ATI: Maternal Newborn Exam
2025
A nurse is assigning a 1 minute Apgar score to a newborn who is crying loudly. The newborn has a heart
rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of their feet, and
is pink with mild acrocyanosis. What Apgar score should the nurse assign to this newborn? - Answer-8
Apgar scoring is an assessment of five indications of a newborn's physiologic state: heart rate,
respiratory effort, muscle tone, reflex irritability, and color at 1 and at 5 min following birth.For heart
rate: 0 means absent, 1 is slow (below 100/min), and 2 means above 100/min. This newborn scores 2 for
a heart rate of 140/min.For respiratory effort: 0 means absent, 1 means slow or weak, and 2 reflects a
loud cry. This newborn scores 2 for crying loudly at delivery.For muscle tone: 0 is flaccid, 1 indicates
some flexion of the extremities, and 2 is well-flexed. This newborn scores 2 for well-flexed
extremities.For reflex irritability: 0 means no response, 1 is a grimace, and 2 is a cry. This newborn
scores 1 for grimacing when the nurse rubs the soles of their feet.For color: 0 is pale or blue, 1 reflects a
pink body with blue extremities, and 2 means completely pink. This newborn scores 1 for being pink
with mild acrocyanosis.The Apgar score is calculated by adding each of these scores together. The
newborn's scores of 2, 2, 2, 1, and 1, respectively, total a 1-minute Apgar score of 8 for this newborn.
A nurse is teaching the parents of a newborn about bathing techniques. Which of the following
instructions should the nurse include?
A. Bathe the newborn once per day
B. Bathe the newborn after a feeding
C. Clean the newborn's face first using plain water
D. Clean the newborn's ears and nose with cotton swabs - Answer-C. Clean the newborn's face first
using plain water
, Rationale: The nurse should instruct the parents to begin the bath by washing the newborn's face using
plain water. The parents should then use a mild soap to wash the rest of the body, working from the
neck down to the toes, and washing the genitals last.
A nurse is assessing a newborn who was born 2 days ago. Which of the following findings should the
nurse report to the provider?
A. Blackening of the stump of the umbilical cord
B. Redness of the skin at the base of the umbilical cord stump
C. Scant amount of dried blood on the skin around the umbilical cord stump
D. Hardening of the umbilical cord - Answer-B. Redness of the skin at the base of the umbilical cord
stump
Rationale: Redness of the skin at the base of the umbilical cord is an indication of infection that requires
further assessment. Therefore, the nurse should report this finding to the provider. Other
manifestations of infection include swelling, purulent drainage, and a foul odor.
A nurse is providing teaching about dangerous signs during pregnancy to a client who is at least 20
weeks of gestation. The nurse should instruct the client to report headaches, blurred vision, and
epigastric pain because these are indications of which of the following complications of pregnancy?
A. Gestational diabetes
B. Preeclampsia
C. Hyperemesis gravidarum
D. Abruptio placentae - Answer-B. Preeclampsia
Manifestations of preeclampsia include headache, vision changes, epigastric or abdominal pain, and
edema, especially of the face and hands. The nurse should instruct the client to report these to the
provider.
2025
A nurse is assigning a 1 minute Apgar score to a newborn who is crying loudly. The newborn has a heart
rate of 140/min, has well flexed arms and legs, grimaces when the nurse rubs the soles of their feet, and
is pink with mild acrocyanosis. What Apgar score should the nurse assign to this newborn? - Answer-8
Apgar scoring is an assessment of five indications of a newborn's physiologic state: heart rate,
respiratory effort, muscle tone, reflex irritability, and color at 1 and at 5 min following birth.For heart
rate: 0 means absent, 1 is slow (below 100/min), and 2 means above 100/min. This newborn scores 2 for
a heart rate of 140/min.For respiratory effort: 0 means absent, 1 means slow or weak, and 2 reflects a
loud cry. This newborn scores 2 for crying loudly at delivery.For muscle tone: 0 is flaccid, 1 indicates
some flexion of the extremities, and 2 is well-flexed. This newborn scores 2 for well-flexed
extremities.For reflex irritability: 0 means no response, 1 is a grimace, and 2 is a cry. This newborn
scores 1 for grimacing when the nurse rubs the soles of their feet.For color: 0 is pale or blue, 1 reflects a
pink body with blue extremities, and 2 means completely pink. This newborn scores 1 for being pink
with mild acrocyanosis.The Apgar score is calculated by adding each of these scores together. The
newborn's scores of 2, 2, 2, 1, and 1, respectively, total a 1-minute Apgar score of 8 for this newborn.
A nurse is teaching the parents of a newborn about bathing techniques. Which of the following
instructions should the nurse include?
A. Bathe the newborn once per day
B. Bathe the newborn after a feeding
C. Clean the newborn's face first using plain water
D. Clean the newborn's ears and nose with cotton swabs - Answer-C. Clean the newborn's face first
using plain water
, Rationale: The nurse should instruct the parents to begin the bath by washing the newborn's face using
plain water. The parents should then use a mild soap to wash the rest of the body, working from the
neck down to the toes, and washing the genitals last.
A nurse is assessing a newborn who was born 2 days ago. Which of the following findings should the
nurse report to the provider?
A. Blackening of the stump of the umbilical cord
B. Redness of the skin at the base of the umbilical cord stump
C. Scant amount of dried blood on the skin around the umbilical cord stump
D. Hardening of the umbilical cord - Answer-B. Redness of the skin at the base of the umbilical cord
stump
Rationale: Redness of the skin at the base of the umbilical cord is an indication of infection that requires
further assessment. Therefore, the nurse should report this finding to the provider. Other
manifestations of infection include swelling, purulent drainage, and a foul odor.
A nurse is providing teaching about dangerous signs during pregnancy to a client who is at least 20
weeks of gestation. The nurse should instruct the client to report headaches, blurred vision, and
epigastric pain because these are indications of which of the following complications of pregnancy?
A. Gestational diabetes
B. Preeclampsia
C. Hyperemesis gravidarum
D. Abruptio placentae - Answer-B. Preeclampsia
Manifestations of preeclampsia include headache, vision changes, epigastric or abdominal pain, and
edema, especially of the face and hands. The nurse should instruct the client to report these to the
provider.
