CPNRE Maternal and Newborn Care 5 — Questions and Answers
Question 1: A nurse is assessing a newborn and notes the Moro reflex is absent on the right side only. This finding most likely indicates:
- Normal asymmetrical response in newborns
- Possible brachial plexus injury (Erb's palsy) (Correct answer)
- Hypocalcemia requiring immediate treatment
- Central nervous system depression from maternal opioids
Correct answer: Possible brachial plexus injury (Erb's palsy)
A unilateral absent Moro reflex suggests brachial plexus injury (Erb's palsy), often associated with shoulder dystocia or difficult delivery.
Question 2: A postpartum client reports saturating more than one perineal pad per hour for two consecutive hours. The nurse's priority action is to:
- Document the finding and reassess in 1 hour
- Encourage the client to ambulate to reduce lochia flow
- Assess uterine fundal tone and notify the physician (Correct answer)
- Administer a scheduled dose of ibuprofen for comfort
Correct answer: Assess uterine fundal tone and notify the physician
Saturating more than one pad per hour indicates postpartum hemorrhage; the nurse must immediately assess uterine tone and notify the physician.
Question 3: When performing a newborn assessment using the APGAR score at 5 minutes, which score indicates the newborn requires continued close monitoring but no immediate resuscitation?
- Score of 0–3
- Score of 4–6 (Correct answer)
- Score of 7–10
- Score of 11–15
Correct answer: Score of 4–6
An APGAR score of 4–6 at 5 minutes indicates the newborn needs continued close monitoring and possible stimulation but typically does not require immediate resuscitation.
Question 4: A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. Which assessment finding requires the nurse to stop the infusion immediately?
- Blood pressure of 148/96 mmHg
- Urinary output of 35 mL/hour
- Respiratory rate of 10 breaths per minute (Correct answer)
- Serum magnesium level of 6 mEq/L
Correct answer: Respiratory rate of 10 breaths per minute
A respiratory rate of 10 breaths per minute indicates magnesium toxicity and is a critical finding requiring immediate cessation of the infusion.
Question 5: A nurse assesses a client who is 12 hours postpartum and notes the uterine fundus is firm, displaced to the right, and located above the umbilicus. The most appropriate intervention is:
- Administer oxytocin as ordered
- Assist the client to void or catheterize if unable to void (Correct answer)
- Perform uterine massage until the fundus descends
- Apply a warm compress to the abdomen to relax the uterus
Correct answer: Assist the client to void or catheterize if unable to void
A displaced, elevated uterine fundus indicates bladder distension; assisting the client to void will allow the uterus to return to the midline.
Question 6: A client who is 28 weeks pregnant arrives reporting decreased fetal movement. The nurse prepares for which initial assessment?
- Biophysical profile (BPP)
- Non-stress test (NST) (Correct answer)
- Contraction stress test (CST)
- Amniocentesis
Correct answer: Non-stress test (NST)
A non-stress test (NST) is the initial, non-invasive assessment used to evaluate fetal well-being when decreased fetal movement is reported.
Question 7: A nurse is teaching a client about warning signs to report after discharge at 48 hours postpartum. Which symptom warrants immediate medical attention?
- Mild breast tenderness when breastfeeding
- Lochia rubra changing to lochia serosa
- Calf pain, redness, and swelling in one leg (Correct answer)
- Mild perineal discomfort relieved by ice packs
Correct answer: Calf pain, redness, and swelling in one leg
Unilateral calf pain, redness, and swelling are signs of deep vein thrombosis (DVT), a serious postpartum complication requiring immediate evaluation.
CPNRE Maternal and Newborn Care 5
A nurse is assessing a newborn and notes the Moro reflex is absent on the right side only.
This finding most likely indicates: