NUR 254 Exam 3 – Maternal and Pediatric
Nursing (Newborn Complications,
Pediatric Growth and Development, and
Pediatric Health Assessment) Questions
And Well Graded Solutions With Rationales
Updated 2026-2027
1. A newborn is 24 hours of age and has a total serum bilirubin of 12 mg/dL. What is
the priority nursing action?
A. Continue to monitor
B. Notify the provider
C. Initiate phototherapy
D. Increase feeding frequency
Answer in italic bold: B. Notify the provider.
Rationale in italic: A bilirubin level of 12 mg/dL at 24 hours is above the 95th
percentile and requires provider notification for possible intervention .
2. A newborn is diagnosed with jaundice and is receiving phototherapy. What is the
priority nursing intervention during phototherapy?
A. Monitor temperature frequently
B. Cover the newborn's eyes with eye shields
C. Position the newborn in a prone position
D. Supplement with water between feedings
Answer in italic bold: B. Cover the newborn's eyes with eye shields.
Rationale in italic: Eye shields must be placed over the newborn's eyes during
phototherapy to prevent retinal damage from the light .
3. A newborn is receiving phototherapy for hyperbilirubinemia. Which assessment
finding indicates the therapy is effective?
A. Decreased urine output
B. Increased stool output (frequent, loose, green stools)
C. Increased temperature
D. Decreased feeding
*Answer in italic bold: B. Increased stool output (frequent, loose, green stools). *
Rationale in italic: Phototherapy breaks down bilirubin into water-soluble
products that are excreted in stool. Increased stool output indicates
effectiveness .
4. A newborn is receiving phototherapy. Which nursing intervention is appropriate to
prevent complications?
A. Cover the newborn's genitalia
, B. Monitor for bronze baby syndrome
C. Maintain adequate hydration
D. All of the above
*Answer in italic bold: D. All of the above. *
Rationale in italic: Phototherapy requires eye shields, genitalia coverage,
hydration monitoring, and monitoring for bronze baby syndrome .
5. A newborn has a positive direct Coombs test. What does this indicate?
A. ABO incompatibility
B. Rh incompatibility
C. Jaundice
D. Infection
*Answer in italic bold: B. Rh incompatibility. *
Rationale in italic: A positive direct Coombs test indicates that maternal
antibodies have coated the fetal red blood cells, which occurs in Rh
incompatibility .
6. A newborn with Rh incompatibility is at risk for which complication?
A. Hyperbilirubinemia
B. Anemia
C. Hydrops fetalis
D. All of the above
*Answer in italic bold: D. All of the above. *
Rationale in italic: Rh incompatibility can cause hemolytic anemia,
hyperbilirubinemia, and hydrops fetalis (severe fetal anemia with edema) .
7. A newborn is diagnosed with ABO incompatibility. The nurse understands this is
most commonly seen in which blood type combination?
A. Mother type O, infant type A or B
B. Mother type A, infant type B
C. Mother type B, infant type A
D. Mother type AB, infant type A
*Answer in italic bold: A. Mother type O, infant type A or B. *
Rationale in italic: ABO incompatibility most commonly occurs when the
mother is blood type O and the infant is type A or B, as type O mothers have
anti-A and anti-B antibodies .
8. A newborn is 6 hours of age and has a respiratory rate of 70 breaths/min with
expiratory grunting, nasal flaring, and retractions. What is the priority nursing action?
A. Continue to monitor
B. Notify the provider immediately
C. Administer oxygen via hood
D. Suction the airway
*Answer in italic bold: B. Notify the provider immediately. *
Rationale in italic: Tachypnea with grunting, flaring, and retractions indicates
respiratory distress. The provider must be notified immediately for further
evaluation and intervention .
,9. A newborn is diagnosed with transient tachypnea of the newborn (TTN). What is the
most common cause?
A. Delayed clearance of fetal lung fluid
B. Surfactant deficiency
C. Meconium aspiration
D. Infection
*Answer in italic bold: A. Delayed clearance of fetal lung fluid. *
Rationale in italic: TTN is caused by delayed absorption of fetal lung fluid,
often seen after cesarean delivery or precipitous labor .
10. A newborn is diagnosed with respiratory distress syndrome (RDS). What is the
primary cause?
A. Meconium aspiration
B. Surfactant deficiency
C. Infection
D. Pneumothorax
*Answer in italic bold: B. Surfactant deficiency. *
Rationale in italic: RDS is caused by a deficiency of surfactant, which is
necessary to keep alveoli open. It is most common in preterm infants .
11. A preterm newborn with RDS is receiving surfactant replacement therapy. How is
surfactant administered?
A. Orally
B. Intramuscularly
C. Endotracheally
D. Subcutaneously
*Answer in italic bold: C. Endotracheally. *
Rationale in italic: Surfactant is administered directly into the lungs through an
endotracheal tube .
12. A newborn is diagnosed with meconium aspiration syndrome. What is the priority
nursing intervention?
