Maternal Newborn Nursing Test Neonatal Assessment and Immediate Care

Question 1

A nurse assesses a newborn at 1 minute and assigns an Apgar score. The infant has a heart rate of 98 bpm, weak cry, some flexion of extremities, grimace to stimulation, and a pink body with blue extremities. What is the Apgar score?

Accepted Answer

6

Answer

HR <100 = 1, weak cry (slow, irregular respirations) = 1, some flexion = 1, grimace = 1, pink body/blue extremities (acrocyanosis) = 1, totaling 6.

Question 2

Which assessment finding in a newborn at 24 hours of life requires immediate provider notification?

Accepted Answer

Respiratory rate of 68 breaths per minute with grunting

Answer

A respiratory rate >60 breaths per minute with grunting indicates respiratory distress and requires immediate provider notification to evaluate for infection or respiratory pathology.

Question 3

A nurse notes a newborn's axillary temperature is 36.1°C (97°F) at 2 hours of life. What is the priority intervention?

Accepted Answer

Place the newborn under a radiant warmer and reassess in 30 minutes

Answer

Neonatal hypothermia (temperature <36.5°C) is managed initially by placing the infant under a radiant warmer to restore normothermia and prevent metabolic complications.

Question 4

When assessing the anterior fontanel of a newborn, which finding is abnormal?

Accepted Answer

Bulging and tense fontanel in a quiet, non-crying infant

Answer

A bulging, tense fontanel in a quiet infant suggests increased intracranial pressure due to conditions such as hydrocephalus, meningitis, or intracranial hemorrhage.

Question 5

Which reflex is assessed by stroking the lateral aspect of the sole of the newborn's foot from heel to toe, resulting in dorsiflexion of the big toe and fanning of other toes?

Accepted Answer

Babinski reflex

Answer

The Babinski reflex (plantar reflex) is elicited by stroking the lateral sole; dorsiflexion of the great toe and toe fanning is a normal finding in newborns due to immature corticospinal tracts.

Maternal Newborn Nursing Test Practice Test

Maternal Newborn Nursing Test Practice Test

Maternal Newborn Nursing Test Neonatal Assessment and Immediate Care