1 | Page
CMS Maternal Newborn Practice 2020 A
Questions and Correct Answers
A nurse is collecting data from a client who is at 36 weeks of
gestation during a prenatal examination. Which of the following
findings should the nurse report to the provider? Ans: — Blurred
vision - indication of preeclampsia
Expected findings: non pitting ankle edema, 10 fetal movements in
2 hr, leg cramps
A nurse is caring or a newborn who is receiving phototherapy.
Which of the following actions should the nurse take? Ans: —
Place an opaque mask over the newborn's eyes - to prevent
damage to the retinas
- Should remove mask for feedings
DO NOT apply a thin layer of lotion to the newborn's skin
A nurse is caring for a client who is at 11 weeks of gestation and
reports frequent vomiting. Which of the following findings should
the nurse identify as an indication that the client has hyperemesis
gravidarum? Ans: — Ketonuria
Occurs due to the breakdown of fat secondary to malnutrition or
starvation
Tachycardia and tachypnea due to dehydration
A nurse is caring for a newborn who has a high-pitched cry and
does not respond to consoling efforts. Which of the following
neonatal data collection tools should the nurse expect to
© 2025 All rights reserved
, 2 | Page
complete? Ans: — Neonatal Abstinence Scoring System: exhibiting
opioid withdrawal
Additional manifestations: restlessness, tremors, increased muscle
tone, and an exaggerated Moro reflex
- Apgar score: heart rate, respiratory rate, muscle tone, reflex
irritability and skin color
- Newborn Hearing Screen should be completed before the
newborn is discharged from the hospital
- Critical Congenital Heart Disease screen should be completed 24-
28 hours following birth and before the newborn is discharged
from the hospital
A nurse is assisting in the care of a newborn immediately
following birth. Which of the following images should the nurse
identify as an indication that the newborn has a
myelomeningocele? Ans: — Occurs when the neural tube fails to
close, and the meninges and spinal cord herniate
Occurs in the lumbar area and may be covered by a thin
membranous sac
- Exstrophy of the bladder; occurs from abnormal development of
the abdominal wall, symphysis pubis and bladder ; visible in the
suprapubic area and requires surgical intervention soon after birth
- Omphalocel: occurs when abdominal organs herniate through the
umbilical ring at the base of the umbilical cord
- Cephalohematoma; collection of blood between the skull bone
and its covering, the periosteum. A cephalohematoma does not
cross the suture lines of the newborn's skull and will
spontaneously resolve in 2-8 weeks
© 2025 All rights reserved
, 3 | Page
A nurse is collecting data from a newborn who is 8hr old. Which of
the following findings should the nurse report to the provider?
Ans: — Apical heart rate of 90/min while crying - normal range
110 - 160 for a newborn, heart rate of 80-100/min while asleep
and up to 180/min while crying
- Apneic episode of 20 seconds or less - normal; newborns
respirations are normally shallow and irregular
- Positive moro reflex present from birth up to 8 weeks
- Vernix in the skin folds - normal
A nurse is caring for a client 6 hr after a vaginal birth who is going
to breastfeed her newborn. The client reports perineal pain of 6 on
a scale from 0 to 10. The nurse also notes mild perineal edema
and ecchymosis, with a fundus that is 2 cm above the umbilicus
with deviation to the right. Which of the following actions is the
nurse's priority?
a. administer analgesics
b. apply an ice pack to the perineum
c. assist the client with breastfeeding
d. help the client ambulate to the toilet Ans: — d. help the client
ambulate to the toilet
The greatest risk for this client is postpartum hemorrhage from
uterine atony. Therefore, the priority intervention by the nurse is
to assist the client to urinate and completely empty the bladder,
which will allow the uterus to contract.
A nurse is reinforcing teaching with a client who is at 20 wks of
gestation and has gestational diabetes mellitus. Which of the
following information should the nurse include in the teaching?
