PN MATERNAL NEWBORN PROCTORED EXAM WITH
VERIFIED QUESTION AND ANSWERS.
A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of
the following laboratory findings should the nurse report to the provider?
a. BUN 14 mg/dL
b. Platelet count 200,000/mm^3
c. Hematocrit 30%
d. Creatinine 1.0 mg/dL
Hematocrit 30%
The nurse should identify that a hematocrit of 30% is below the expected reference range of
greater than 33% for a client who is pregnant. A low Hct is an indication of anemia. Therefore,
the nurse should report this finding to the provider.
A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction.
Which of the following statements by the parent indicates an understanding of the teaching?
a. "Some assistive personnel might not have name badges."
b. "A nurse will carry my baby back to the nursery in their arms for routine care when it is
needed."
c. "I will ask the nurse to take my baby back to the nursery if I need to leave my room."
d. "I can remove my baby's security band before giving her a bath."
c. ."I will ask the nurse to take my baby back to the nursery if I need to leave my room."
The nurse should instruct the parent not to leave the newborn unattended. If the parent needs to
leave the room, the parent should call the nurse to transport the newborn back to the nursery.
A nurse in a prenatal clinic is caring for a client who Is at 16 weeks of gestation and has a
positive hepatitis B result. Which of the following actions should the nurse take?
a. Instruct the client to avoid crowds until a repeat hepatitis B test is negative.
b. Tell the client that they will need to start the hepatitis B vaccine series after birth.
c. Explain to the client that they will receive the hepatitis B immune globulin immediately.
d. Inform the client that hepatitis B cannot be transmitted to the fetus.
c. Explain to the client that they will receive the hepatitis B immune globulin immediately.
The nurse should explain to the client the need to receive the hepatitis immune globulin to
decrease the risk of transmission to the fetus. The nurse should also instruct the client that all
sexual partners and members of the client's household should see their providers to begin
prophylactic treatment.
A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why
folic acid supplements are necessary. The nurse should inform the client that the purpose of the
folic acid supplement is to do which of the following?
a. Facilitate the storage of iron in the fetus' liver
b. Prevent certain kinds of birth defects
c. Inhibit premature labor
d. Aid in the absorption of other important nutrients
b. Prevent certain kinds of birth defects.
The nurse should inform the client that adequate folic acid intake prior to and early during
pregnancy is necessary to help prevent neural tube defects.
A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the
following outcomes should the nurse expect from this medication?
,a. Fetal lung maturity
b. Maternal blood glucose control
c. Cessation of uterine contractions
d. Resolution of maternal nausea
c. Cessation of uterine contractions
Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the
smooth muscle of the uterus.
A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings
should the nurse report to the provider?
a. 2+ urinary protein
b. Leukorrhea
c. Spider nevi
d. 30 cm fundal height
a. 2+ urinary protein
The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the
nurse should report this finding to the provider.
A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents.
Which of the following instructions should the nurse include?
a. Begin giving approximately 240 mL (8 oz) per feeding after the first week.
b. Position the bottle at a 45° angle during feedings.
c. Ensure that the newborn empties the bottle.
d. Wait to burp the newborn until the end of the feeding.
b. Position the bottle at a 45° angle during feedings.
The nurse should reinforce with the parents to position the bottle at a 45° angle during feedings
to allow the newborn to have more control during feedings and prevent the swallowing of air.
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should
the nurse recommend the provider see first?
a. A client who is at 37 weeks of gestation and reports a persistent headache.
b. A client who is at 38 weeks of gestation and reports irregular uterine contractions.
c. A client who is at 12 weeks of gestation and reports abdominal cramping.
d. A client who is at 26 weeks of gestation and reports periodic numbness in the fingers.
a. A client who is at 37 weeks of gestation and reports a persistent headache.
When using the urgent vs. non-urgent approach to care, the nurse should determine that the
priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The
nurse should identify that a persistent headache is a manifestation of preeclampsia and
recommend that the provider see this client first.
A nurse is reinforcing family planning options with a client who is requesting information about
contraceptives. Which of the following client statements indicates an understanding of the
teaching?
a. "The diaphragm should be removed 2 hours after having intercourse."
b. "I can use water-soluble lubricant when my partner wears a latex condom."
c. "It is okay for me to remove the birth control sponge within 2 hours after having intercourse."
d. "When I use the birth control patch, it must be changed once a month."
b. "I can use a water-soluble lubricant when my partner wears a latex condom."
Water-soluble lubricants should be used with male latex condoms, because the use of any other
lubricant can compromise the integrity of the condom.
