a head-to-toe assessment of a newborn?
A) Examining the newborn's eyes
B) Assessing the newborn's mouth
C) Observing the newborn's skin color
D) Conducting an ear assessment
Answer: C
The first action in a newborn head-to-toe assessment is observing the newborn's skin color. This provides immediate
information about oxygenation, perfusion, and overall well-being. Any signs of cyanosis, pallor, or jaundice should be
identified and addressed promptly.
Question 4: The assessment finding of pink mucous membranes and nailbeds in a newborn indicates which of the
following?
A) Proper hydration
B) Good cardiac function
C) Poor respiratory function
D) Low thyroid function
Answer: B
Pink mucous membranes and nailbeds indicate adequate oxygenation and good cardiac function. This finding
suggests that the newborn is effectively oxygenating tissues and that the cardiovascular system is functioning
properly.
Question 5: The nurse is conducting a skin assessment for a newborn patient. Which data indicate a normal skin
variation that requires no further intervention?
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,A) Melanocytic nevus on the left forearm
B) Nevus simplex on the nape of the neck
C) Hemangioma on the back that is 1 cm
D) Erythema toxicum neonatorum noted on the trunk
Answer: A
A melanocytic nevus (mole) on the forearm is a benign, normal skin variation that requires no intervention. Nevus
simplex (stork bite) is also normal, but the question asks which data indicate a normal variation; erythema toxicum is
a common benign rash; hemangiomas may require monitoring depending on location and size.
Question 6: A postpartum woman expresses concern about a raised bump on her newborn's head that appeared a
few hours after birth. How should the nurse respond?
A) "I'll call the doctor to come take a look."
B) "This looks like caput succedaneum."
C) "The swelling will take 3-4 months to resolve."
D) "The swelling is caused by birth trauma and should resolve."
Answer: D
Caput succedaneum is swelling of the soft tissues of the scalp caused by pressure from the uterus or vaginal wall
during delivery. It crosses suture lines and typically resolves within a few days. The nurse should provide
reassurance and explain that this is a common finding from birth trauma.
Question 7: Which assessment finding should the nurse anticipate for a male newborn as a result of exposure to
maternal hormones?
A) Gynecomastia
B) Pseudomenstruation
C) Small and tight scrotum
D) Nocturnal emission
Answer: A
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, Gynecomastia (breast enlargement) is a common finding in both male and female newborns due to maternal
estrogen exposure. It typically resolves within a few weeks. Pseudomenstruation occurs in female newborns; a small,
tight scrotum is not a typical hormonal effect.
Question 8: Which of the following causes caput succedaneum?
A) Rupture of blood vessels between the skull and periosteum
B) A fibrous membrane that lies between the bones of the cranium
C) Pressure from the uterus or vaginal wall during delivery
D) Dehydration and decreased intracranial pressure
Answer: C
Caput succedaneum is caused by pressure from the uterus or vaginal wall during delivery, resulting in edema of the
soft tissues of the scalp. It crosses suture lines and resolves within a few days. The description of rupture of blood
vessels between the skull and periosteum describes a cephalohematoma, not caput succedaneum.
Question 9: A mother tells the nurse that she noticed her baby turning the mouth to the same side of the cheek that
is stroked. The mother is describing which newborn reflex?
A) Babinski's reflex
B) Rooting reflex
C) Moro's reflex
D) Tonic neck reflex
Answer: B
The rooting reflex is elicited by stroking the cheek or corner of the mouth, causing the newborn to turn the head
toward the stimulus and open the mouth. This reflex helps the newborn find the breast or bottle for feeding. The Moro
reflex (startle), Babinski reflex (toe fanning), and tonic neck reflex (fencer position) are different reflexes.
Question 10: Which of the following describes Moro's reflex?
A) A newborn exhibits symmetrical abduction of the extremities and places the index fingers and thumbs into a "C"
shape
B) A newborn turns the head toward the side of the cheek that is stroked
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