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1. A nurse is teaching new parents about the factors that
stimulate a newborn's first breath. Which factor is considered
a chemical stimulus?
A) The drop in ambient temperature upon delivery
B) Hypoxia, hypercarbia, and acidosis from clamping of the
umbilical cord
C) The thoracic squeeze during a vaginal birth
D) Tactile stimulation from drying the infant
Correct Answer: B) Hypoxia, hypercarbia, and acidosis from
clamping of the umbilical cord
Rationale: Chemical factors are the most critical stimulants for the
first breath. Falling oxygen levels (hypoxia), rising carbon dioxide
levels (hypercarbia), and decreased pH (acidosis) that occur with
clamping of the umbilical cord stimulate the respiratory center in
the medulla to initiate breathing . Option A is a thermal factor, C is
a mechanical factor, and D is a sensory factor.
2. A nurse is assessing a newborn 1 minute after birth. Which
finding indicates effective thermoregulation?
,A) Axillary temperature of 96.8°F (36°C)
B) Axillary temperature of 98.6°F (37°C)
C) Axillary temperature of 95.0°F (35°C)
D) Axillary temperature of 94.0°F (34.4°C)
Correct Answer: B) Axillary temperature of 98.6°F (37°C)
Rationale: Normal newborn axillary temperature is 97.7°F to 99.5°F
(36.5°C to 37.5°C). A temperature of 98.6°F (37°C) indicates
effective thermoregulation. Temperatures below 97.7°F indicate
hypothermia and require intervention .
3. A term newborn delivered by elective cesarean section is at
increased risk for which respiratory complication?
A) Meconium aspiration syndrome
B) Transient tachypnea of the newborn (TTN)
C) Respiratory distress syndrome (RDS)
D) Persistent pulmonary hypertension
Correct Answer: B) Transient tachypnea of the newborn (TTN)
Rationale: TTN occurs when fetal lung fluid is not adequately
cleared, which is more common in newborns delivered by cesarean
section without labor. The lack of thoracic squeeze during vaginal
delivery contributes to retained fluid . Surfactant deficiency causes
RDS, not TTN.
,4. A nurse is performing an Apgar assessment at 1 minute of
life. The newborn has a heart rate of 110, a weak cry, some
flexion of extremities, grimaces when stimulated, and has a
pink body with blue extremities. What is the Apgar score?
A) 6
B) 5
C) 7
D) 8
Correct Answer: A) 6
Rationale: Heart rate >100 (2 points), weak cry/respiratory effort (1
point), some flexion/muscle tone (1 point), grimace/reflex irritability
(1 point), acrocyanosis/color (1 point) = 6. This indicates the
newborn may need some assistance with transition to extrauterine
life .
5. A nurse is teaching parents about preventing sudden infant
death syndrome (SIDS). Which instruction is most important?
A) "Place the baby on the stomach to sleep."
B) "Place the baby on the back to sleep."
C) "Use a soft mattress with pillows."
D) "Keep the room warm during sleep."
Correct Answer: B) "Place the baby on the back to sleep."
, Rationale: The "Back to Sleep" campaign recommends placing
infants on their backs to sleep to reduce the risk of SIDS. Soft
bedding, pillows, and overheating should be avoided .
6. A nurse is assessing a newborn's umbilical cord. Which
finding requires immediate intervention?
A) The cord is dry and brown
B) The cord has a foul-smelling discharge
C) The cord is clamped and intact
D) The cord is moist with a small amount of bleeding
Correct Answer: B) The cord has a foul-smelling discharge
Rationale: A foul-smelling discharge from the umbilical cord is a
sign of infection (omphalitis) and requires immediate intervention.
A dry cord, a clamped cord, and minimal moisture are normal
findings .
7. A client at 32 weeks gestation reports painless, bright red
vaginal bleeding. The nurse suspects which condition?
A) Placental abruption
B) Preterm labor
C) Placenta previa
D) Vasa previa
Correct Answer: C) Placenta previa