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MATERNITY NEWBORN AND WOMEN’S HEALTH NURSING A
CASE-BASED APPROACH |QUESTIONS AND ACCURATE
SOLUTIONS WITH RATIONALES |ALREADY GRADED A+.
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH ( Toxoplasmosis,
Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and
Herpes infections) infections. How and when may it have been transmitted to the newborn?
A.In utero through the placenta
B.In the postpartum period through breast milk
C.During birth through contact with the maternal vagina
D.After the birth through a blood transfusion given to the mother - CORRECT ✓✓ A.In utero
through the placenta
Rationale: Toxoplasmosis is caused by a parasitic protozoon that is acquired from
inadequately cooked contaminated food or through handling of infected cat feces; the most
common form of transmission to the newborn is by way of placental perfusion when in utero.
There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not
contract toxoplasmosis from the maternal genital tract during the birth process. There is no
evidence that toxoplasmosis is transmitted in blood transfused into the mother.
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes
cyanotic. Which is the nurse's initial action?
A. Suctioning the mouth
B. Administering oxygen
C. Notifying the health care provider
D. Initiate chest compressions - CORRECT ✓✓ A. Suctioning the mouth
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Rationale: To maintain a patent airway and promote respiration and gaseous exchange, the
nurse's priority action is removing mucus from the newborn's mouth and pharynx. If the
airway is obstructed, oxygenation is useless; suctioning is the priority. The health care
provider should be notified if oral suctioning does not clear the airway. If suctioning the
mouth and administering oxygen does not improve the newborn's health status, the nurse
would need to initiate chest compressions.
Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention
is appropriate to reduce the potentially harmful side effect of the phototherapy?
A. Covering the trunk to prevent hypothermia
B. Using shields on the eyes to protect them from the light
C. Massaging vitamin E oil into the skin to minimize drying
D. Turning after each feeding to reduce exposure of each surface area - CORRECT ✓✓ B.
Using shields on the eyes to protect them from the light
Rationale: The lights used for phototherapy can damage the infant's eyes, and eye shields are
standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface
is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns
and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless
of feeding times so that all body surfaces are exposed to the light and no single body surface
is overexposed.
The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned
neonate. How would this observation be documented?
A. Stork bites
B. Forceps marks
C. Mongolian spots
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D. Ecchymotic areas - CORRECT ✓✓ C. Mongolian spots
Rationale: Mongolian spots are bluish-black areas of pigmentation commonly found on the
back and buttocks of dark-skinned newborns; they are benign and fade gradually over time.
Stork bites are short red marks commonly found near the base of the neck of the newborn.
Forceps marks are red and have a distinctive imprint on the face and head matching the
configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the
extravasation of blood into subcutaneous tissue.
In a noisy room, a sleeping newborn initially startles and exhibits rapid movements but soon
goes back to sleep. What is the most appropriate nursing action in response to this behaviour?
A.Document an intact reflex.
B.Assess the infant's vital signs.
C.Test the infant's ability to hear.
D.Stimulate the infant's respirations. - CORRECT ✓✓ A.Document an intact reflex.
Rationale: The initial response is a reflection of the startle reflex; when the stimulus is
repetitive, the response to the stimulus decreases; this decrease in response is called
habituation and is expected. Assessing the infant's vital signs and stimulating the infant's
respirations are not necessary because the neonate's response is expected. The infant is
responding to noise and therefore hears.
While inspecting her newborn, a mother asks the nurse whether her baby has flat feet. How
should the nurse respond?
A."Flat feet are more common in children than adults."
B."That's hard to assess because the feet are so small."
C."There may be a bone defect that needs further assessment."
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D."Infants' feet appear flat because the arch is covered with a fat pad." - CORRECT ✓✓
D."Infants' feet appear flat because the arch is covered with a fat pad."
Rationale: A fat pad covers the arch in newborns and infants; the arch develops when the
child begins to walk. Flat feet are no more common in children than in adults. The size of the
feet is not relevant; arch development is related to walking. Flat feet are not associated with
deformities of the bones.
A new mother with class II heart disease tells a nurse that she is afraid that her heart condition
will prevent her from caring for her baby and her home when she is discharged. How should
the nurse respond?
A.By suggesting that she arrange for help at home
B.By asking her to describe her concerns more fully
C.By telling her to speak to her health care provider about her concerns
D.By recommending that she schedule times when family members can assist her -
CORRECT ✓✓ B.By asking her to describe her concerns more fully
Rationale: Information-seeking is the first step in problem solving. Suggesting that the client
arrange for help at home is presumptuous and possibly too expensive. The nurse should not
make decisions for the client. Telling her to speak to her health care provider shifts the
responsibility to the health care provider; the nurse should explore the client's concerns.
Recommending that she schedule times when family members can assist her is presumptuous
because it assumes that the family is willing and able to help.
A large-for-gestational-age (LGA) full-term infant should be monitored for which risk?
A.Hypotension
B.Hypothermia
4|Page
MATERNITY NEWBORN AND WOMEN’S HEALTH NURSING A
CASE-BASED APPROACH |QUESTIONS AND ACCURATE
SOLUTIONS WITH RATIONALES |ALREADY GRADED A+.
