NEWBORN ASSESSMENT
Normal newborn respiratory rate is:
30–60 breaths per minute
The fundus should be assessed for firmness and location to prevent which complication?
Postpartum hemorrhage
The newborn’s first breath is stimulated primarily by which factors?
Hypoxia, hypercapnia, and acidosis
A newborn born before 37 completed weeks of gestation is classified as:
Preterm
A laboring patient has strong, frequent, and painful contractions but minimal cervical dilation. The nurse recognizes this pattern as which type of dysfunctional labor?
Hypertonic Labor
This reflex causes extension and abduction of the arms followed by flexion
Moro reflex
Normal lochia progression after birth follows which order?
Rubra → Serosa → Alba
Which fetal shunt allows blood to bypass the lungs by flowing from the right atrium to the left atrium?
Foramen ovale
Which complication is most common in infants of diabetic mothers?
Hypoglycemia
A patient receiving oxytocin infusion develops contractions lasting 95 seconds and occurring every 1.5 minutes. What is the nurse’s priority action?
A. Increase the oxytocin rate
B. Stop the oxytocin infusion
C. Encourage ambulation
D. Administer pain medication
B. Stop the oxytocin infusion
Which finding is normal in the first 24 hours after birth?
A. Central cyanosis
B. Grunting
C. Acrocyanosis
D. Nasal flaring
Acrocyanosis
A postpartum client has a boggy uterus. What is the nurse’s FIRST action?
Perform fundal massage
Failure of closure of which fetal structure results in a patent ductus arteriosus (PDA)?
Ductus arteriosus
A preterm newborn with grunting, nasal flaring, and retractions is most likely experiencing:
Respiratory distress syndrome (RDS)
During delivery, the fetal head is delivered but retracts against the perineum (“turtle sign”). What is the nurse’s first action?
A. Apply fundal pressure
B. Call for help and prepare for McRoberts maneuver
C. Attempt vacuum extraction
D. Encourage maternal pushing
B. Call for help and prepare for McRoberts maneuver
Which newborn heart rate requires no nursing intervention?What is 88 beats/min while sleeping?
A. 88 beats/min while sleeping
B. 90 beats/min with apnea lasting 25 seconds
C. 170 beats/min while at rest
D. 110 beats/min with nasal flaring
88 beats/min while sleeping?
A postpartum client is 2 hours after delivery. Assessment findings include: Fundus deviated to the right, Moderate lochia rubra and Difficulty voiding.
What is the priority nursing intervention?
A. Administer oxytocin
B. Massage the fundus
C. Assist the client to void
D. Increase IV fluids
Assist the client to void
A newborn is 30 minutes old. Assessment findings include: RR 68 breaths/min, Nasal flaring, Intercostal retractions and Oxygen saturation 86% on room air.
Which physiologic problem is MOST likely occurring?
A. Delayed lung fluid absorption
B. Persistent fetal circulation
C. Cold stress
D. Hypoglycemia
Delayed lung fluid absorption
A newborn is 2 days old and has frequent spit‑ups after feedings.
Assessment findings include: Arching of the back, Irritability during feeds, Adequate weight gain andNormal vital signs
Which condition does the nurse suspect?
A. Pyloric stenosis
B. Gastroesophageal reflux disease (GERD)
C. Necrotizing enterocolitis
D. Intestinal obstruction
Gastroesophageal reflux disease (GERD)
The nurse identifies a prolapsed umbilical cord after rupture of membranes. What is the priority nursing intervention?
A. Place the patient in supine position
B. Apply fundal pressure
C. Relieve pressure on the cord manually
D. Administer oxytocin
C. Relieve pressure on the cord manually
A 2‑hour‑old newborn has not passed meconium. Which additional finding would be most concerning and require further evaluation?
A. Soft abdomen and active bowel sounds
B. Meconium‑stained amniotic fluid at birth
C. Abdominal distention with bilious vomiting
D. Poor feeding during the first feeding attempt
Abdominal distention with bilious vomiting
A client 12 hours postpartum reports sudden shortness of breath, chest pain, and anxiety.
Vital signs: HR 128, RR 32, SpO₂ 88%.
What complication does the nurse suspect FIRST?
A. Amniotic fluid embolism
B. Pulmonary embolism
C. Postpartum hemorrhage
D. Endometritis
Pulmonary embolism
A newborn is 1 hour old and has a temperature of 36.1°C (97°F). Assessment findings include: Jitteriness, Tachypnea, Decreased oxygen saturation and Blood glucose 42 mg/dL
Which physiologic process is MOST responsible for these findings?
A. Brown fat metabolism
B. Peripheral vasoconstriction
C. Increased pulmonary vascular resistance
D. Immature hepatic function
Brown fat metabolism
A newborn develops abdominal distention, feeding intolerance, and bloody stools on day 5 of life.
Which condition does the nurse suspect FIRST?
A. Pyloric stenosis
B. Hirschsprung disease
C. Necrotizing enterocolitis
D. Meconium ileus
Necrotizing enterocolitis
During labor, a patient suddenly reports severe abdominal pain followed by cessation of contractions. The fetal heart rate shows bradycardia. Which complication should the nurse suspect?
A. Placenta previa
B. Shoulder dystocia
C. Uterine rupture
D. Precipitous labor
C. Uterine rupture