,A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has
repiratory distress. Which of the following findings should the nurse report to the provider?
a. Acrocyanosis
b. Tachypnea
c. Nasal flaring
d. Retractions
e. Expiratory grunting
Tachypnea is correct. Tachypnea is a respiratory rate greater than 60/min and is a finding
associated with respiratory distress in the newborn.
Nasal flaring is correct. Nasal flaring is a finding associated with respiratory distress in the
newborn.
Retractions is correct. Retractions are a finding associated with respiratory distress in the
newborn.
Expiratory grunting is correct. Expiratory grunting is a finding associated with respiratory
distress in the newborn..
Acrocyanosis is incorrect. Acrocyanosis is a bluish discoloration of the hands and feet of the
newborn and is an expected finding during the first 48 hr after birth.
A nurse is caring for a newborn.
For each potential nursing action, click to specify if the intervention is indicated or
contraindicated for the newborn.
Physical Examination:
1830: Absent Moro reflex noted in right arm.Right shoulder and arm are internally rotated and
adducted. Elbow extended. Forearm pronated with wrist and fingers flexed.Positive palmar grasp
reflex bilaterally.Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy)
paralysis.
Which of the following actions should the nurse plan to implement?
a. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after 1
week.
b. Check grasp reflex.
c. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
d. Reinforce to parents to limit physical handling for 2 weeks.
a. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after
1 week. Indicated
Passive ROM exercises of the arm are indicated to restore function of the extremity. The
initiation of these exercises is delayed for approximately 1 week to prevent additional injury to
the brachial plexus.
b. Check grasp reflex. Indicated
With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and
fingers should be unaffected; the nurse should check for a palmar grasp reflex.
c. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their
shirt. Indicated
Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved
by pinning their sleeve to their shirt.
d. Reinforce to parents to limit physical handling for 2 weeks. Contraindicated.
, Parents need to participate in the physical care of their newborn to increase parental-infant
attachment. Reinforcing teaching and providing practice opportunities for the parents will
decrease their fears of injuring the newborn and increase confidence and bonding.
A nurse is reinforcing teaching with a client who has asked about continuing routine exercise
during pregnancy. Which of the following responses should the nurse make?
a. "Drink plenty of water after exercising."
b. "Lie on your back for 5 minutes after exercising."
c. "You should limit exercise to once per week"
d. "Increase your exercise intensity as your pregnancy progresses."
a. "Drink plenty of water after exercising."
The client should drink plenty of water during and after exercising to decrease the risk of
dehydration from diaphoresis.
A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions
should the nurse identify as an indication that the clinet understands how to bathe her newborn?
a. The client shakes powder from the container onto the newborn's skin.
b. The client uses a cotton-tipped swab to clean the newborn's ears.
c. The client washes the newborn's hair before unwrapping them.
d. The client rinses the newborn under warm, running water.
c. The client washes the newborn's hair before unwrapping them.
Keeping the newborn wrapped while washing their hair helps prevent heat loss.
A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's
grandfather asks if he may take the newborn to his daughter's room. Which of the following
responses should the nurse make?
a. "I'll first need to see your photo ID before I can release the baby to you."
b. "Let me wash my hands and then I'll take the baby to his mother."
c. "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room."
d. "Have your daughter call the nursery so that the staff can release the baby to you."
b. "Let me wash my hands and then I'll take the baby to his mother."
Only facility personnel with appropriate identification badges that indicate that the individual
works specifically in the maternal-newborn unit should transport newborns.
A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium
sulfate via continuous IV infusion. Which of the following statements should the nurse include in
the teaching?
a. "We will monitor your blood pressure every 2 hours."
b. "Your fluid intake will be limited to no more than 125 milliliters per hour."
c. "You might notice that you will begin breathing faster than normal."
d. "We will monitor your baby's heart rate once per hour."
b. "Your fluid intake will be limited to no more than 125 milliliters per hour."
The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid
overload
A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus.
Which of the following findings should the nurse report to the provider?
a. Calcium 9.2 mg/dL
b. Heart Rate 160 BPM
c. Blood Glucose 28 mg/dL
d. Axillary temperature 36.5° C (97.7° F)
VERIFIED QUESTION AND ANSWERS.
A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of
the following laboratory findings should the nurse report to the provider?
a. BUN 14 mg/dL
b. Platelet count 200,000/mm^3
c. Hematocrit 30%
d. Creatinine 1.0 mg/dL
Hematocrit 30%
The nurse should identify that a hematocrit of 30% is below the expected reference range of
greater than 33% for a client who is pregnant. A low Hct is an indication of anemia. Therefore,
the nurse should report this finding to the provider.
