Maternal Newborn Nursing Test Newborn Assessment and Care 1 — Questions and Answers
Question 1: At 1 minute of life, a newborn has a heart rate of 98 bpm, slow irregular respirations, some flexion of extremities, a grimace in response to stimulation, and a pink body with blue extremities. What is the Apgar score?
Correct answer: 6
Heart rate <100=1, slow respirations=1, some flexion=1, grimace=1, acrocyanosis=1 — totaling an Apgar score of 6.
Question 2: A term newborn is delivered and placed on the mother's abdomen. The nurse's initial assessment reveals the baby is breathing but has central cyanosis. What is the priority action?
- Administer blow-by oxygen and reassess within 60 seconds (Correct answer)
- Begin chest compressions immediately
- Stimulate the infant vigorously by rubbing the back
- Transfer to the NICU without delay
Correct answer: Administer blow-by oxygen and reassess within 60 seconds
Central cyanosis in a breathing newborn warrants supplemental oxygen delivery (blow-by) and immediate reassessment to determine if further resuscitation is needed.
Question 3: The nurse is performing a newborn assessment at 2 hours of life. Which finding requires immediate notification of the healthcare provider?
- Respiratory rate of 52 breaths per minute
- Nasal flaring and expiratory grunting (Correct answer)
- Milia on the nose and cheeks
- Lanugo on the shoulders and back
Correct answer: Nasal flaring and expiratory grunting
Nasal flaring and expiratory grunting are signs of respiratory distress in the newborn and require prompt medical evaluation.
Question 4: Which normal newborn reflex disappears by approximately 3–4 months of age and indicates intact neurological function at birth?
- Babinski reflex
- Moro (startle) reflex (Correct answer)
- Plantar grasp reflex
- Rooting reflex
Correct answer: Moro (startle) reflex
The Moro reflex (symmetric arm extension/abduction followed by adduction) is present at birth and normally disappears by 3–4 months as cortical control matures.
Question 5: A newborn's blood glucose is 38 mg/dL at 2 hours of life. The infant is alert and breastfeeding well. What is the appropriate nursing intervention?
- Initiate IV dextrose immediately
- Encourage breastfeeding and recheck glucose in 30–60 minutes (Correct answer)
- Transfer to NICU for monitoring
- Administer glucagon intramuscularly
Correct answer: Encourage breastfeeding and recheck glucose in 30–60 minutes
A mildly low glucose of 38 mg/dL in an asymptomatic, feeding newborn is managed with continued breastfeeding and glucose recheck per protocol before escalating treatment.
Question 6: When performing a gestational age assessment using the Ballard scale, which physical characteristic would indicate a post-term newborn?
- Abundant lanugo covering the body
- Smooth, peeling skin with little vernix caseosa (Correct answer)
- Soft, flat ear cartilage
- Fused eyelids
Correct answer: Smooth, peeling skin with little vernix caseosa
Post-term infants typically have dry, peeling, cracked skin with minimal vernix because vernix production decreases as the pregnancy extends beyond 40 weeks.
