Maternal Child NCLEX Practice Exam

Maternal Child NCLEX Practice Exam

 

A nurse is assessing a premature infant. What would initially alert the nurse that the infant is having respiratory distress?

 

1. Flaring nostrils
   B. Sporadic crying
   C. Ineffective cough
   D. Decreased pulse rate

 



Answer: A

Rationale:

In attempt to increase intake of oxygen, the respiratory rate increases with flaring of nostrils as a cardinal sign. It is significant to note that when a neonate is in respiratory distress, the rate of respirations will increase. Sporadic crying, ineffective cough, and decreased pulse rate may be indicative of infant distress but are not classic signs of respiratory distress.

 

 

A newborn infant is diagnosed with a patent ductus arteriosus (PDA). The nurse is aware that this is indicative of a defect that:

1. typically results in cyanosis
   B. may result in congestive heart failure
   C. also causes pulmonary stenosis
   D. normally does not close after birth

 

Answer: B

Rationale:
Defects that result in increased pulmonary blood flow such as patent ductus arteriosus (PDA) and other atrial and ventricular septal defects may cause congestive heart failure. PDA is a vascular connection that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. Defects that involve decreased pulmonary blood (such as tetralogy of Fallot) or obstruction to blood flow out of the heart (such as pulmonary stenosis) typically result in cyanosis. PDA does not cause pulmonary stenosis. A PDA normally closes soon after birth. If the ductus does remain open after birth, the direction of blood flow in the ductus is reversed by the higher pressure in the aorta, so there may not be any signs of the disorder.

 

 

Which of the following signs would alert a nurse to withdrawal in the infant of a mother addicted to heroin?

1. lethargy and a lack of appetite
   B. restlessness, irritability, and tremors
   C. no crying and hypoactive reflexes
   D. hyperactive reflexes and diaphoresis

 

Answer: B

Rationale:
Heroin does cross the placental barrier; therefore the infant is born addicted to heroin and will display signs of withdrawal such as restlessness, irritability, and tremors. The items listed in answer options A, C, and D are not associated with heroin withdrawal.

 

 

A neonate weights 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. The nurse should instruct the mother to:

1. increase the amount of formula to prevent further dehydration and weight loss
   B. continue feeding on demand because the noted weight loss is within normal limits
   C. give additional feedings because the weight loss indicates inadequate caloric intake
   D. switch to a different formula because the current one is inadequate to maintain weight

 

Answer: B

Rationale:
Neonates tend to lose 5% — 10% of their birth weight during the first few days after birth, mostly because of decreased, but acceptable, nutrition and extracellular fluid loss. Increasing formula volumes and feedings or changing the formula is not necessary in this situation.

 

 

A nurse explains to a new mother reasons for her newborn’s cranial molding and determines that the mother needs further instruction when she makes which of the following statements?

1. “The molding should disappear within a few days.”
   B. “The molding is caused by an overriding of the cranial bones.”
   C. “The brain may be damaged if the molding doesn’t resolve quickly.”
   D. “The amount of molding is related to the amount and length of pressure on the head.”

 

Answer: C

Rationale:
Brain damage is not directly associated with cranial molding. During vaginal delivery, the cranial bones tend to override when the head accommodates the size of the mother’s birth canal. The amount and length of pressure influence the degree of molding, which usually disappears in a few days without any other interventions or long-lasting effects.

 

 

An infant is born with Down syndrome should be assessed for which condition?

1. Clubfoot
   B. Cleft palate
   C. Cardiac defect
   D. Choanal atresia

 

Answer: C

Rationale:
Approximately 30% — 40% of infants born with Down Syndrome have congenital heart defects, typically endocardial cushion defects. Clubfoot, cleft palate, and choanal atresia are all congenital defects. Clubfoot is a deformity in which portions of the foot and ankle are twisted out of normal position. A cleft palate is incomplete closure of the palate resulting in failure of the primary palate to fuse. Choanal atresia is an obstruction of the posterior nares by tissue or bone.

