TIA Maternal-Newborn Nursing 1 — Questions and Answers
Question 1: A nurse is assessing a newborn at 1 minute after birth. The infant has a heart rate of 90 bpm, weak cry, some flexion, grimace to stimulation, and blue hands and feet. What is the APGAR score?
- 5
- 6 (Correct answer)
- 7
- 8
Correct answer: 6
HR <100 (1) + weak cry (1) + some flexion (1) + grimace (1) + acrocyanosis (1) = APGAR score of 6.
Question 2: A patient is 36 weeks pregnant and has a blood pressure of 158/104 mmHg with 3+ proteinuria. The nurse should prepare for management of:
- Gestational hypertension
- Chronic hypertension
- Severe preeclampsia (Correct answer)
- HELLP syndrome
Correct answer: Severe preeclampsia
BP ≥160/110 with significant proteinuria at or after 20 weeks gestation meets criteria for severe preeclampsia.
Question 3: Which fetal heart rate pattern requires the nurse to immediately reposition the mother and notify the provider?
- Accelerations with fetal movement
- Early decelerations during pushing
- Late decelerations in a non-reactive NST (Correct answer)
- Baseline FHR of 140 bpm
Correct answer: Late decelerations in a non-reactive NST
Late decelerations indicate uteroplacental insufficiency and fetal hypoxia, requiring immediate intervention.
Question 4: A nurse is caring for a patient in active labor receiving magnesium sulfate. Which finding signals toxicity?
- Respiratory rate of 14 breaths/min
- Urinary output of 35 mL/hr
- Loss of deep tendon reflexes (Correct answer)
- Mild flushing and warmth
Correct answer: Loss of deep tendon reflexes
Loss of deep tendon reflexes (DTR) is an early sign of magnesium sulfate toxicity and must prompt immediate action.
Question 5: A newborn has not passed meconium within 48 hours of birth. The nurse should assess for:
- Dehydration
- Hyperbilirubinemia
- Hirschsprung's disease or imperforate anus (Correct answer)
- Neonatal abstinence syndrome
Correct answer: Hirschsprung's disease or imperforate anus
Failure to pass meconium within 24–48 hours suggests intestinal obstruction such as Hirschsprung's disease or imperforate anus.
Question 6: Which nursing action is the priority when a prolapsed umbilical cord is identified?
- Prepare the patient for an emergency cesarean section
- Apply warm saline-soaked gauze to the cord
- Place the patient in Trendelenburg or knee-chest position (Correct answer)
- Notify the charge nurse and document findings
Correct answer: Place the patient in Trendelenburg or knee-chest position
The priority is relieving cord compression by positioning (Trendelenburg or knee-chest) while calling for emergency assistance.
TIA Maternal-Newborn Nursing 1
A nurse is assessing a newborn at 1 minute after birth.
The infant has a heart rate of 90 bpm, weak cry, some flexion, grimace to stimulation, and blue hands and feet.
What is the APGAR score?