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NSG 2500 Maternal-Infant Nursing Care Clinical Evaluation
Questions And Correct Answers (Verified Answers) Plus
Rationales 2025 Q&A | Instant Download PDF
This test covers clinical decision-making, maternal and newborn assessment, interventions, and patient education.
- A nurse assesses a postpartum patient who complains of dizziness and increased vaginal bleeding. What is the nurse’s first action? A. Check the patient’s temperature B. Assess fundal firmness C. Apply a perineal ice pack D. Notify the healthcare provider Fundal assessment is critical because uterine atony is the most common cause of postpartum hemorrhage.
- Which action best supports maternal-infant bonding in the immediate postpartum period? A. Giving the newborn their first bath B. Taking the baby to the nursery to rest C. Placing the newborn skin-to-skin on the mother’s chest D. Performing a full newborn assessment immediately
Skin-to-skin contact promotes attachment, regulates the newborn’s temperature, and stabilizes vital signs.
- A newborn is noted to have acrocyanosis at birth. What is the appropriate nursing action? A. Administer supplemental oxygen B. Notify the provider immediately C. Document the finding as normal D. Initiate resuscitation Acrocyanosis is a normal finding in newborns for the first 24-48 hours.
- A mother asks when she can start breastfeeding after a cesarean section. What is the best response? A. “Wait until you are discharged.” B. “Once your milk comes in.” C. “As soon as you are alert and stable.” D. “After 24 hours.” Breastfeeding should begin as early as possible to promote bonding and stimulate milk production.
- Which is the best indicator of effective breastfeeding? A. Baby sleeps through the night B. 6 – 8 wet diapers per day
A. Prevents infection B. Increases need for phototherapy C. Improves iron stores D. Reduces bilirubin Delayed clamping increases the newborn’s blood volume and improves iron levels.
- A mother reports her breast feels warm, red, and painful. What should the nurse do first? A. Call the physician B. Encourage weaning C. Apply an ice pack D. Assess for mastitis and promote breastfeeding Mastitis requires assessment and continuing to breastfeed if tolerated. 10.Which newborn reflex is elicited by stroking the cheek? A. Moro B. Babinski C. Grasp D. Rooting The rooting reflex helps the baby locate the nipple for feeding.
11.A postpartum woman refuses to hold her baby. What is the nurse’s best initial response? A. Ask how she is feeling emotionally B. Notify the provider C. Force her to hold the infant D. Leave the room immediately Assessment of the mother's emotional state is necessary before assuming pathology. 12.Which sign indicates that the placenta has separated during delivery? A. Placenta is seen at the introitus B. Lengthening of the umbilical cord C. Sudden gush of blood D. Contractions stop Cord lengthening and a gush of blood are signs of placental separation. 13.Which assessment finding should be reported immediately in a newborn? A. Irregular breathing pattern B. Grunting with nasal flaring C. Acrocyanosis D. Transient strabismus Grunting and nasal flaring suggest respiratory distress.
17.What instruction is most important when teaching postpartum perineal care? A. Use cool compresses B. Wipe front to back C. Douche daily D. Avoid washing Wiping front to back prevents introduction of bacteria to the vaginal area. 18.Which assessment is normal in a newborn? A. Irregular respirations B. Chest retractions C. Grunting D. Cyanosis of lips Irregular breathing is common; retractions and cyanosis are abnormal. 19.What is the nurse’s best action after noting a postpartum fundus displaced to the right? A. Document and reassess later B. Ask the mother to empty her bladder C. Massage the fundus D. Administer oxytocin A full bladder can displace the uterus and hinder involution.
20.Which behavior is consistent with postpartum bonding? A. Lack of eye contact with infant B. Frequent crying without cause C. Talking to and touching the baby D. Avoiding infant care Interaction and affection toward the newborn are signs of bonding. 21.A newborn's blood glucose is 38 mg/dL. What should the nurse do first? A. Administer IV dextrose B. Initiate breastfeeding or formula feeding C. Notify the physician immediately D. Place the baby under a radiant warmer Feeding is the first-line intervention for mild hypoglycemia in a stable newborn. 22.Which action is appropriate when preparing a newborn for circumcision? A. NPO for 8 hours B. Obtain parental consent C. Administer antibiotics D. Place the newborn prone Consent is legally and ethically required prior to the procedure.