 

 

A nursery nurse performs an initial newborn assessment and checks the umbilical cord to identify which normal finding?

1. One artery and two veins
   B. One artery and one vein
   C. Two arteries and two veins
   D. Two arteries and one vein

 

Answer: D

Rationale:
The umbilical cord consists of two arteries and one vein. In the umbilical cord, the vein provides oxygen and nutrients, and the arteries pump oxygen-depleted blood back to the placenta. The other answer options A, B, and C are incorrect.

 

 

A nurse is admitting a newborn to the nursery and learns that forceps were used during delivery. What condition should the nurse assess for in the infant?

 

1. Torticollis
   B. Facial paralysis
   C. Fractured clavicle
   D. Cephalohematoma

 

Answer: B

Rationale:
Facial paralysis can occur when the forceps blades compress cranial nerve VII (facial) anterior to the ears. It is usually mild and temporary, lasting only several days. Torticollis is a deformity of the neck not associated with newborns. A fracture clavicle may occur during birth as a result of dystocia, vacuum extraction, or large birth weight. Cephalohematoma is an extravasation of blood from ruptured vessels between the skull bone and its external covering known as the periosteum. The hematoma does not cross over a cranial suture line.

 

 

During assessment the nurse understands that the Moro reflex should disappear by what age in an infant?

1. 4 weeks
   B. 6 weeks
   C. 2 months
   D. 4 months

 

Answer: D

Rationale:
The Moro reflex is exhibited by the infant when suddenly jarred or a change in equilibrium occurs. This reflex usually disappears by 4 months. If the Moro reflex is still present after the age of 6 months, neurological maturity may be delayed or another neurological disorder may be present. The other answer options A, B, and C are incorrect.

 

 

Which disorder seen in newborns consists of right ventricular hypertrophy, stenosis of the pulmonary artery, ventricular septal defect, and overriding of the aorta?

1. Tetralogy of Fallot
   B. Atrial septal defect
   C. Coarctation of the aorta
   D. Ventricular septal defect

 

Answer: A

Rationale:
Tetralogy of Fallot is a major heart defect resulting in cyanosis at birth. The classic cyanotic symptoms result from these four congenital defects: right ventricular hypertrophy, stenosis of the pulmonary artery, ventricular septal defect, and overriding of the aorta. Atrial septal defect is an abnormal opening between the right and the left atria with a left-to-right shunting of blood. Coarctation of the aorta is a localized narrowing of the aorta causing increased pressure proximal to the defect (head and neck). There is decreased pressure distal to the defect, which is the body and lower extremities. Ventricular septal defect is an abnormal opening between the right and left ventricles. High pressure in the left ventricle causes blood to shunt from the left to the right ventricle.

 

 

A nurse assesses a newborn with asymmetric gluteal and thigh skinfolds, a left leg shorter than the right, and a clicking sound of the right hip. What condition does this information indicate that the newborn most likely has?

1. fractured pelvis
   B. fractured right leg
   C. congenital hip dysplasia
   D. underdeveloped femur

 

Answer: C

Rationale:
With congenital hip dysplasia, the hip is not correctly situated or rotating in the socket. The affected leg will appear longer, and a clicking sound can be heard when the leg is moved. The symptoms listed do not describe a fracture pelvis or leg; however a newborn could sustain a fracture as a result of a traumatic birth. An underdeveloped femur is not a newborn condition.

 

 

The parents of a newborn question the nurse regarding the blue-black discoloration in the sacral area of their infant. The nurse explains these are known as “Mongolian spots” and:

1. indicate a birth defect
   B. usually fade over time
   C. result from trauma during delivery
   D. are indicative of an internal problem

 

Answer: B

Rationale: Monogolian spots are discolorations that appear in the dark-skinned infants and will fade in appearance. They are often mistaken for child abuse. Mongolian spots are not considered a birth defect, do not result from a traumatic delivery, and do not indicate an internal problem.