A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction.
Which of the following statements by the parent indicates an understanding of the teaching?
a. "Some assistive personnel might not have name badges."
b. "A nurse will carry my baby back to the nursery in their arms for routine care when it is
needed."
c. "I will ask the nurse to take my baby back to the nursery if I need to leave my room."
d. "I can remove my baby's security band before giving her a bath."
c. ."I will ask the nurse to take my baby back to the nursery if I need to leave my room."
The nurse should instruct the parent not to leave the newborn unattended. If the parent needs to
leave the room, the parent should call the nurse to transport the newborn back to the nursery.
A nurse in a prenatal clinic is caring for a client who Is at 16 weeks of gestation and has a
positive hepatitis B result. Which of the following actions should the nurse take?
a. Instruct the client to avoid crowds until a repeat hepatitis B test is negative.
b. Tell the client that they will need to start the hepatitis B vaccine series after birth.
c. Explain to the client that they will receive the hepatitis B immune globulin immediately.
d. Inform the client that hepatitis B cannot be transmitted to the fetus.
c. Explain to the client that they will receive the hepatitis B immune globulin immediately.
The nurse should explain to the client the need to receive the hepatitis immune globulin to
decrease the risk of transmission to the fetus. The nurse should also instruct the client that all
sexual partners and members of the client's household should see their providers to begin
prophylactic treatment.
A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why
folic acid supplements are necessary. The nurse should inform the client that the purpose of the
folic acid supplement is to do which of the following?
a. Facilitate the storage of iron in the fetus' liver
b. Prevent certain kinds of birth defects
c. Inhibit premature labor
d. Aid in the absorption of other important nutrients
b. Prevent certain kinds of birth defects.
The nurse should inform the client that adequate folic acid intake prior to and early during
pregnancy is necessary to help prevent neural tube defects.
A nurse is caring for a client who is pregnant and has a prescription for nifedipine. Which of the
following outcomes should the nurse expect from this medication?
,a. Fetal lung maturity
b. Maternal blood glucose control
c. Cessation of uterine contractions
d. Resolution of maternal nausea
c. Cessation of uterine contractions
Nifedipine is a calcium channel blocker used to decrease uterine contractions by relaxing the
smooth muscle of the uterus.
A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings
should the nurse report to the provider?
a. 2+ urinary protein
b. Leukorrhea
c. Spider nevi
d. 30 cm fundal height
a. 2+ urinary protein
The nurse should identify that 2+ proteinuria is a manifestation of preeclampsia. Therefore, the
nurse should report this finding to the provider.
A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents.
Which of the following instructions should the nurse include?
a. Begin giving approximately 240 mL (8 oz) per feeding after the first week.
b. Position the bottle at a 45° angle during feedings.
c. Ensure that the newborn empties the bottle.
d. Wait to burp the newborn until the end of the feeding.
b. Position the bottle at a 45° angle during feedings.
The nurse should reinforce with the parents to position the bottle at a 45° angle during feedings
to allow the newborn to have more control during feedings and prevent the swallowing of air.
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should
the nurse recommend the provider see first?
a. A client who is at 37 weeks of gestation and reports a persistent headache.
b. A client who is at 38 weeks of gestation and reports irregular uterine contractions.
c. A client who is at 12 weeks of gestation and reports abdominal cramping.
d. A client who is at 26 weeks of gestation and reports periodic numbness in the fingers.
a. A client who is at 37 weeks of gestation and reports a persistent headache.
When using the urgent vs. non-urgent approach to care, the nurse should determine that the
priority finding is a client who is at 37 weeks gestation and reports a persistent headache. The
nurse should identify that a persistent headache is a manifestation of preeclampsia and
recommend that the provider see this client first.
A nurse is reinforcing family planning options with a client who is requesting information about
contraceptives. Which of the following client statements indicates an understanding of the
teaching?
a. "The diaphragm should be removed 2 hours after having intercourse."
b. "I can use water-soluble lubricant when my partner wears a latex condom."
c. "It is okay for me to remove the birth control sponge within 2 hours after having intercourse."
d. "When I use the birth control patch, it must be changed once a month."
b. "I can use a water-soluble lubricant when my partner wears a latex condom."
Water-soluble lubricants should be used with male latex condoms, because the use of any other
lubricant can compromise the integrity of the condom.