A. Suction the trachea immediately after birth
B. Administer antibiotics
C. Provide oxygen via hood
D. Initiate phototherapy
*Answer in italic bold: A. Suction the trachea immediately after birth. *
Rationale in italic: For meconium-stained amniotic fluid, the priority is to
suction the newborn's trachea immediately after delivery to prevent meconium
aspiration .
13. A newborn with meconium aspiration syndrome is at risk for which complication?
A. Pneumothorax
B. Persistent pulmonary hypertension
C. Infection
D. All of the above
*Answer in italic bold: D. All of the above. *
, Rationale in italic: Meconium aspiration can lead to pneumothorax, persistent
pulmonary hypertension, and infection (pneumonia) .
14. A newborn is 48 hours of age and has not passed meconium. The nurse notes the
abdomen is distended and the newborn is vomiting bile-stained emesis. What is the
priority action?
A. Continue to monitor
B. Notify the provider
C. Administer a suppository
D. Insert a nasogastric tube
*Answer in italic bold: B. Notify the provider. *
Rationale in italic: Failure to pass meconium with abdominal distention and
bile-stained emesis may indicate a bowel obstruction. The provider must be
notified immediately .
15. A newborn is diagnosed with a tracheoesophageal fistula (TEF). What is the classic
presentation?
A. Excessive drooling and choking with feeding
B. Respiratory distress with grunting
C. Abdominal distension
D. Jaundice
*Answer in italic bold: A. Excessive drooling and choking with feeding. *
Rationale in italic: Excessive drooling, choking with feeding, and abdominal
distension are classic signs of TEF due to the connection between the trachea
and esophagus .
16. A newborn with a tracheoesophageal fistula is at risk for which complication?
A. Aspiration pneumonia
B. Dehydration
C. Malnutrition
D. All of the above
*Answer in italic bold: D. All of the above. *
Rationale in italic: TEF puts the newborn at risk for aspiration pneumonia,
dehydration, and malnutrition due to feeding difficulties .
17. A newborn is diagnosed with a diaphragmatic hernia. What is the priority nursing
intervention?
A. Place the newborn in a supine position
B. Administer oxygen
C. Insert a nasogastric tube and place in an upright position
D. Initiate phototherapy
*Answer in italic bold: C. Insert a nasogastric tube and place in an upright
position. *
Rationale in italic: In a diaphragmatic hernia, the abdominal organs are in the
chest, compressing the lungs. Placing the newborn upright and decompressing
the stomach with an NG tube helps reduce pressure on the lungs .
Nursing (Newborn Complications,
Pediatric Growth and Development, and
Pediatric Health Assessment) Questions
And Well Graded Solutions With Rationales
Updated 2026-2027
1. A newborn is 24 hours of age and has a total serum bilirubin of 12 mg/dL. What is
the priority nursing action?
A. Continue to monitor
B. Notify the provider
C. Initiate phototherapy
D. Increase feeding frequency
Answer in italic bold: B. Notify the provider.
Rationale in italic: A bilirubin level of 12 mg/dL at 24 hours is above the 95th
percentile and requires provider notification for possible intervention .
2. A newborn is diagnosed with jaundice and is receiving phototherapy. What is the
priority nursing intervention during phototherapy?
A. Monitor temperature frequently
B. Cover the newborn's eyes with eye shields
C. Position the newborn in a prone position
D. Supplement with water between feedings
Answer in italic bold: B. Cover the newborn's eyes with eye shields.
Rationale in italic: Eye shields must be placed over the newborn's eyes during
phototherapy to prevent retinal damage from the light .
3. A newborn is receiving phototherapy for hyperbilirubinemia. Which assessment
finding indicates the therapy is effective?
A. Decreased urine output
B. Increased stool output (frequent, loose, green stools)
C. Increased temperature
D. Decreased feeding
*Answer in italic bold: B. Increased stool output (frequent, loose, green stools). *
Rationale in italic: Phototherapy breaks down bilirubin into water-soluble
products that are excreted in stool. Increased stool output indicates
effectiveness .
4. A newborn is receiving phototherapy. Which nursing intervention is appropriate to
prevent complications?
A. Cover the newborn's genitalia
, B. Monitor for bronze baby syndrome
C. Maintain adequate hydration
D. All of the above
*Answer in italic bold: D. All of the above. *
Rationale in italic: Phototherapy requires eye shields, genitalia coverage,
hydration monitoring, and monitoring for bronze baby syndrome .
5. A newborn has a positive direct Coombs test. What does this indicate?
A. ABO incompatibility
B. Rh incompatibility
C. Jaundice
D. Infection
*Answer in italic bold: B. Rh incompatibility. *
Rationale in italic: A positive direct Coombs test indicates that maternal
antibodies have coated the fetal red blood cells, which occurs in Rh
incompatibility .
