MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 10
1. A 1-day-old neonate, 32 weeks’ gestation, is in
an overhead warmer. The nurse assesses the
morning axillary temperature as 96.9ºF. Which of
the following could explain this assessment
finding?
1. This is a normal temperature for a preterm
neonate.
2. Axillary temperatures are not valid for preterm
babies.
3. The supply of brown adipose tissue is
incomplete.
4. Conduction heat loss is pronounced in the
baby.
2. Which of the following neonates is at highest
risk for cold stress syndrome?
1. Infant of diabetic mother.
2. Infant with Rh incompatibility.
3. Postdates neonate.
4. Down syndrome neonate.
3. Which of the following would lead the nurse to
suspect cold stress syndrome in a newborn with
a temperature of 96.5ºF?
1. Blood glucose of 50 mg/dL.
2. Acrocyanosis.
3. Tachypnea.
4. Oxygen saturation of 96%.
4. Four babies are in the newborn nursery. The
nurse pages the neonatalogist to see the baby
who exhibits which of the following?
1. Intracostal retractions.
2. Erythema toxicum.
3. Pseudostrabismus.
4. Vernix caseosa.
5. A baby is grunting in the neonatal nursery.
Which of the following actions by the nurse is
appropriate?
1. Place a pacifier in the baby’s mouth.
2. Check the baby’s diaper.
3. Have the mother feed the baby.
4. Assess the respiratory rate.
6. A 6-month-old child developed kernicterus
immediately after birth. Which of the
following tests should be done to determine
whether or not this child has developed
any sequelae to the illness?
1. Blood urea nitrogen and serum creatinine.
2. Alkaline phosphotase and bilirubin.
3. Hearing and vision assessments.
4. Peak expiratory flow and blood gas
assessments.
7. A baby with hemolytic jaundice is being treated
with fluorescent phototherapy. To provide safe
newborn care, which of the following actions
should the nurse perform?
1. Cover the baby’s eyes with eye pads.
2. Turn the lights on for ten minutes every hour.
3. Clothe the baby in a shirt and diaper only.
4. Tightly swaddle the baby in a baby blanket.
8. A baby is born with erythroblastosis fetalis.
Which of the following signs/symptoms would the
nurse expect to see?
1. Ruddy complexion.
2. Anasarca.
3. Alopecia.
4. Erythema toxicum.
9. Which of the following laboratory findings
would the nurse expect to see in a baby
diagnosed with erythroblastosis fetalis?
1. Hematocrit 24%.
2. Leukocyte count 45,000 cells/mm3.
3. Sodium 125 mEq/L.
4. Potassium 5.5 mEq/L.
10. A baby’s blood type is B negative. The baby
is at risk for hemolytic jaundice if the mother has
which of the following blood types?
1. Type O negative.
2. Type A negative.
3. Type B positive.
4. Type AB positive.
11. A newborn admitted to the nursery has a
positive direct Coombs’ test. Which of the
following is an appropriate action by the nurse?
1. Monitor the baby for jitters.
2. Assess the blood glucose level.
3. Assess the rectal temperature.
4. Monitor the baby for jaundice.
12. An 18-hour-old baby is placed under the bili-
lights with an elevated bilirubin level. Which of
the following is an expected nursing action in
these circumstances?
1. Give the baby oral rehydration therapy after all
feedings.
2. Rotate the baby from side to back to side to
front every two hours.
3. Tightly swaddle in baby blankets to maintain
normal temperature.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 10
4. Administer intravenous fluids via pump per
doctor orders.
13. A jaundice neonate must have a heel stick to
assess bilirubin levels. Which of the following
actions should the nurse make during the
procedure?
1. Cover the foot with an iced wrap for one
minute prior to the procedure.
2. Avoid puncturing the lateral heel to prevent
damaging sensitive structures.
3. Blot the site with a dry gauze after rubbing it
with an alcohol swab.
4. Grasp the calf of the baby during the
procedure to prevent injury.
14. A newborn nursery nurse notes that a baby’s
body is jaundiced at 36 hours of life.
Which of the following nursing interventions will
be most therapeutic?
1. Maintain a warm ambient environment.
2. Have the mother feed the baby frequently.
3. Have the mother hold the baby skin to skin.
4. Place the baby naked by a closed sunlit
window.
15. A neonate is under phototherapy for elevated
bilirubin levels. The baby’s stools are now loose
and green. Which of the following actions should
the nurse take at this time?
1. Discontinue the phototherapy.
2. Notify the health care practitioner.
3. Take the baby’s temperature.
4. Assess the baby’s skin integrity.
16. A nursing diagnosis for a 5-day-old newborn
under phototherapy is: Risk for fluid volume
deficit. For which of the following client outcomes
should the nurse plan to monitor the baby?
1. 6 saturated diapers in 24 hours.
2. Breastfeeds 6 times in 24 hours.
3. 12% weight loss since birth.
