MATERNAL NEWBORN NURSING CRITICAL
COMPONENTS OF NURSING CARE 4 2026
ASSESSMENT SCRIPT DETAILED RESPONSES
COMPREHENSIVE REVIEW
◉ A 6-month old child who had a cleft-lip repair has elbow
restraints in place. What nursing intervention should the nurse plan
to implement?
A. remove restraints q4h for 30 minutes and place gloves on the
child's hands
B. record observations of the restraints q2h and ensure that they are
in place at all times
C. obtain the HCP advice as to when the restraints should be
removed
D. remove restraints one at a time to provide ROM exercises
Answer: D. remove restraints one at a time to provide ROM exercises
◉ A new mother calls the nurse stating that she wants to start
feeding her 6-month-old child something besides breast milk, but is
concerned that the infant is too young to start eating solid foods.
How should the nurse respond?
,A. encourage the mother to schedule a developmental assessment of
the infant
B. advise the mother to wait at least another month before starting
any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at
each meal
D. reassure the mother that the infant is old enough to eat iron-
fortified cereal
Answer: D. reassure the mother that the infant is old enough to eat
iron-fortified cereal
◉ While caring for a laboring client on continuous fetal monitoring,
the nurse notes a fetal heart rate pattern that falls and rises abruptly
with a "V" shaped appearance. What action should the nurse take
first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position
Answer: D. Change the maternal position
◉ A postpartum client who is Rh-negative refuses to receive Rho (D)
immune globulin (RhoGam) after delivery of an infant who is Rh-
positive. Which information should the nure provide this client?
,A. RhoGam is not necessary unless all her pregnancies are Rh-
positive
B. The R-positive factor from the fetus threatens her blood cells
C. The mother should receive RhoGam when the baby is Rh-negative
D. RhoGam prevents maternal antibody formation for future Rh-
positive babies
Answer: D. RhoGam prevents maternal antibody formation for
future Rh-positive babies
◉ A 6-week-old infant diagnosed with pyloric stenosis has recently
developed projectile vomiting. Which assessment finding indicates
to the nurse that the infant is becoming dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant
Answer: A. Weak cry without any tears
◉ A full-term, 24-hour-old infant in the nursery regurgitates and
suddenly turns cyanotic. What should the nurse do first?
A. Suction the oral and nasal passages
B. Give oxygen by positive pressure
, C. Stimulate the infant to cry
D. Turn the infant onto the right side
Answer: C. Stimulate the infant to cry
◉ A client at 40-weeks' gestation presents to the obstetrical floor
and indicates that the amniotic membranes ruptured spontaneously
at home. She is in active labor and feels the need to bear down and
push. What information is most important for the nurse to obtain
first?
A. the estimated amount of fluid
B. time the membranes ruptured
C. color and consistency of the fluid
D. any odor noted when membranes ruptured.
Answer: C. color and consistency of the fluid
◉ An infant with tetralogy of Fallot becomes acutely cyanotic and
hyper apneic. Which action should the nurse implement first?A.
Administer morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask.
Answer: C. Place the infant in a knee-chest position
COMPONENTS OF NURSING CARE 4 2026
ASSESSMENT SCRIPT DETAILED RESPONSES
COMPREHENSIVE REVIEW
◉ A 6-month old child who had a cleft-lip repair has elbow
restraints in place. What nursing intervention should the nurse plan
to implement?
A. remove restraints q4h for 30 minutes and place gloves on the
child's hands
B. record observations of the restraints q2h and ensure that they are
in place at all times
C. obtain the HCP advice as to when the restraints should be
removed
D. remove restraints one at a time to provide ROM exercises
Answer: D. remove restraints one at a time to provide ROM exercises
◉ A new mother calls the nurse stating that she wants to start
feeding her 6-month-old child something besides breast milk, but is
concerned that the infant is too young to start eating solid foods.
How should the nurse respond?
,A. encourage the mother to schedule a developmental assessment of
the infant
B. advise the mother to wait at least another month before starting
any solid foods
C. instruct the mother to offer a few spoons of 2-3 pureed fruit at
each meal
D. reassure the mother that the infant is old enough to eat iron-
fortified cereal
Answer: D. reassure the mother that the infant is old enough to eat
iron-fortified cereal
◉ While caring for a laboring client on continuous fetal monitoring,
the nurse notes a fetal heart rate pattern that falls and rises abruptly
with a "V" shaped appearance. What action should the nurse take
first?
A. Prepare for a potential cesarean
B. Allow the client to begin pushing
C. Administer oxygen at 10/L by mask
D. Change the maternal position
Answer: D. Change the maternal position
◉ A postpartum client who is Rh-negative refuses to receive Rho (D)
immune globulin (RhoGam) after delivery of an infant who is Rh-
positive. Which information should the nure provide this client?
,A. RhoGam is not necessary unless all her pregnancies are Rh-
positive
B. The R-positive factor from the fetus threatens her blood cells
C. The mother should receive RhoGam when the baby is Rh-negative
D. RhoGam prevents maternal antibody formation for future Rh-
positive babies
Answer: D. RhoGam prevents maternal antibody formation for
future Rh-positive babies
◉ A 6-week-old infant diagnosed with pyloric stenosis has recently
developed projectile vomiting. Which assessment finding indicates
to the nurse that the infant is becoming dehydrated?
A. Weak cry without any tears
B. Bulging fontanel
C. Visible peristaltic wave.
D. Palpable mass in the right upper quadrant
Answer: A. Weak cry without any tears
◉ A full-term, 24-hour-old infant in the nursery regurgitates and
suddenly turns cyanotic. What should the nurse do first?
A. Suction the oral and nasal passages
B. Give oxygen by positive pressure
, C. Stimulate the infant to cry
D. Turn the infant onto the right side
Answer: C. Stimulate the infant to cry
◉ A client at 40-weeks' gestation presents to the obstetrical floor
and indicates that the amniotic membranes ruptured spontaneously
at home. She is in active labor and feels the need to bear down and
push. What information is most important for the nurse to obtain
first?
A. the estimated amount of fluid
B. time the membranes ruptured
C. color and consistency of the fluid
D. any odor noted when membranes ruptured.
Answer: C. color and consistency of the fluid
◉ An infant with tetralogy of Fallot becomes acutely cyanotic and
hyper apneic. Which action should the nurse implement first?A.
Administer morphine sulphate.
B. Start IV fluids.
C. Place the infant in a knee-chest position
D. Provide 100% oxygen by face mask.
Answer: C. Place the infant in a knee-chest position