 

 

A nurse is assessing a newborn and and recognizes which of the following as a sign of postmaturity?

A. presence of vernix caseosa
B. long, brittle fingernails
C. fine lanugo hair on the face, shoulders, and back
D. creases in the soles of the feet

 

Answer: B

Rationale: The fingernails begin to form around 12 weeks’ gestation. By 39–40 weeks, the nails have covered the nailbeds. After 40 weeks, the nails begin to extend and have a long appearance. Presence of vernix caseosa (a cheeselike whitish substance that serves as a protective covering), a fine lanugo hair, and creases in the soles of the feet are all signs of the normal term newborn.

 

 

 

Which finding would be manifested in an infant with a myelomeningocele?

1. clubbed feet and paralysis in the legs and arms
   B. Obstruction of bowel and impaired bladder function
   C. Spastic movement of upper and lower extremities
   D. Impaired bowel and bladder function and paralysis of the legs

 

Answer: D

Rationale:
A myelomeningocele is an external sac containing meninges, spinal fluid, and nerves that protrude through a defect in the vertebral column. The nerves of the cauda equina are involved with a myelomeningocele, which results in lower extremity paralysis. Innervation to the anal sphincter and the bladder is decreased, causing incontinence. In myelomeningocele, bowel function may be affected, but it is not associated with obstruction. The upper extremities are not affected by this disorder. In addition, clubfoot is not associated with this disorder.

 

 

A new mother expresses concern over strabismus in her infant. What would the nurse explain to the mother regarding this condition?

1. it is a normal finding in newborns
   B. this may be a permanent defect
   C. it will require corrective surgery
   D. it will result in impaired vision

 

Answer: A

Rationale: Muscle control of the eyes in the newborn is undeveloped, resulting in temporary strabismus (pseudostrbismus), or a cross-eyed appearance. This is considered normal in the newborn and usually corrects by the 3rd to 4th month. Strabismus is not a permanent defect, does not require corrective surgery, and does not cause impaired vision.

 

 

An infant is born to an alcoholic mother. Which assessment finding would the nurse anticipate that would contribute to the finding of fetal alcohol syndrome?

1. lethargy
   B. irritability
   C. blindness
   D. unresponsiveness

 

Answer: B

Rationale:
Fetal alcohol syndrome (FAS) is a congenital abnormality resulting from excessive maternal alcohol intake during pregnancy. It is characterized by typical craniofacial and limb defects, cardiovascular defects, intrauterine growth restriction and developmental delays. Newborns with FAS are very irritable and difficult to calm and comfort. Seizure activity may also occur. The other answer options A, C, and D are not associated with fetal alcohol syndrome.

 

 

 

Which observation in a 24-hour-old newbon should be reported to the physician immediately?

1. jaundice
   B. positive Babinski reflex
   C. heart rate of 130/bpm
   D. High-pitched crying and arching of the back

 

Answer: D

Rationale:
A high-pitched cry and arching of the back (opisthotonos) are cardinal signs of a neurological abnormality. Physiological jaundice occurs in 50% of term infants after the first 24 hours. A serum bilirubin level should be drawn to determine if treatment with phototherapy is necessary. A positive babinski reflex is a normal response in newborns. It is characterized by all the toes hyperextending with dorsiflexion of the big toe. A heart rate of 130 bpm falls within the range.

 

 



Which statement is accurate regarding the reason premature infants develop neonatal respiratory distress syndrome?

1. the alveoli lack surfactant
   B. the lungs lack ability to absorb oxygen
   C. the lungs cannot remove CO2 from the blood
   D. immature lungs cannots exchange CO2 and O2 effecively.