4. Apical heart rate of 176 bpm.
17. There is a baby in the neonatal intensive care
unit (NICU) who is exhibiting signs of neonatal
abstinence syndrome. Which of the following
medications is contraindicated for this neonate?
1. Morphine.
2. Opium.
3. Narcan.
4. Phenobarbital.
18. A baby is in the NICU whose mother was
addicted to heroin during the pregnancy.
Which of the following nursing actions would be
appropriate?
1. Tightly swaddle the baby.
2. Place the baby prone in the crib.
3. Provide needed stimulation to the baby.
4. Feed the baby half-strength formula.
19. A newborn in the nursery is exhibiting signs
of neonatal abstinence syndrome.
Which of the following signs/symptoms is the
nurse observing? Select all that apply.
1. Hyperphagia.
2. Lethargy.
3. Prolonged periods of sleep.
4. Hyporeflexia.
5. Persistent shrill cry.
20. Based on maternal history of alcohol
addiction, a baby in the neonatal nursery is
being monitored for signs of fetal alcohol
syndrome (FAS). The nurse should assess
this baby for which of the following?
1. Poor suck reflex.
2. Ambiguous genitalia.
3. Webbed neck.
4. Absent Moro reflex.
21. A baby born addicted to cocaine is being
given paregoric. The nurse knows that
which of the following is a rationale for its use?
1. Paregoric is nonaddictive.
2. Paregoric corrects diarrhea.
3. Paregoric is nonsedating.
4. Paregoric suppresses the cough reflex.
22. A baby was born 24 hours ago to a mother
who received no prenatal care. The infant has
tremors, sneezes excessively, constantly mouths
for food, and has a shrill, high-pitched cry. The
baby’s serum glucose levels are normal. For
which of the following should the nurse request
an order from the pediatrician?
1. Urine drug toxicology test.
2. Biophysical profile test.
3. Chest and abdominal ultrasound evaluations.
4. Oxygen saturation and blood gas
assessments.
23. A nurse makes the following observations
when admitting a full-term, breastfeeding
baby into the neonatal nursery: 9 lbs 2 oz, 21
inches long, TPR: 96.6ºF, 158, 62, jittery, pink
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 10
body with bluish hands and feet, crying. Which of
the following actions should the nurse perform
first?
1. Swaddle the baby to provide warmth.
2. Assess the glucose level of the baby.
3. Take the baby to the mother for feeding.
4. Administer the neonatal medications.
24. An infant admitted to the newborn nursery
has a blood glucose level of 35 mg/dL. The nurse
should monitor this baby carefully for which of
the following?
1. Jaundice.
2. Jitters.
3. Erythema toxicum.
4. Subconjunctival hemorrhages.
25. A full-term infant admitted to the newborn
nursery has a blood glucose level of
35 mg/dL. Which of the following actions should
the nurse perform at this time?
1. Feed the baby formula or breast milk.
2. Assess the baby’s blood pressure.
3. Tightly swaddle the baby.
4. Monitor the baby’s urinary output.
26. A nurse is inserting a gavage tube into a
preterm baby who is unable to suck and swallow.
Which of the following actions must the nurse
take during the procedure?
1. Measure the distance from the tip of the ear to
the nose.
2. Lubricate the tube with an oil-based solution.
3. Insert the tube quickly if the baby becomes
cyanotic.
4. Inject a small amount of sterile water to check
placement.
27. A neonate is in the warming crib for poor
thermoregulation. Which of the following sites is
appropriate for the placement of the skin thermal
sensor?
1. Xiphoid process.
2. Forehead.
3. Abdominal wall.
4. Great toe.
28. The nurse must perform nasopharyngeal
suctioning of a newborn with profuse secretions.
Place the following nursing actions for
nasopharyngeal suctioning in chronological
order.
1. Slowly rotate and remove the suction catheter.
2. Place thumb over the suction control on the
catheter.
3. Assess type and amount of secretions.
4. Insert free end of the tubing through the nose.
29. A neonate is being given intravenous fluids
through the dorsal vein of the wrist.
Which of the following actions by the nurse is
essential?
1. Tape the arm to an arm board.
2. Change the tubing every 24 hours.
3. Monitor the site every 5 minutes.
4. Infuse the fluid intermittently.
30. A Roman Catholic couple has just delivered a
baby with an Apgar of 1 at 1 minute, 2 at 5
minutes, and 2 at 10 minutes. Which of the
following interventions is appropriate at this time?
1. Advise the parents that they should pray very
hard so that everything turns out well.
2. Ask the parents whether they would like the
nurse to baptize the baby.
3. Leave the parents alone to work through their
thoughts and feelings.
4. Inform the parents that a priest will listen to
their confessions whenever they are ready.