6. A newborn with Rh incompatibility is at risk for which complication?
A. Hyperbilirubinemia
B. Anemia
C. Hydrops fetalis
D. All of the above
*Answer in italic bold: D. All of the above. *
Rationale in italic: Rh incompatibility can cause hemolytic anemia,
hyperbilirubinemia, and hydrops fetalis (severe fetal anemia with edema) .
7. A newborn is diagnosed with ABO incompatibility. The nurse understands this is
most commonly seen in which blood type combination?
A. Mother type O, infant type A or B
B. Mother type A, infant type B
C. Mother type B, infant type A
D. Mother type AB, infant type A
*Answer in italic bold: A. Mother type O, infant type A or B. *
Rationale in italic: ABO incompatibility most commonly occurs when the
mother is blood type O and the infant is type A or B, as type O mothers have
anti-A and anti-B antibodies .
8. A newborn is 6 hours of age and has a respiratory rate of 70 breaths/min with
expiratory grunting, nasal flaring, and retractions. What is the priority nursing action?
A. Continue to monitor
B. Notify the provider immediately
C. Administer oxygen via hood
D. Suction the airway
*Answer in italic bold: B. Notify the provider immediately. *
Rationale in italic: Tachypnea with grunting, flaring, and retractions indicates
respiratory distress. The provider must be notified immediately for further
evaluation and intervention .
,9. A newborn is diagnosed with transient tachypnea of the newborn (TTN). What is the
most common cause?
A. Delayed clearance of fetal lung fluid
B. Surfactant deficiency
C. Meconium aspiration
D. Infection
*Answer in italic bold: A. Delayed clearance of fetal lung fluid. *
Rationale in italic: TTN is caused by delayed absorption of fetal lung fluid,
often seen after cesarean delivery or precipitous labor .
10. A newborn is diagnosed with respiratory distress syndrome (RDS). What is the
primary cause?
A. Meconium aspiration
B. Surfactant deficiency
C. Infection
D. Pneumothorax
*Answer in italic bold: B. Surfactant deficiency. *
Rationale in italic: RDS is caused by a deficiency of surfactant, which is
necessary to keep alveoli open. It is most common in preterm infants .
11. A preterm newborn with RDS is receiving surfactant replacement therapy. How is
surfactant administered?
A. Orally
B. Intramuscularly
C. Endotracheally
D. Subcutaneously
*Answer in italic bold: C. Endotracheally. *
Rationale in italic: Surfactant is administered directly into the lungs through an
endotracheal tube .
12. A newborn is diagnosed with meconium aspiration syndrome. What is the priority
nursing intervention?
A. Suction the trachea immediately after birth
B. Administer antibiotics
C. Provide oxygen via hood
D. Initiate phototherapy
*Answer in italic bold: A. Suction the trachea immediately after birth. *
Rationale in italic: For meconium-stained amniotic fluid, the priority is to
suction the newborn's trachea immediately after delivery to prevent meconium
aspiration .
13. A newborn with meconium aspiration syndrome is at risk for which complication?
A. Pneumothorax
B. Persistent pulmonary hypertension
C. Infection
D. All of the above
*Answer in italic bold: D. All of the above. *
, Rationale in italic: Meconium aspiration can lead to pneumothorax, persistent
pulmonary hypertension, and infection (pneumonia) .
14. A newborn is 48 hours of age and has not passed meconium. The nurse notes the
abdomen is distended and the newborn is vomiting bile-stained emesis. What is the
priority action?
A. Continue to monitor
B. Notify the provider
C. Administer a suppository
D. Insert a nasogastric tube
*Answer in italic bold: B. Notify the provider. *
Rationale in italic: Failure to pass meconium with abdominal distention and
bile-stained emesis may indicate a bowel obstruction. The provider must be
notified immediately .
15. A newborn is diagnosed with a tracheoesophageal fistula (TEF). What is the classic
presentation?
A. Excessive drooling and choking with feeding
B. Respiratory distress with grunting
C. Abdominal distension
D. Jaundice
*Answer in italic bold: A. Excessive drooling and choking with feeding. *
Rationale in italic: Excessive drooling, choking with feeding, and abdominal
distension are classic signs of TEF due to the connection between the trachea
and esophagus .
16. A newborn with a tracheoesophageal fistula is at risk for which complication?
A. Aspiration pneumonia
B. Dehydration
C. Malnutrition
D. All of the above
*Answer in italic bold: D. All of the above. *
Rationale in italic: TEF puts the newborn at risk for aspiration pneumonia,
dehydration, and malnutrition due to feeding difficulties .
17. A newborn is diagnosed with a diaphragmatic hernia. What is the priority nursing
intervention?
A. Place the newborn in a supine position
B. Administer oxygen
C. Insert a nasogastric tube and place in an upright position
D. Initiate phototherapy
*Answer in italic bold: C. Insert a nasogastric tube and place in an upright
position. *
Rationale in italic: In a diaphragmatic hernia, the abdominal organs are in the
chest, compressing the lungs. Placing the newborn upright and decompressing
the stomach with an NG tube helps reduce pressure on the lungs .
