RN MATERNAL NEWBORN 2023
Question 1 Exhibit 1
A nurse is caring for a newborn who is 4 hr old.
Nurses’ Notes
Newborn is lying in bassinet, lightly swaddled.
Newborn is noted to be jittery with a weak cry when disturbed.
Extremities are mottled with acrocyanosis
Respirations are rapid and unlabored
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sample
Action 2: administer penicilin IM
Potential Condition: Congenital Syphilis
Parameter 1: Sking integrity
Parameter 2: Respiratory status
Question 1 Exhibit 2
A nurse is caring for a newborn who is 4 hr old.
Medical History
Gravida 2 para 2
Spontaneous vaginal birth at 41 weeks of gestation.
Maternal history positive for syphilis in the first semester, which was treated with penicillin. No reoccurrence
during the pregnancy.
Client reports intermittent cannabis use during pregnancy.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
, Action 1: Collect urine sample
Action 2: Obtain a capillary blood sample
Potential condition: Congenital syphilis
Parameter to monitor 1: Respiratory states
Parameter to monitor 2: Skin integrity
Question 1 Exhibit 3
A nurse is caring for a newborn who is 4 hr old.
Vital Signs
Newborn vita signs:
Axillary temperature 36oC (96.8oF)
Heart rate 132/min
Respiratory rate 72/min
Weight 4,366 g (9 lb to 10 oz)
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sample
Action 2: Place the newborn under a phototherapy lamp
Potential condition: Congenital syphilis
Parameter to monitor: Respiratory states
Parameter to monitor: skin integrity
,Question 1 Exhibit 4
A nurse is caring for a newborn who is 4 hr old.
Diagnostic Results
Maternal Laboratory Result:
Blood type: A+
Rapid plasma regain (RRR)/Venereal Disease Research Laboratories (VDRL): negative
Urine drug screen: Positive for cannabis, negative for opiates, cocaine, amphetamines, and barbiturates.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sample
Action 2: Place the newborn under a phototherapy lamp
Potential condition: Congenital syphilis
Parameter to monitor: Respiratory states
Paremeter to monitor: Skin integrity
Question 2 Exhibit 1
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses’ Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute
score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed
meconium stool since birth.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
, Question 2 Exhibit 2
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination
Fontanels soft and flat
Head molded with caput succedaneum
Eyes symmetric, no discharge, sclera yellow
Mucous membranes dry
Abdomen soft and rounded, bowel sounds present x 4 quadrants.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
Question 2 Exhibit 3
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Vital Signs
Heart rate 154/min
Respiratory rate 44/min
Temperature 36.9oC (98.4oF)
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
Question 1 Exhibit 1
A nurse is caring for a newborn who is 4 hr old.
Nurses’ Notes
Newborn is lying in bassinet, lightly swaddled.
Newborn is noted to be jittery with a weak cry when disturbed.
Extremities are mottled with acrocyanosis
Respirations are rapid and unlabored
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sample
Action 2: administer penicilin IM
Potential Condition: Congenital Syphilis
Parameter 1: Sking integrity
Parameter 2: Respiratory status
Question 1 Exhibit 2
A nurse is caring for a newborn who is 4 hr old.
Medical History
Gravida 2 para 2
Spontaneous vaginal birth at 41 weeks of gestation.
Maternal history positive for syphilis in the first semester, which was treated with penicillin. No reoccurrence
during the pregnancy.
Client reports intermittent cannabis use during pregnancy.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
, Action 1: Collect urine sample
Action 2: Obtain a capillary blood sample
Potential condition: Congenital syphilis
Parameter to monitor 1: Respiratory states
Parameter to monitor 2: Skin integrity
Question 1 Exhibit 3
A nurse is caring for a newborn who is 4 hr old.
Vital Signs
Newborn vita signs:
Axillary temperature 36oC (96.8oF)
Heart rate 132/min
Respiratory rate 72/min
Weight 4,366 g (9 lb to 10 oz)
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sample
Action 2: Place the newborn under a phototherapy lamp
Potential condition: Congenital syphilis
Parameter to monitor: Respiratory states
Parameter to monitor: skin integrity
,Question 1 Exhibit 4
A nurse is caring for a newborn who is 4 hr old.
Diagnostic Results
Maternal Laboratory Result:
Blood type: A+
Rapid plasma regain (RRR)/Venereal Disease Research Laboratories (VDRL): negative
Urine drug screen: Positive for cannabis, negative for opiates, cocaine, amphetamines, and barbiturates.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely
experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should
monitor to assess the client’s progress.
Action 1: Obtain a capillary blood sample
Action 2: Place the newborn under a phototherapy lamp
Potential condition: Congenital syphilis
Parameter to monitor: Respiratory states
Paremeter to monitor: Skin integrity
Question 2 Exhibit 1
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Nurses’ Notes
Term newborn birthed via spontaneous vaginal delivery at 39 weeks of gestation. Apgar 9/9 at 5-minute
score. Breastfeeding 3 to 4 times per day. Newborn has voided once since birth and has not passed
meconium stool since birth.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
, Question 2 Exhibit 2
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Physical Examination
Fontanels soft and flat
Head molded with caput succedaneum
Eyes symmetric, no discharge, sclera yellow
Mucous membranes dry
Abdomen soft and rounded, bowel sounds present x 4 quadrants.
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
Question 2 Exhibit 3
A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.
Vital Signs
Heart rate 154/min
Respiratory rate 44/min
Temperature 36.9oC (98.4oF)
Which of the following findings should the nurse report to the provider?
Select all that apply
A. Sclera color
B. Head assessment finding
C. Coombs test result
D. Mucous membrane assessment
E. Heart rate
F. Intake and output
G. Glucose level
H. Respiratory rate