31. The nurse assesses a newborn as follows:
heart rate: 70
respirations: weak and irregular
tone: flaccid
color: pale
baby grimaces when a pediatrician attempts to
insert an endotracheal tube
What should the nurse calculate the baby’s
Apgar score to be? ____________
32. A neonate is in the neonatal intensive care
nursery with a diagnosis of large-for gestational
age. The baby was born at 38 weeks’ gestation
and weighed 3500 grams. Based on this
information, which of the following responses is
correct?
1. The diagnosis is inaccurate because the
baby’s weight is too high for a diagnosis of
appropriate-for-gestational age.
2. The diagnosis is inaccurate because the
baby’s weight needs to be higher than
3500 grams.
3. The diagnosis is inaccurate because the
baby’s weight needs to be lower than
3500 grams.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 10
4. The diagnosis is inaccurate because full-term
babies are never large-for gestational age.
33. A neonate has been admitted to the neonatal
intensive care unit with the following
findings:
completely flaccid posturing
square window sign of 60º
arm recoil of 180º
popliteal angle of 160º
full scarf sign
heel that touches the ear
skin that is red and translucent
sparse lanugo
faint red marks on the plantar surface
barely perceptible breast tissue
eye lids that are open but flat ear pinnae
prominent clitoris and small labia minora
Using the Ballard scale, what is the gestational
age of this neonate estimated to be?
_____________ weeks
34. A neonate is in the neonatal intensive care
unit. The baby is 28 weeks’ gestation and weighs
1000 grams. Which of the following is correct in
relation to this baby’s growth?
1. Weight is appropriate-for-gestational age.
2. Weight is below average for gestational age.
3. Baby experienced intrauterine growth
restriction.
4. Baby experienced congenital growth
hypertrophy.
35. A neonate, 40 weeks by dates, has been
admitted to the nursery. Place an “X” on the
graph where the baby would be labeled large-for-
gestational age.
36. A 42-week-gestation baby, 2400 grams,
whose mother had no prenatal care, is admitted
into the NICU. The neonatalogist orders blood
work. Which of the following laboratory findings
would the nurse expect to see?
1. Blood glucose 30 mg/dL.
2. Leukocyte count 1000 cells/mm3.
3. Hematocrit 30%.
4. Serum pH 7.8.
37. A woman who received an intravenous
analgesic 4 hours ago has had prolonged late
decelerations in labor. She will deliver her baby
shortly. Which of the following is the priority
action for the delivery room nurse to take?
1. Preheat the overhead warmer.
2. Page the neonatalogist on call.
3. Draw up Narcan (naloxone) for injection.
4. Assemble the neonatal eye prophylaxis.
38. A baby has been admitted to the neonatal
intensive care unit with a diagnosis of
postmaturity. The nurse expects to find which of
the following during the initial newborn
assessment?
1. Abundant lanugo.
2. Flat breast tissue.
3. Prominent clitoris.
4. Wrinkled skin.
39. A 42-week-gestation baby has been admitted
to the neonatal intensive care unit. At delivery,
thick green amniotic fluid was noted. Which of
the following actions by the nurse is critical at this
time?
1. Bath to remove meconium-contaminated fluid
from the skin.
2. Ophthalmic assessment to check for
conjunctival irritation.
3. Rectal temperature to assess for septic
hyperthermia.
4. Respiratory evaluation to monitor for
respiratory distress.
40. A 42-week gravida is delivering her baby. A
nurse and pediatrician are present at the bith.
The amniotic fluid is green and thick. The baby
fails to breathe spontaneously. Which of the
following actions should the nurse take next?
1. Stimulate the baby to breathe.
2. Assess neonatal heart rate.
3. Assist with intubation.
4. Place the baby in the prone position.
41. At 1 minute of life a baby, who appears
preterm, has exhibited no effort to breathe even
after being stimulated. Which of the following
actions should the nurse perform first?
1. Perform a gestational age assessment.
2. Inflate the lungs with positive pressure.
3. Provide external chest compressions.
4. Palpate the base of the umbilical cord.
42. A neonatalogist requests Narcan (naloxone)
during a neonatal resuscitation effort.
Which of the following dosages would the nurse
expect to prepare?
1. 1 microgram/kg.
2. 10 microgram/kg.
3. 0.1 milligrams/kg.
4. 1 milligram/kg.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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43. During neonatal cardiopulmonary
resuscitation, which of the following actions
should be performed?
1. Provide assisted ventilation at 40 to 60 breaths
per minute.
2. Begin chest compressions when heart rate is 0
to 20 beats per minute.
3. Compress the chest using the three-finger
technique.
4. Administer compressions and breaths in a 5 to
1 ratio.
44. The staff on the maternity unit is developing a
protocol for nurses to follow after a baby is
delivered who fails to breathe spontaneously.
Which of the following should be included in the
protocol as the first action for the nurse to take?