,A nurse is assisting with collecting data from a newborn who was born 2 hr ago and has
repiratory distress. Which of the following findings should the nurse report to the provider?
a. Acrocyanosis
b. Tachypnea
c. Nasal flaring
d. Retractions
e. Expiratory grunting
Tachypnea is correct. Tachypnea is a respiratory rate greater than 60/min and is a finding
associated with respiratory distress in the newborn.
Nasal flaring is correct. Nasal flaring is a finding associated with respiratory distress in the
newborn.
Retractions is correct. Retractions are a finding associated with respiratory distress in the
newborn.
Expiratory grunting is correct. Expiratory grunting is a finding associated with respiratory
distress in the newborn..
Acrocyanosis is incorrect. Acrocyanosis is a bluish discoloration of the hands and feet of the
newborn and is an expected finding during the first 48 hr after birth.
A nurse is caring for a newborn.
For each potential nursing action, click to specify if the intervention is indicated or
contraindicated for the newborn.
Physical Examination:
1830: Absent Moro reflex noted in right arm.Right shoulder and arm are internally rotated and
adducted. Elbow extended. Forearm pronated with wrist and fingers flexed.Positive palmar grasp
reflex bilaterally.Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy)
paralysis.
Which of the following actions should the nurse plan to implement?
a. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after 1
week.
b. Check grasp reflex.
c. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
d. Reinforce to parents to limit physical handling for 2 weeks.
a. Remind the parents to begin range-of-motion (ROM) exercises on the affected arm after
1 week. Indicated
Passive ROM exercises of the arm are indicated to restore function of the extremity. The
initiation of these exercises is delayed for approximately 1 week to prevent additional injury to
the brachial plexus.
b. Check grasp reflex. Indicated
With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and
fingers should be unaffected; the nurse should check for a palmar grasp reflex.
c. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their
shirt. Indicated
Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved
by pinning their sleeve to their shirt.
d. Reinforce to parents to limit physical handling for 2 weeks. Contraindicated.
, Parents need to participate in the physical care of their newborn to increase parental-infant
attachment. Reinforcing teaching and providing practice opportunities for the parents will
decrease their fears of injuring the newborn and increase confidence and bonding.
A nurse is reinforcing teaching with a client who has asked about continuing routine exercise
during pregnancy. Which of the following responses should the nurse make?
a. "Drink plenty of water after exercising."
b. "Lie on your back for 5 minutes after exercising."
c. "You should limit exercise to once per week"
d. "Increase your exercise intensity as your pregnancy progresses."
a. "Drink plenty of water after exercising."
The client should drink plenty of water during and after exercising to decrease the risk of
dehydration from diaphoresis.
A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions
should the nurse identify as an indication that the clinet understands how to bathe her newborn?
a. The client shakes powder from the container onto the newborn's skin.
b. The client uses a cotton-tipped swab to clean the newborn's ears.
c. The client washes the newborn's hair before unwrapping them.
d. The client rinses the newborn under warm, running water.
c. The client washes the newborn's hair before unwrapping them.
Keeping the newborn wrapped while washing their hair helps prevent heat loss.
A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn's
grandfather asks if he may take the newborn to his daughter's room. Which of the following
responses should the nurse make?
a. "I'll first need to see your photo ID before I can release the baby to you."
b. "Let me wash my hands and then I'll take the baby to his mother."
c. "Please wash your hands first, then I'll allow you to carry the baby to your daughter's room."
d. "Have your daughter call the nursery so that the staff can release the baby to you."
b. "Let me wash my hands and then I'll take the baby to his mother."
Only facility personnel with appropriate identification badges that indicate that the individual
works specifically in the maternal-newborn unit should transport newborns.
A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium
sulfate via continuous IV infusion. Which of the following statements should the nurse include in
the teaching?
a. "We will monitor your blood pressure every 2 hours."
b. "Your fluid intake will be limited to no more than 125 milliliters per hour."
c. "You might notice that you will begin breathing faster than normal."
d. "We will monitor your baby's heart rate once per hour."
b. "Your fluid intake will be limited to no more than 125 milliliters per hour."
The nurse should restrict the client's fluid intake to no more than 125 mL per hr to prevent fluid
overload
A nurse is collecting data from a newborn whose mother had gestational diabetes mellitus.
Which of the following findings should the nurse report to the provider?
a. Calcium 9.2 mg/dL
b. Heart Rate 160 BPM
c. Blood Glucose 28 mg/dL
d. Axillary temperature 36.5° C (97.7° F)
