MATERNAL NEWBORN SIMULATION 3.0
TEST QUESTIONS AND ANSWERS
Question 1
A nurse is caring for a client who has voided 70 mL of urine since giving birth 6
hr ago. Which of the following actions should the nurse take?
Palpate for bladder distention.
Document this as an expected finding.
Encourage the client to attempt voiding after 4 to 6 hr.
Obtain a prescription for the insertion of an indwelling catheter.
Correct Answer
Palpate for bladder distention.
Voiding a small volume of urine is a finding associated with urinary retention. The
nurse should palpate the bladder to assess for distention. The nurse should
anticipate a prescription for intermittent catheterization for a client who has urinary
retention.
Page 1 of 36
,Question 2
A nurse in the newborn nursery is caring for a group of newborns. Which of the
following findings requires immediate attention?
A newborn has not passed stool within the first 12 hr of life.
A newborn has not voided within the first 8 hr of life.
A 2-day-old newborn has a respiratory rate of 62/min.
A 1-day-old newborn has molding of the scalp.
Correct Answer
A 2-day-old newborn has a respiratory rate of 62/min.
This is an unexpected finding that indicates respiratory distress. The newborn's
respiratory rate is above the expected reference range of 40 to 60/min.
Page 2 of 36
,Question 3
A nurse is preparing to care for a newborn immediately following birth. Which of the
following actions should the nurse plan to take during the first hour following birth?
Select all that apply.
Examine the newborn's breathing.
Confirm the newborn's gestational age.
Assess the newborn's muscle tone.
Obtain the newborn's Apgar scores at 10 and 15 min following birth.
Measure the newborn's blood pressure.
Correct Answer
Confirm the newborn's gestational age is correct. Confirming the newborn's
gestational age is important. This will help determine the need for immediate
intervention. For a newborn who is greater than or equal to 35 weeks of gestation,
has good muscle tone, and is breathing or crying, the nurse can prepare to promote
bonding and skin-to-skin contact.
Assess the newborn's muscle tone is correct. To determine a newborn's
disposition and continue with the routine newborn care, the nurse should confirm
that the newborn is greater than or equal to 35 weeks of gestation, has good
muscle tone, and is breathing or crying.
Examine the newborn's breathing is correct. To determine a newborn's
disposition and continue with the routine newborn care, the nurse should confirm
that the newborn is greater than or equal to 35 weeks of gestation, has good
muscle tone, and is breathing or crying.
Page 3 of 36
, Question 4
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take when performing Leopold maneuvers? (Move the steps
into the box on the right, placing them in the order of performance. Use all the steps.)
Stand facing the client's head and use one hand to palpate for the fetal back and the
other hand to identify the small parts of the fetus.
Stand facing the client's head and place hands on either side of the client's upper
uterus to palpate wh
Correct Answer
Stand facing the client's head and place hands on either side of the client's upper
uterus to palpate which fetal part is in the fundus is the first step. Leopold
maneuvers are composed of four maneuvers. In the first maneuver, the nurse
palpates the fetal part in the fundus.Stand facing the client's head and use one hand
to palpate for the fetal back and the other hand to identify the small parts of the
fetus is the second step. In the second maneuver, the nurse continues palpating
each side of the maternal abdomen to determine which side contains the curve of
the fetal back and which contains the small parts, such as the feet, knees, and
elbows.Stand facing the client's head and use one hand to gently grasp the lower
uterus to determine the presenting part and degree of descent is the third step. In
the third maneuver, the nurse determines the location of the fetal presenting part,
degree of fetal descent, and engagement by palpating above the symphysis
pubis.Stand facing the client'
Page 4 of 36
TEST QUESTIONS AND ANSWERS
Question 1
A nurse is caring for a client who has voided 70 mL of urine since giving birth 6
hr ago. Which of the following actions should the nurse take?
Palpate for bladder distention.
Document this as an expected finding.
Encourage the client to attempt voiding after 4 to 6 hr.
Obtain a prescription for the insertion of an indwelling catheter.
Correct Answer
Palpate for bladder distention.
Voiding a small volume of urine is a finding associated with urinary retention. The
nurse should palpate the bladder to assess for distention. The nurse should
anticipate a prescription for intermittent catheterization for a client who has urinary
retention.
Page 1 of 36
,Question 2
A nurse in the newborn nursery is caring for a group of newborns. Which of the
following findings requires immediate attention?
A newborn has not passed stool within the first 12 hr of life.
A newborn has not voided within the first 8 hr of life.
A 2-day-old newborn has a respiratory rate of 62/min.
A 1-day-old newborn has molding of the scalp.
Correct Answer
A 2-day-old newborn has a respiratory rate of 62/min.
This is an unexpected finding that indicates respiratory distress. The newborn's
respiratory rate is above the expected reference range of 40 to 60/min.
Page 2 of 36
,Question 3
A nurse is preparing to care for a newborn immediately following birth. Which of the
following actions should the nurse plan to take during the first hour following birth?
Select all that apply.
Examine the newborn's breathing.
Confirm the newborn's gestational age.
Assess the newborn's muscle tone.
Obtain the newborn's Apgar scores at 10 and 15 min following birth.
Measure the newborn's blood pressure.
Correct Answer
Confirm the newborn's gestational age is correct. Confirming the newborn's
gestational age is important. This will help determine the need for immediate
intervention. For a newborn who is greater than or equal to 35 weeks of gestation,
has good muscle tone, and is breathing or crying, the nurse can prepare to promote
bonding and skin-to-skin contact.
Assess the newborn's muscle tone is correct. To determine a newborn's
disposition and continue with the routine newborn care, the nurse should confirm
that the newborn is greater than or equal to 35 weeks of gestation, has good
muscle tone, and is breathing or crying.
Examine the newborn's breathing is correct. To determine a newborn's
disposition and continue with the routine newborn care, the nurse should confirm
that the newborn is greater than or equal to 35 weeks of gestation, has good
muscle tone, and is breathing or crying.
Page 3 of 36
, Question 4
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following
actions should the nurse take when performing Leopold maneuvers? (Move the steps
into the box on the right, placing them in the order of performance. Use all the steps.)
Stand facing the client's head and use one hand to palpate for the fetal back and the
other hand to identify the small parts of the fetus.
Stand facing the client's head and place hands on either side of the client's upper
uterus to palpate wh
Correct Answer
Stand facing the client's head and place hands on either side of the client's upper
uterus to palpate which fetal part is in the fundus is the first step. Leopold
maneuvers are composed of four maneuvers. In the first maneuver, the nurse
palpates the fetal part in the fundus.Stand facing the client's head and use one hand
to palpate for the fetal back and the other hand to identify the small parts of the
fetus is the second step. In the second maneuver, the nurse continues palpating
each side of the maternal abdomen to determine which side contains the curve of
the fetal back and which contains the small parts, such as the feet, knees, and
elbows.Stand facing the client's head and use one hand to gently grasp the lower
uterus to determine the presenting part and degree of descent is the third step. In
the third maneuver, the nurse determines the location of the fetal presenting part,
degree of fetal descent, and engagement by palpating above the symphysis
pubis.Stand facing the client'
Page 4 of 36