1. Prepare epinephrine for administration.
2. Provide positive pressure oxygen.
3. Administer chest compressions.
4. Rub the back and feet of the baby.
45. A nurse in the newborn nursery suspects that
a new admission, 42 weeks’ gestation, was
exposed to meconium in utero. What would lead
the nurse to suspect this?
1. The baby is bradycardic.
2. The baby’s umbilical cord is green.
3. The baby’s anterior fontanel is sunken.
4. The baby is desquamating.
46. The birth of a baby, weight 4500 grams, was
complicated by shoulder dystocia.
Which of the following neonatal complications
should the nursery nurse observe for?
1. Leg deformities.
2. Brachial palsy.
3. Fractured radius.
4. Buccal abrasions.
47. During a health maintenance visit at the
pediatrician’s office, the nurse notes that a
breastfeeding baby has thrush. Which of the
following actions should the nurse take?
1. Nothing because thrush is a benign problem.
2. Advise the mother to bottlefeed until the thrush
is cured.
3. Obtain an order for antifungals for both mother
and baby.
4. Assess for other evidence of
immunosuppression.
48. A neonate, whose mother is HIV positive, is
admitted to the NICU. A nursing diagnosis: Risk
for infection related to perinatal exposure to
HIV/AIDS is made.
Which of the following interventions should the
nurse make in relation to the diagnosis?
1. Monitor daily viral load laboratory reports.
2. Check the baby’s viral antibody status.
3. Obtain an order for antiviral medication.
4. Place the baby on strict precautions.
49. A baby was just born to a mother who had
positive vaginal cultures for group B
streptococcus. The mother was admitted to the
labor room 2 hours before the birth.
For which of the following should the nursery
nurse closely observe this baby?
1. Hypothermia.
2. Mottling.
3. Omphalocele.
4. Stomatitis.
50. A baby in the newborn nursery was born to a
mother with spontaneous rupture of membranes
for 14 hours. The woman has Candida vaginitis.
For which of the following should the baby be
assessed?
1. Papular facial rash.
2. Thrush.
3. Fungal conjunctivitis.
4. Dehydration.
51. A baby has been admitted to the neonatal
nursery whose mother is hepatitis B–surface
antigen positive. Which of the following actions
by the nurse should be taken at this time?
1. Monitor the baby for signs of hepatitis B.
2. Place the baby on contact isolation.
3. Obtain an order for the hepatitis B vaccine and
the immune globulin.
4. Advise the mother that breastfeeding is
absolutely contraindicated.
52. Four full-term babies were admitted to the
neonatal nursery. The mothers of each of the
babies had labors of 4 hours or less. The nursery
nurse should carefully monitor which of the
babies for hypothermia?
1. The baby whose mother cultured positive for
group B strep during her third trimester.
2. The baby whose mother had gestational
diabetes.
3. The baby whose mother was hospitalized for 3
months with complete placenta
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 10
previa.
4. The baby whose mother previously had a
stillbirth.
53. Four 38-week-gestation gravidas have just
delivered. Which of the babies should be
monitored closely by the nurse for respiratory
distress?
1. The baby whose mother has diabetes mellitus.
2. The baby whose mother has lung cancer.
3. The baby whose mother has hypothyroidism.
4. The baby whose mother has asthma.
54. A client is seeking preconception counseling.
She has type 1 diabetes mellitus and is found to
have an elevated glycosylated hemoglobin
(HgbA1c) level. Before actively trying to become
pregnant, she is strongly encouraged to stabilize
her blood glucose to reduce the possibility of her
baby developing which of the following?
1. Port wine stain.
2. Cardiac defect.
3. Hip dysplasia.
4. Intussusception.
55. A baby is born with caudal agenesis. Which
of the following maternal complications
is associated with this defect?
1. Poorly controlled myasthenia gravis.
2. Poorly controlled diabetes mellitus.
3. Poorly controlled splenic syndrome.
4. Poorly controlled hypothyroidism.
56. A macrosomic infant of a non–insulin
dependent diabetic mother has been admitted
to the neonatal nursery. The baby’s glucose level
on admission to the nursery is 25 mg/dL and
after a feeding of mother’s expressed breast milk
is 35 mg/dL. Which of the following actions
should the nurse take at this time?
1. Nothing because the glucose level is normal
for an infant of a diabetic mother.
2. Administer intravenous glucagon slowly over
five minutes.
3. Feed the baby a bottle of dextrose and water
and reassess the glucose level.
4. Notify the neonatalogist of the abnormal
glucose levels.
57. A baby has just been born to a type 1
diabetic mother with retinopathy and
nephropathy. Which of the following neonatal
findings would the nurse expect to see?
1. Hyperalbuminemia.
2. Polycythemia.
3. Hypercalcemia.
4. Hypoinsulinemia.
58. A baby is born to a type 1 diabetic mother.
Which of the following lab values would
the nurse expect the neonate to exhibit?