26.A newborn is 2 hours old and has not voided yet. What is the appropriate nursing action? A. Call the physician B. Insert a catheter C. Document and continue to monitor D. Apply a diaper warmer Newborns should void within the first 24 hours. Monitoring is appropriate in the early hours. 27.A nurse teaching a postpartum woman about signs of complications should include which instruction? A. “Call if your breasts leak milk.” B. “Call if you have a fever over 100.4°F (38°C).” C. “Expect bleeding to increase daily.” D. “Do not worry about severe headaches.” Fever is a warning sign of postpartum infection. 28.A postpartum client reports chills and shaking but has a normal temperature. What does the nurse suspect? A. Sepsis B. Normal postpartum reaction
C. Hemorrhage D. Dehydration Chills shortly after birth are a common and harmless postpartum occurrence. 29.The nurse is teaching about newborn jaundice. What should the parent report? A. Yellowing of the sclera B. Lethargy and poor feeding C. Sneezing D. Acrocyanosis Lethargy and feeding difficulty are signs of rising bilirubin and risk for kernicterus. 30.A patient is 6 hours postpartum. Where should the nurse expect to find the fundus? A. 2 cm below the umbilicus B. At the level of the umbilicus C. 2 cm above the umbilicus D. Midway between symphysis and umbilicus Immediately after birth, the fundus is at or slightly below the umbilicus. 31.A nurse preparing a postpartum patient for discharge should emphasize which teaching?
34.What is the appropriate method to assess fetal heart tones in labor? A. Use a Doppler on the mother’s back B. Place the Doppler over the fetal back C. Use a stethoscope near the pubis D. Measure uterine contractions The fetal heart is best heard through the fetal back during labor. 35.Which newborn finding requires further evaluation? A. Mongolian spots B. Bulging fontanelle at rest C. Milia D. Lanugo A bulging fontanelle suggests increased intracranial pressure. 36.A nurse explains the importance of colostrum. Which benefit should be included? A. Decreases crying B. Provides antibodies C. Increases appetite D. Reduces birthmarks Colostrum is rich in immunoglobulins and provides passive immunity.
37.What is the most appropriate nursing action when a newborn's APGAR score is 4 at 1 minute? A. Swaddle and monitor B. Initiate resuscitative measures C. Provide skin-to-skin D. Perform full head-to-toe assessment An APGAR score of 4 indicates moderate depression requiring resuscitation. 38.What is the purpose of erythromycin eye ointment for the newborn? A. To prevent blindness from jaundice B. To prevent ophthalmia neonatorum C. To enhance vision development D. To lubricate the eyes It prevents gonococcal and chlamydial infections that can cause blindness. 39.The nurse notes a newborn with central cyanosis. What is the first action? A. Apply a warm blanket B. Assess oxygen saturation C. Perform heel stick D. Initiate feeding Central cyanosis is concerning and requires prompt oxygen assessment.
43.What should be included when teaching about newborn bathing? A. Bathe daily B. Use cold water C. Sponge bathe until cord falls off D. Apply powder after bathing To prevent infection, sponge bathing is preferred until the umbilical cord detaches. 44.A postpartum woman complains of severe leg pain and swelling. What does the nurse suspect? A. Normal postpartum soreness B. Deep vein thrombosis C. Urinary retention D. Round ligament pain Leg pain and swelling require immediate evaluation for thrombosis. 45.A nurse caring for a newborn with circumcision notes bleeding. What is the best action? A. Call the surgeon B. Apply gentle pressure with gauze C. Remove the dressing D. Give pain medication
Gentle pressure typically stops minor bleeding after circumcision. 46.Which maternal condition requires newborn blood glucose monitoring? A. Hypothyroidism B. Gestational diabetes C. Iron deficiency D. Anemia Babies of diabetic mothers are at risk for hypoglycemia. 47.Which finding indicates the newborn is transitioning well to extrauterine life? A. Pink skin with acrocyanosis B. Respiratory rate of 78 C. Nasal flaring D. Heart rate of 90 Acrocyanosis is normal, and a pink trunk shows adequate oxygenation. 48.What is a sign of effective uterine involution? A. Fundus soft and midline B. Lochia rubra increasing C. Fundus firm and decreasing in height daily D. Temperature elevation
Positioning the newborn side-lying or slightly extended aids airway clearance and breathing. 52.What is the priority nursing intervention immediately after the rupture of membranes? A. Check maternal temperature B. Assess fetal heart rate C. Document fluid color D. Prepare for delivery The risk of cord prolapse increases after membrane rupture. Assess FHR first. 53.A mother asks how long she should breastfeed on each side. What is the best response? A. 2 minutes B. 5 minutes C. Until the baby stops sucking or releases D. 20 minutes Feeding until the baby stops ensures full transfer of foremilk and hindmilk. 54.What assessment indicates a need for phototherapy in a newborn? A. Bilirubin of 8 at 24 hours B. Bilirubin of 14 at 24 hours
C. Slight yellowing of skin at 72 hours D. Yellowing of hands and feet A bilirubin of ≥14 at 24 hours indicates need for treatment. 55.What teaching is most appropriate for postpartum perineal discomfort? A. Use hot compresses B. Apply talcum powder C. Use a sitz bath and ice packs D. Perform vigorous perineal massage Cold first 24 hours then warm sitz baths reduce swelling and pain. 56.When assessing a postpartum patient for bonding, what is a concerning behavior? A. Staring at the infant B. Ignoring the infant’s cries C. Asking questions about feeding D. Stroking the baby’s hand Lack of response to infant cues suggests bonding issues. 57.Which of the following is a priority action following delivery of the placenta?
