Practice Mode Assessment

Rhenis Nursing

RN Proctored Maternal Newborn 2023 (2026 Feb)

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1 :
A nurse is caring for a newborn immediately following birth.

Erythromycin ophthalmic ointment once 1 to 2 hr after birth

Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth.

WBC count 15,000/mm3 (9,000 to 30,000/mm3)

Hgb 19 g/dL (15 to 24 g/dL)

Hct 57% (44% to 70%)

Blood glucose 44 mg/dL (40 to 60 mg/dL)

Apgar

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus ß-hemolytic

Mother received two doses of ampicillin IV bolus during labor

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication that the client's condition is improving, or an indication that the client's condition is worsening.

Findings	Unrelated to Diagnosis	Indication of Improvement	Indication of Worsening Condition
Color: Consistent with genetic background
Reflex irritability: cry
Axillary temperature 36.3 °C (97.4 °F)
Muscle tone: flaccid
Respiration effort: good cry
Heart rate 140/min

Hint : 🧠Pick improvement for findings showing strong respiratory effort, normal heart rate, and responsive reflexes, and pick worsening for signs of temperature instability or poor tone.

Correct Answers

Color: Consistent with genetic background [ Indication of Improvement ]
Reflex irritability: cry [ Indication of Improvement ]
Axillary temperature 36.3 °C (97.4 °F) [ Indication of Worsening Condition ]
Muscle tone: flaccid [ Indication of Worsening Condition ]
Respiration effort: good cry [ Indication of Improvement ]
Heart rate 140/min [ Indication of Improvement ]

Rationale :

Rationale to be Available Soon

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Findings 24 Hr Later	Unrelated to Diagnosis	Sign of Potential Improvement	Sign of Potential Worsening Condition
Heart rate 100/min
Urine specific gravity 1.050
WBC count 10,000/mm³
Urinary output 40 mL/hr
3+ ketones
Urine pH 5

Findings 30 min later	Unrelated to diagnosis	Potential improvement	Worsening condition
Moderate lochia rubra
Thready pulse
Fundus at level of umbilicus
Blood pressure 80/50 mm Hg
Cloudy urine
Fundus firm to palpation

1 :
A nurse is caring for a newborn immediately following birth.

Correct Answers

2 :
A nurse is preparing to administer medications to a client who is 72 hr postpartum following a cesarean birth.

3 :
A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

Correct Answers

4 :
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.

Correct Answers

5 :
A nurse is caring for a client who is at 15 weeks of gestation during a routine prenatal visit.

Answer Options

6 :
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

7 :
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

8 :
A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

9 :
A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

10 :
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

1 : A nurse is caring for a newborn immediately following birth.

Correct Answers

2 : A nurse is preparing to administer medications to a client who is 72 hr postpartum following a cesarean birth.

3 : A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

Correct Answers

4 : A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.

Correct Answers

5 : A nurse is caring for a client who is at 15 weeks of gestation during a routine prenatal visit.

Answer Options

6 : A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

7 : A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

8 : A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

9 : A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

10 : A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?

1 :
A nurse is caring for a newborn immediately following birth.

2 :
A nurse is preparing to administer medications to a client who is 72 hr postpartum following a cesarean birth.

3 :
A nurse is caring for a client who is at 12 weeks of gestation and has hyperemesis gravidarum.

4 :
A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.

5 :
A nurse is caring for a client who is at 15 weeks of gestation during a routine prenatal visit.

6 :
A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

7 :
A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

8 :
A postpartum nurse is caring for a client and their newborn. Which of the following observations should indicate to the nurse that the client is in the taking-in phase of maternal role attainment?

9 :
A nurse is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to the client?

10 :
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?