1. Plasma glucose 30 mg/dL.
2. Red blood cell count 1 million/mm3.
3. White blood cell count 2000/mm3.
4. Hemoglobin 8 g/dL.
59. A baby has just been admitted into the
neonatal intensive care unit with a diagnosis
of intrauterine growth restriction (IUGR). Which
of the following maternal factors would
predispose the baby to this diagnosis? Select all
that apply.
1. Hyperopia.
2. Gestational diabetes.
3. Substance abuse.
4. Chronic hypertension.
5. Advanced maternal age.
60. A baby has been admitted to the neonatal
intensive care unit with a diagnosis of
symmetrical intrauterine growth restriction. Which
of the following pregnancy complications would
be consistent with this diagnosis?
1. Severe preeclampsia.
2. Chromosomal defect.
3. Infarcts in an aging placenta.
4. Premature rupture of the membranes.
61. A neonate has intrauterine growth restriction
secondary to placental insufficiency.
Which of the following signs/symptoms should
the nurse expect to observe at delivery?
1. Thrombocytopenia.
2. Neutropenia.
3. Polycythemia.
4. Hyperglycemia.
62. A woman is visiting the NICU to see her 26-
week-gestation baby for the first time.
Which of the following methods would the nurse
expect the mother to use when first making
physical contact with her baby?
1. Fingertip touch.
2. Palmar touch.
3. Kangaroo hold.
4. Cradle hold.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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63. A 6-month-old child is being seen in the
pediatrician’s office. The child was born preterm
and remained in the neonatal intensive care unit
for the first 5 months of life. The child is being
monitored for 5 chronic problems. Which of the
following problems are directly related to the
prematurity? Select all that apply.
1. Bronchopulmonary dysplasia.
2. Cerebral palsy.
3. Retinopathy.
4. Hypothyroidism.
5. Seizure disorders.
64. A neonatalogist prescribes Garamycin
(gentamicin) for a 2-day-old, septic preterm
infant who weighs 1653 grams and is 38
centimeters long. The drug reference states:
Neonatal dosage of Garamycin for babies less
than 1 week of age is 2.5 mg/kg q 12–24 hours.
Calculate the safe daily dosage of this
medication.
_____________ mg q 24 hours.
65. The neonatalogist has ordered 12.5
micrograms of digoxin po for a neonate in
congestive heart failure. The medication is
available in the following elixir— 0.05 mg/mL.
How many milliliters (mL) should the nurse
administer?
_____________ mL.
66. A neonatalogist prescribes Platinol-AQ
(cisplatin) for a neonate born with a
neuroblastoma. The baby’s current weight is
3476 grams and the baby is 57 centimeters long.
The drug reference states: Children: IV 30
mg/m2 q week. Calculate the safe dosage of this
medication. ____________ mg q week.
67. A preterm baby is to receive 4 mg Garamycin
(gentamicin) IV every 24 hours. The medication
is being injected into an IV soluset. A total of 5 cc
is to be administered via IV pump over 90
minutes. The pump should be set at what rate?
_____________ mL/hr.
68. A mother of a preterm baby is performing
kangaroo care in the neonatal nursery.
Which of the following responses would the
nurse evaluate as a positive neonatal outcome?
1. Respiratory rate of 70.
2. Temperature of 97.0ºF.
3. Licking the mother’s nipples.
4. Flaring of the baby’s nares.
69. A neonate is being assessed for necrotizing
enterocolitis (NEC). Which of the following
actions by the nurse is appropriate? Select all
that apply.
1. Perform hemoccult test on stools.
2. Monitor for an increase in abdominal girth.
3. Measure gastric contents before each feed.
4. Assess bowel sounds before each feed.
5. Assess for anal fissures daily.
70. A woman whose 32-week-gestation neonate
is to begin oral feedings is expressing breast milk
(EBM) for the baby. The neonatalogist is
recommending that fortifier be added to the milk
because which of the following needs of the baby
are not met by EBM?
1. Need for iron and zinc.
2. Need for calcium and phosphorus.
3. Need for protein and fat.
4. Need for sodium and potassium.
71. A 1000-gram neonate is being admitted to
the neonatal intensive care unit. The surfactant
Survanta (beractant) has just been prescribed to
prevent respiratory distress syndrome. Which of
the following actions should the nurse take while
administering this medication?
1. Flush the intravenous line with normal saline
solution.
2. Assist the neonatalogist during the intubation
procedure.
3. Inject the medication deep into the vastus
lateralis muscle.
4. Administer the reconstituted liquid via an oral
syringe.
72. A 30-week-gestation neonate, 2 hours old,
has received Survanta (beractant).
Which of the following would indicate a positive
response to the medication?
1. Axillary temperature 98.0ºF.
2. Oxygen saturation 96%.
3. Apical heart rate 154 bpm.
4. Serum potassium 4.0 mEq/L.
73. For which of the following reasons would a
nurse in the well baby nursery report to the
neonatalogist that a newborn appears to be
preterm?