 

Answer: A

Rationale:
Surfactant is a sticky lubricant on the surface of the alveoli that essentially maintains patency of the alveoli in newborns. Premature infants lack surfactant, which causes the alveoli to collapse and requires increasing effort to reexpand the alveoli. Immature lungs are able to exchange O2 and CO2 but without surfactant, the alveoli collapse and cannot reexpland without ventilatory assistance.

 

 

A neonate experiences meconium aspiration at the time of delivery and develops respiratory distress syndrome (RDS). Which nursing diagnosis would be most appropriate for an infant diagnosed with this disorder?

1. Risk for Infection
   B. Risk for Aspiration
   C. Impaired Gas Exchange
   D. Dysfunctional Ventilatory Weaning Response

 

Answer: C

Rationale:
Impaired gas exchange is the most appropriate nursing diagnosis because meconium aspiration interferes with the exchange of O2 and CO2. Risk for infection is present but is not as high a priority as impaired gas exchange. Risk for aspiration has already occurred. Dysfunctional ventilatory weaning response may be appropriate i the newborn demonstrates difficulty with the ventilatory weaning process

 

 

When performing a physical assessment of an unusually small newborn infant, the nurse can determine that the infant is small for gestation age (SGA) rather than premature by which of the following characteristics?

1. vigorous cry
   B. increased lanugo
   C. weaking sucking reflex
   D. diminished ear recoil

 

Answer: A

Rationale:
In contrast to a premature infant, an SGA baby has a vigorous cry and appears alert. Increased lanugo, weak sucking reflex, and diminished ear recoil are all present in the premature newborn that is physiologically underdeveloped.

 

 

Compared with an infant born vaginally an infant born via cesarean section is more likely to manifest which condition?

1. crib death syndrome
   B. neurological deficits
   C. failure to thrive syndrome
   D. Respiratory distress syndrome

 

Answer: D

Rationale:
Research has shown that respiratory distress syndrome (RDS) is more common in infants born by cesarean birth without labor than in those born vaginally. The other answer options A, B, and C are not associated with cesarean births

 

 

A nurse should observe for which particular complication in infants who are born breech?

 

1. cyanosis
   B. fracture hip
   C. hydrocephalus
   D. brachial palsy

 

Answer: D

Rationale:
Brachial palsy results from the stretching of nerve fibers in the neck, shoulder, and arm when the shoulder is being pulled away from the neck during breech delivery. Cyanosis, fractured hip, and hydrocephalus are not directly associated with breech deliveries.

 

 

A nurse caring for the newborn of a diabetic mother would give highest priority to assessing for which conditions?

1. Hypocapnia
   B. Hyponatremia
   C. Hyperglycemia
   D. Hyperinsulinism

 

Answer: D

Rationale:
The infant of a diabetic mother has become accustomed to high levels of glucose in the maternal circulation and therefore makes insulin accordingly. After deliver, the infant’s glucose source is withdrawn and the infant is then prone to hyperinsulinism thus manifesting as hypoglycemia. Blood glucose levels should be closely monitored and early feedings are recommended. Hypocapnia and hyponatremia are not associated with newborns of diabetic mothers. Hyperglycemia is a risk, especially if the newborn is receiving parenteral glucose to treat hypoglycemia.

 

 

What is the best technique for assessing jaundice in a newborn?

1. testing capillary refill
   B. blanching skin on the forehead
   C. assessing the skin on the palm of the hands
   D. assisng the skin on the bottom of the feet

 

Answer: B

Rationale:
The best tecnique to assess jaundice in the newborn is to apply pressure to a bony area (e.g., forehead and observe the color of the skin before blood returns. Blanched skin is yellow if the infant is jaundiced. The answers in option A, C, and D may determine jaundice; however, they are not as good as applying pressure (blanching the skin) over a bony prominence.

 

 

 

A 48-hour-old infant who is being breast-fed is diagnosed with physiological jaundice and is prescribed phototherapy treatment. Which measure taken by the nurse would enhance bilirubin excretion?