© 2025 All rights reserved
CMS Maternal Newborn Practice 2020 A
Questions and Correct Answers
A nurse is collecting data from a client who is at 36 weeks of
gestation during a prenatal examination. Which of the following
findings should the nurse report to the provider? Ans: — Blurred
vision - indication of preeclampsia
Expected findings: non pitting ankle edema, 10 fetal movements in
2 hr, leg cramps
A nurse is caring or a newborn who is receiving phototherapy.
Which of the following actions should the nurse take? Ans: —
Place an opaque mask over the newborn's eyes - to prevent
damage to the retinas
- Should remove mask for feedings
DO NOT apply a thin layer of lotion to the newborn's skin
A nurse is caring for a client who is at 11 weeks of gestation and
reports frequent vomiting. Which of the following findings should
the nurse identify as an indication that the client has hyperemesis
gravidarum? Ans: — Ketonuria
Occurs due to the breakdown of fat secondary to malnutrition or
starvation
Tachycardia and tachypnea due to dehydration
A nurse is caring for a newborn who has a high-pitched cry and
does not respond to consoling efforts. Which of the following
neonatal data collection tools should the nurse expect to
© 2025 All rights reserved
, 2 | Page
complete? Ans: — Neonatal Abstinence Scoring System: exhibiting
opioid withdrawal
Additional manifestations: restlessness, tremors, increased muscle
tone, and an exaggerated Moro reflex
- Apgar score: heart rate, respiratory rate, muscle tone, reflex
irritability and skin color
- Newborn Hearing Screen should be completed before the
newborn is discharged from the hospital
- Critical Congenital Heart Disease screen should be completed 24-
28 hours following birth and before the newborn is discharged
from the hospital
A nurse is assisting in the care of a newborn immediately
following birth. Which of the following images should the nurse
identify as an indication that the newborn has a
myelomeningocele? Ans: — Occurs when the neural tube fails to
close, and the meninges and spinal cord herniate
Occurs in the lumbar area and may be covered by a thin
membranous sac
- Exstrophy of the bladder; occurs from abnormal development of
the abdominal wall, symphysis pubis and bladder ; visible in the
suprapubic area and requires surgical intervention soon after birth
- Omphalocel: occurs when abdominal organs herniate through the
umbilical ring at the base of the umbilical cord
- Cephalohematoma; collection of blood between the skull bone
and its covering, the periosteum. A cephalohematoma does not
cross the suture lines of the newborn's skull and will
spontaneously resolve in 2-8 weeks
© 2025 All rights reserved
, 3 | Page
A nurse is collecting data from a newborn who is 8hr old. Which of
the following findings should the nurse report to the provider?
Ans: — Apical heart rate of 90/min while crying - normal range
110 - 160 for a newborn, heart rate of 80-100/min while asleep
and up to 180/min while crying
- Apneic episode of 20 seconds or less - normal; newborns
respirations are normally shallow and irregular
- Positive moro reflex present from birth up to 8 weeks
- Vernix in the skin folds - normal
A nurse is caring for a client 6 hr after a vaginal birth who is going
to breastfeed her newborn. The client reports perineal pain of 6 on
a scale from 0 to 10. The nurse also notes mild perineal edema
and ecchymosis, with a fundus that is 2 cm above the umbilicus
with deviation to the right. Which of the following actions is the
nurse's priority?
a. administer analgesics
b. apply an ice pack to the perineum
c. assist the client with breastfeeding
d. help the client ambulate to the toilet Ans: — d. help the client
ambulate to the toilet
The greatest risk for this client is postpartum hemorrhage from
uterine atony. Therefore, the priority intervention by the nurse is
to assist the client to urinate and completely empty the bladder,
which will allow the uterus to contract.
A nurse is reinforcing teaching with a client who is at 20 wks of
gestation and has gestational diabetes mellitus. Which of the
following information should the nurse include in the teaching?
© 2025 All rights reserved