1. Baby has a square window angle of 90º.
2. Baby has leathery and cracked skin.
3. Baby has popliteal angle of 90º.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
CHAPTER 10
4. Baby has pronounced plantar creases.
74. A full-term neonate in the NICU has been
diagnosed with congestive heart failure
secondary to a cyanotic heart defect. Which of
the following activities is most likely to result in a
cyanotic episode?
1. Feeding.
2. Sleeping in the supine position.
3. Rocking in an infant swing.
4. Swaddling.
75. The nurse is providing discharge teaching to
the parents of a baby born with a cleft lip and
palate. Which of the following should be included
in the teaching?
1. Correct technique for the administration of a
gastrostomy feeding.
2. Need to watch for the appearance of blood-
stained mucus from the nose.
3. Optimal position for burping after nasogastric
feedings.
4. Need to give the baby sufficient time to rest
during each feeding.
76. A baby is suspected of having esophageal
atresia. The nurse would expect to see
which of the following signs/symptoms?
1. Frequent vomiting.
2. Excessive mucus.
3. Ruddy complexion.
4. Abdominal distention.
77. The nurse is teaching a couple about the
special health care needs of their newborn
child with Down syndrome. The nurse knows that
the teaching was successful when the parents
state that the child will need which of the
following?
1. Yearly three-hour glucose tolerance testing.
2. Immediate intervention during bleeding
episodes.
3. A formula that is low in lactose and
phenylalanine.
4. Prompt treatment of upper respiratory
infections.
78. An infant in the neonatal nursery has low set
ears, Simian creases, and slanted eyes.
The nurse should monitor this infant carefully for
which of the following
signs/symptoms?
1. Blood-tinged urine.
2. Hemispheric paralysis.
3. Cardiac murmur.
4. Hemolytic jaundice.
79. Which of the following actions would the
NICU nurse expect to perform when caring for a
neonate with esophageal atresia and
tracheoesophageal fistula (TEF)?
1. Position the baby flat on the left side.
2. Maintain low nasogastric suction.
3. Give small frequent feedings.
4. Place on hypothermia blanket.
80. A nurse is assisting a mother to feed a baby
born with cleft lip and palate. Which of the
following should the nurse teach the mother?
1. The baby is likely to cry from pain during the
feeding.
2. The baby is likely to expel milk through the
nose.
3. The baby will feed more quickly than other
babies.
4. The baby will need milk with added calories.
81. A neonate that is admitted to the neonatal
nursery is noted to have a 2-vessel cord.
The nurse notifies the neonatalogist to get an
order for which of the following assessments?
1. Renal function tests.
2. Echocardiogram.
3. Glucose tolerance test.
4. Electroencephalogram.
82. In the delivery room, which of the following
infant care interventions must a nurse
perform when a neonate with a
meningomyelocele is born?
1. Perform nasogastric suctioning.
2. Place baby in the prone position.
3. Administer oxygen via face mask.
4. Swaddle the baby in warm blankets.
83. A baby in the NICU, who is exhibiting signs of
congestive heart failure from an atrioventricular
canal defect, is receiving a diuretic. In the plan of
care, the nurse should include that the desired
outcome for the child will be which of the
following?
1. Loss of body weight.
2. Drop in serum sodium level.
3. Rise in urine specific gravity.
4. Increase in blood pressure.
84. The nurse caring for a neonate with
congestive heart failure identifies which of the
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following nursing diagnoses as highest priority?
1. Fatigue.
2. Activity intolerance.
3. Sleep pattern disturbance.
4. Altered tissue perfusion.
85. The nurse administers Lanoxin (digoxin) to a
baby in the NICU that has a cardiac defect. The
baby vomits shortly after receiving the
medication. Which of the following actions should
the nurse perform next?
1. Give a repeat dose.
2. Notify the physician.
3. Assess the apical and brachial pulses
concurrently.
4. Check the vomitus for streaks of blood.
86. A baby is born with a meningomyelocele at
L2. In assessing the baby, which of the following
would the nurse expect to see?
1. Sensory loss in all four extremities.
2. Tuft of hair over the lumbosacral region.
3. Flaccid paralysis of the legs.
4. Positive Moro reflex.
87. When examining a nenonate in the well-baby
nursery, the nurse notes that the sclerae of both
of the baby’s eyes is visible above the iris of the
eyes. Which of the following assessments is
highest priority for the nurse to make next?
1. Babinski and tonic neck reflexes.
2. Evaluation of bilateral eye coordination.
3. Blood type and Coombs’ test results.
4. Circumferences of the head and chest.
88. A baby is born with a suspected coarctation
of the aorta. Which of the following assessments
should be done by the nurse?
