Maternal Newborn Nursing Test Neonatal Assessment and Immediate Care 2 — Questions and Answers
Question 1: Which finding on newborn skin assessment is a normal variation that does NOT require intervention?
- Erythema toxicum (Correct answer)
- Port-wine stain over the face
- Pustular rash spreading rapidly
- Pallor with mottling persisting beyond 2 hours
Correct answer: Erythema toxicum
Erythema toxicum neonatorum is a benign, self-limiting rash of unknown cause appearing in 30–70% of full-term newborns and requires no treatment.
Question 2: What is the expected weight loss considered normal in a newborn during the first week of life?
- Up to 7–10% of birth weight (Correct answer)
- Up to 15% of birth weight
- Up to 3% of birth weight
- No weight loss is normal
Correct answer: Up to 7–10% of birth weight
Newborns typically lose up to 7–10% of birth weight in the first few days due to fluid shifts and meconium passage; birth weight is usually regained by 10–14 days.
Question 3: A nurse is assessing gestational age using the Ballard score. Which neuromuscular maturity finding is expected in a full-term newborn (38–40 weeks)?
- Arm recoil with brisk return to flexion (Correct answer)
- Arms remaining extended after release
- Scarf sign with elbow easily past midline
- Popliteal angle of 180 degrees
Correct answer: Arm recoil with brisk return to flexion
Full-term newborns demonstrate active flexion tone, so when the arm is extended and released, it quickly returns to the flexed position (brisk arm recoil).
Question 4: A newborn has a yellow discoloration of the skin and sclerae at 18 hours of life. How should the nurse interpret this finding?
- Pathological jaundice — notify the provider immediately (Correct answer)
- Normal physiological jaundice
- Sign of adequate breastfeeding
- Benign finding that resolves without treatment
Correct answer: Pathological jaundice — notify the provider immediately
Jaundice appearing within the first 24 hours of life is always pathological (e.g., hemolytic disease) and requires immediate evaluation and treatment to prevent kernicterus.
Question 5: Which newborn measurement indicates macrosomia and increases risk for birth injuries?
- Birth weight greater than 4,000 g (8 lb 13 oz) (Correct answer)
- Birth weight of 3,200 g (7 lb 1 oz)
- Head circumference of 34 cm
- Length of 50 cm
Correct answer: Birth weight greater than 4,000 g (8 lb 13 oz)
Macrosomia is defined as birth weight >4,000 g and is associated with increased risk of shoulder dystocia, fractures, and brachial plexus injury during delivery.
Question 6: Which newborn vital sign range is considered normal for a term newborn?
- Heart rate 110–160 bpm, respiratory rate 30–60 breaths/min, temperature 36.5–37.5°C (Correct answer)
- Heart rate 80–100 bpm, respiratory rate 20–30 breaths/min, temperature 37.5–38.5°C
- Heart rate 160–200 bpm, respiratory rate 60–80 breaths/min, temperature 36.0–36.5°C
- Heart rate 100–120 bpm, respiratory rate 40–50 breaths/min, temperature 37.0–38.0°C
Correct answer: Heart rate 110–160 bpm, respiratory rate 30–60 breaths/min, temperature 36.5–37.5°C
Normal newborn vital signs: HR 110–160 bpm, RR 30–60 breaths/min, and temperature 36.5–37.5°C axillary.