1. keeping the infant snugly wrapped
   B. placing the infant in a quite, darkened area
   C. providing the infant with additional oral fluids every 3 hours
   D. encouraging the mother to temporarily suspend breast-feeding her infant

 

 

Answer: C

Rationale: Phototherapy can cause insensible water loss, thus it is important to assess for dehydration and provide fluids. Proper fluid balance will promote bilirubin excretion. Keeping the infant wrapped in the dark and suspending breast-feedings will not enhance the excretion of bilirubin.

 

 

 

The nurse is assisting a new mother with breast-feeding. The nurse notes that the infant is nursing well when which behaviors are observed? (SELECT ALL THAT APPLY)

1. The infants makes a clicking noise
   B. Swallowing is audible
   C. The mother reports a pulling sensation on her nipple
   D. The infants sucks with dimpled cheeks
   E. The tip of the infant’s nose and chin touch the breast

 

Answer: B, C, E

Rationale:
When the infant has latched on correctly and is sucking appropriately, swallowing is audible, the mother will report a pulling sensation on the nipple, and the tip of the baby’s nose, cheeks, and chin are all touching the breast. If the infant makes a clicking or smacking sound and sucks with dimpled cheeks the infant may be having trouble keeping the tongue out over the lower gum ridge. The jaw may need to be stabilized. If this is not helpful, take the baby off the breast and re-attempt latching.

 

 

A 12-hour-old infant has hemolytic disease of the newborn. What is the most common complication of this disorder?

1. respiratory failure
   B. Liver failure
   C. Jaundice
   D. Blindness

 

Answer: C

Rationale:
Hemolytic disease of the newborn is caused by incompatibility of maternal and fetal blood types. When the fetal Rh-positive antigens or anti-A or anti-B antigens cross into the maternal circulation, the mother produces anti-Rh, anti-A, or anti-B antibodies. When the maternal anti-Rh, anti-A, or anti-B antibodies cross into the fetal circulation, these antibodies attack the fetal RBCs. The RBC destruction results in release of excess bilirubin, which the fetal or newborn’s immature liver cannot metabolize; the result is newborn jaundice. Respiratory failure, liver failure, and blindness are not common complications of hemolytic disease of the newborn when appropriate treatment is provided.

 

 

When instructing a new mother about the newborn’s need for sensory stimulation, the nurse should explain that the most highly developed sense is the neonate is:

 

1. taste
   B. smell
   C. touch
   D. hearing

 

Answer: C

Rationale:
It is believed that the sense of touch is the most highly developed sense at birth. For this reason, neonates respond well to touch. The senses of taste, smell, and hearing are functional in the newborn; however, not the extent of touch.

 

 

At the time of delivery, the nurse assigns a newborn an Apgar score at 1 and 5 minutes. THe purpose of this scoring system is to obtain:

1. the infant’s initial vital signs
   B. a survey of gross functioning
   C. an initial assessment of vital functions
   D. an assessment of mental retardation

 

Answer: C

Rationale:
The Apgar score is an initial assessment of vital functions. These include heart rate, respiratory effort, muscle tone, reflex response, and color. The other answer options A, B, and D are not primary purposes of the Apgar score. However, vital signs and gross function are taken into consideration.

 

 

 

A new father observes his newborn infant receiving a vitamin K injection and asks the nurse, “Why did my son need a shot?” The nurse’s response should be based on the understanding that infants:

1. need vitamin K to stimulate liver maturation
   B. cannot get enough vitamin K from their feeeings
   C. have a sterile intestinal tract and cannot synthesize vitamin K
   D. are often born with hypokalemia, which responds to vitamin K therapy

 

Answer: C

Rationale:
There seems to be some controversy as to whether vitamin K should be given, but often it is because the newborn infant cannot synthesize vitamin K due to the lack of intestinal bacteria at birth. The other answer options A, B, and D are incorrect rationales for administration of vitamin K in newborns.