1. Check blood pressures in all four limbs.
2. Palpate the anterior fontanel for bulging.
3. Assess hematocrit and hemoglobin values.
4. Monitor for harlequin color changes.
89. The nurse is developing a teaching plan for
parents of an infant with a tetralogy of Fallot.
Which of the following positions should parents
be taught to place the infant during a “blue,” or
“tet,” spell?
1. Supine.
2. Prone.
3. Knee-chest.
4. Semi-Fowler’s.
90. A child has been diagnosed with a small
ventricular septal defect (VSD). Which of the
following symptoms would the nurse expect to
see?
1. Cyanosis and clubbing of the fingers.
2. Respiratory distress and extreme fatigue.
3. Systolic murmur with no other obvious
symptoms.
4. Feeding difficulties with marked polycythemia.
91. A newborn in the NICU has just had a
ventriculoperitoneal shunt inserted. Which
of the following signs indicates that the shunt is
functioning properly?
1. Decrease of the baby’s head circumference.
2. Absence of cardiac arrhythmias.
3. Rise of the baby’s blood pressure.
4. Appearance of setting sun sign.
92. A neonate has just been born with a
meningomyelocele. Which of the following
nursing diagnoses should the nurse identify as
related to this medical diagnosis?
1. Deficient fluid volume.
2. High risk for infection.
3. Ineffective breathing pattern.
4. Imbalanced nutrition: less than body
requirements.
93. The neonatalogist assesses a newborn for
Hirschsprung’s disease after the baby exhibited
which of the following signs/symptoms?
1. Passed meconium at 50 hours of age.
2. Apical heart rate of 200 beats per minute.
3. Maculopapular rash.
4. Asymmetrical leg folds.
94. The nurse assessed four newborns admitted
to the neonatal nursery and called the
neonatalogist for a consult on the baby who
exhibited which of the following?
1. Excessive amounts of frothy saliva from the
mouth.
2. Blood-tinged discharge from the vaginal canal.
3. Secretion of a milk-like substance from both
breasts.
4. Heart rate that sped during inhalation and
slowed with exhalation.
95. The nurse is caring for a baby diagnosed with
developmental dysplasia of the hip
(DDH). Which of the following therapeutic
interventions should the nurse expect to
perform?
1. Place the baby’s legs in abduction.
2. External rotation of the baby’s hips.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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3. Assist with bilateral leg casting.
4. Monitor pedal pulses bilaterally.
96. A baby has been diagnosed with
developmental dysplasia of the hip. Which of the
following findings would the nurse expect to see?
1. Pronounced hip abduction.
2. Swelling at the site.
3. Asymmetrical leg folds.
4. Weak femoral pulses.
97. The nurse suspects that a newborn in the
nursery has a clubbed right foot because the foot
is plantar flexed and because the nurse also
notices which of the following?
1. Inability to move the foot into proper
alignment.
2. Notes positive Ortolani sign on the right.
3. Notes shortened right metatarsal arch.
4. Elicits positive Babinski reflex on the right.
98. The parents of a baby born with bilateral
talipes equinovarus ask the nurse what
medical care the baby will likely need. Which of
the following should the nurse tell the parents?
1. Need a series of leg casts until the correction
is accomplished.
2. Have a Harrington rod inserted when the child
is about three years old.
3. Have a Pavlik harness fitted before discharge
from the nursery.
4. Need to wear braces on both legs until the
child begins to walk.
99. The nurse caring for an infant with a
congenital cardiac defect is monitoring the child
for which of the following early signs of
congestive heart failure?
1. Hypertension, cyanosis, bradycardia.
2. Irritability, hypotension, palpitations.
3. Tachypnea, tachycardia, diaphoresis.
4. Angina, oliguria, dysrhythmias.
100. The nurse assessed four newborns in the
neonatal nursery. The nurse called the
neonatalogist for a cardiology consult on the
baby who exhibited which of the following
signs/symptoms?
1. Setting sun sign.
2. Anasarca.
3. Flaccid extremities.
4. Polydactyly.
101. A preterm infant has a patent ductus
arteriosus (PDA). Which of the following
explanations should the nurse give to the parents
about the condition?
1. Hole has developed between the left and right
ventricles.
2. Hypoxemia occurs as a result of the poor
systemic circulation.
3. Oxygenated blood is reentering the pulmonary
system.
4. Blood is shunting from the right side of the
heart to the left.
102. A nurse hears a heart murmur on a full-term
neonate in the well baby nursery. The baby’s
color is pink while at rest and while feeding. The
baby most likely has which of the following
cardiac defects?
1. Transposition of the great vessels.
2. Tetralogy of Fallot.
3. Pulmonic stenosis.
4. Patent ductus arteriosus.
103. Four babies are born with distinctive skin
markings. Identify which marking matches its
description:
1. Cafe au lait spot A. Raised, blood vessel-filled
tumor.
2. Hemangioma B. Flat, sharply demarcated red-
to-purple lesion.
3. Mongolian spots C. Multiple grayish blue
hyperpigmented skin areas.
4. Port wine stain D. Pale tan- to coffee-colored
marking.
104. A baby, admitted to the nursery, was
diagnosed with galactosemia from an
amniocentesis.
Which of the following actions must the nurse
take?
1. Feed the baby a specialty formula.
2. Monitor the baby for central cyanosis.
3. Do hemoccult testing on every stool.
4. Monitor baby for signs of abdominal pain.
105. On admission to the nursery, a baby’s head
and chest circumferences are 39 cm and
32 cm, respectively. Which of the following
actions should the nurse take next?
1. Assess the anterior fontanel.
2. Measure the abdominal girth.
3. Check the apical pulse rate.
4. Monitor the respiratory effort.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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106. A neonate is found to have choanal atresia
on admission to the nursery. Which of
the following physiological actions will be
hampered by this diagnosis?
1. Feeding.
2. Digestion.
3. Immune response.
4. Glomerular filtration.
107. A baby is born to a mother who was
diagnosed with oligohydramnios during her
pregnancy. The nurse notifies the neonatalogist
to order tests to assess the functioning of which
of the following systems?
1. Gastrointestinal.
2. Hepatic.
3. Endocrine.
4. Renal.
108. A baby is born with esophageal atresia and
tracheoesophageal fistula. Which of the
following complications of pregnancy would the
nurse expect to note in the mother’s history?
1. Preeclampsia.
2. Idiopathic thrombocytopenia.
3. Polyhydramnios.
4. Severe iron deficiency anemia.
109. A baby is born with a diaphragmatic hernia.
Which of the following signs/symptoms
would the nurse observe in the delivery room?
1. Projectile vomiting.
2. High-pitched crying.
3. Respiratory distress.
4. Fecal incontinence.
110. A woman, who has recently received
Demerol (meperidine) 100 mg IM for labor
pain, is about to deliver. Which of the following
medications is highest priority for the nurse to
prepare in case it must be administered to the
baby following the delivery?
1. Oxytocin (Pitocin).
2. Xylocaine (Lidocaine).
3. Naloxone (Narcan).
4. Butorphanol (Stadol).
111. A newborn in the well baby nursery is noted
to have a chignon. The nurse concludes that the
baby was born via which of the following
methods?
1. Cesarean section.
2. High forceps delivery.
3. Low forceps delivery.
4. Vacuum extraction.
112. A baby born by vacuum extraction has been
admitted to the well baby nursery. The nurse
should assess this baby for which of the
following?
1. Pedal abrasions.
2. Hypobilirubinemia.
3. Hyperglycemia.
4. Cephalhematoma.
113. A macrosomic baby in the nursery is
suspected of having a fractured clavicle from a
traumatic delivery. Which of the following
signs/symptoms would the nurse expect to see?
Select all that apply.
1. Pain with movement.
2. Hard lump at the fracture site.
3. Malpositioning of the arm.
4. Asymmetrical Moro reflex.
5. Marked localized ecchymosis.
114. Four babies in the well baby nursery were
born with congenital defects. Which of the
babies’ complications developed as a result of
the delivery method?
1. Club foot.
2. Brachial palsy.
3. Gastroschisis.
4. Hydrocele.
115. Monochorionic twins, whose gestation was
complicated by twin-to-twin transfusion, are
admitted to the neonatal intensive care unit.
Which of the following characteristic findings
would the nurse expect to see in the smaller
twin?
1. Pallor.
2. Jaundice.
3. Opisthotonus.
4. Hydrocephalus.
116. Monochorionic twins, whose gestation was
complicated by twin-to-twin transfusion, are
admitted to the neonatal intensive care unit.
Which of the following characteristic findings
would the nurse expect to see?
1. Recipient twin has petechial rash.
2. Recipient twin is 20% larger than the donor
twin.
3. Donor twin has 30% higher hematocrit than
recipient twin.
4. Donor twin is ruddy and plethoric.
MARGOT-DESEVO MATERNAL AND CHILD NURSING
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117. A nurse working with a 24-hour-old neonate

in the well baby nursery has made the following
nursing diagnosis: Risk for altered growth. Which
of the following assessments would warrant this
diagnosis?
1. The baby has lost 8% of weight since birth.
2. The baby has not urinated since birth.
3. The baby weighed 3000 grams at birth.
4. The baby exhibited signs of torticollis.

118. A baby exhibits weak rooting and sucking

reflexes. Which of the following nursing
diagnoses would be appropriate?
1. Risk for deficient fluid volume.
2. Activity intolerance.
3. Risk for aspiration.
4. Feeding self-care deficit.

119. A baby, born at 3199 grams, now weighs

2746 grams. The baby is being monitored for
dehydration because of the following percent
weight loss? __________%