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH ( Toxoplasmosis,
Other (syphilis, varicella-zoster, parvovirus B19), Rubella, Cytomegalovirus (CMV), and
Herpes infections) infections. How and when may it have been transmitted to the newborn?
A.In utero through the placenta
B.In the postpartum period through breast milk
C.During birth through contact with the maternal vagina
D.After the birth through a blood transfusion given to the mother - CORRECT ✓✓ A.In utero
through the placenta
Rationale: Toxoplasmosis is caused by a parasitic protozoon that is acquired from
inadequately cooked contaminated food or through handling of infected cat feces; the most
common form of transmission to the newborn is by way of placental perfusion when in utero.
There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not
contract toxoplasmosis from the maternal genital tract during the birth process. There is no
evidence that toxoplasmosis is transmitted in blood transfused into the mother.
At 10 hours of age a newborn has a large amount of mucus in the nasopharynx and becomes
cyanotic. Which is the nurse's initial action?
A. Suctioning the mouth
B. Administering oxygen
C. Notifying the health care provider
D. Initiate chest compressions - CORRECT ✓✓ A. Suctioning the mouth
1|Page
, Page |2
Rationale: To maintain a patent airway and promote respiration and gaseous exchange, the
nurse's priority action is removing mucus from the newborn's mouth and pharynx. If the
airway is obstructed, oxygenation is useless; suctioning is the priority. The health care
provider should be notified if oral suctioning does not clear the airway. If suctioning the
mouth and administering oxygen does not improve the newborn's health status, the nurse
would need to initiate chest compressions.
Phototherapy is prescribed for a neonate with hyperbilirubinemia. Which nursing intervention
is appropriate to reduce the potentially harmful side effect of the phototherapy?
A. Covering the trunk to prevent hypothermia
B. Using shields on the eyes to protect them from the light
C. Massaging vitamin E oil into the skin to minimize drying
D. Turning after each feeding to reduce exposure of each surface area - CORRECT ✓✓ B.
Using shields on the eyes to protect them from the light
Rationale: The lights used for phototherapy can damage the infant's eyes, and eye shields are
standard equipment. Maximal effectiveness is achieved when the infant's entire skin surface
is exposed to the light. Vitamin E oil massage is contraindicated because it can cause burns
and result in an overdose of the vitamin. The infant should be turned every 2 hours regardless
of feeding times so that all body surfaces are exposed to the light and no single body surface
is overexposed.
The nurse observes several dark round areas on a newborn's buttocks on a dark-skinned
neonate. How would this observation be documented?
A. Stork bites
B. Forceps marks
C. Mongolian spots
2|Page
, Page |3
D. Ecchymotic areas - CORRECT ✓✓ C. Mongolian spots
Rationale: Mongolian spots are bluish-black areas of pigmentation commonly found on the
back and buttocks of dark-skinned newborns; they are benign and fade gradually over time.
Stork bites are short red marks commonly found near the base of the neck of the newborn.
Forceps marks are red and have a distinctive imprint on the face and head matching the
configuration of the instrument. These are not ecchymotic areas; ecchymosis represents the
extravasation of blood into subcutaneous tissue.
In a noisy room, a sleeping newborn initially startles and exhibits rapid movements but soon
goes back to sleep. What is the most appropriate nursing action in response to this behaviour?
A.Document an intact reflex.
B.Assess the infant's vital signs.
C.Test the infant's ability to hear.
D.Stimulate the infant's respirations. - CORRECT ✓✓ A.Document an intact reflex.
Rationale: The initial response is a reflection of the startle reflex; when the stimulus is
repetitive, the response to the stimulus decreases; this decrease in response is called
habituation and is expected. Assessing the infant's vital signs and stimulating the infant's
respirations are not necessary because the neonate's response is expected. The infant is
responding to noise and therefore hears.
While inspecting her newborn, a mother asks the nurse whether her baby has flat feet. How
should the nurse respond?
A."Flat feet are more common in children than adults."
B."That's hard to assess because the feet are so small."
C."There may be a bone defect that needs further assessment."
3|Page
, Page |4
D."Infants' feet appear flat because the arch is covered with a fat pad." - CORRECT ✓✓
D."Infants' feet appear flat because the arch is covered with a fat pad."
Rationale: A fat pad covers the arch in newborns and infants; the arch develops when the
child begins to walk. Flat feet are no more common in children than in adults. The size of the
feet is not relevant; arch development is related to walking. Flat feet are not associated with
deformities of the bones.
A new mother with class II heart disease tells a nurse that she is afraid that her heart condition
will prevent her from caring for her baby and her home when she is discharged. How should
the nurse respond?
A.By suggesting that she arrange for help at home
B.By asking her to describe her concerns more fully
C.By telling her to speak to her health care provider about her concerns
D.By recommending that she schedule times when family members can assist her -
CORRECT ✓✓ B.By asking her to describe her concerns more fully
Rationale: Information-seeking is the first step in problem solving. Suggesting that the client
arrange for help at home is presumptuous and possibly too expensive. The nurse should not
make decisions for the client. Telling her to speak to her health care provider shifts the
responsibility to the health care provider; the nurse should explore the client's concerns.
Recommending that she schedule times when family members can assist her is presumptuous
because it assumes that the family is willing and able to help.
A large-for-gestational-age (LGA) full-term infant should be monitored for which risk?
A.Hypotension
B.Hypothermia
4|Page
