1. A nurse is performing an initial assessment of a newborn who was delivered with a nuchal

cord. Which of the following clinical findings should the nurse expect?

A. Telangiectactic nevi

• Pink, flat. Birth mark that appears in first months of life (forehead, eyelids, nose, upper lip,

back/neck) considered normal

B. Periauricular papillomas

• Couldn’t find any info on this. Most likely a squamous growth on ear, not cancerous and not

dangerous (per Google)

C. Erythema toxicum

• Common rash seen in full term newborns. Appears in first days after birth and fades within a

week. Transient maculopapular rash. Newborn rash considered normal and no treatment is

needed

D. Facial petechiae

• Petechiae is present when there is birth trauma. Seen most often with soft tissue injuries.

2. A nurse is monitoring a newborn whose mother reports recent opiate use for neonatal

abstinence syndrome. Which of the following findings indicates narcotic withdrawal?

A. Respiratory rate 50/min

• Tachypnea greater than 60/min

B. Unequal pupils

• Small eyes

C. Hypotonia (boggy muscles)

• Hyperactive reflexes and increased muscle tone are common

D. Excessive crying

• Common finding in newborns to whom mothers were opiate users

3. A nurse is caring for a client who is in the second stage of labor. The nurse observes the fetal

head retract against the client’s perineum immediately following emergence. Which of the

following actions should the nurse take? (turtle sign)

A. Assess fetal position using Leopold maneuvers

• External palpations of the maternal uterus through the abdominal wall to determine: number of

fetuses, presenting part, fetal lie + attitude, degree of descent, location of the fetus’s back

B. Reposition the client in the left lateral position

• Used if fetus is in distress during first stage of labor

C. Apply pressure to the client’s suprapubic area

D. Empty the client’s bladder using Crede’s maneuver

• This is mostly used post-partum if mother cannot empty bladder

4. A client and her partner ask the nurse for information about permanent contraception. Which

of the following statements should the nurse include in the counseling?

A. “A man is usually sterile immediately after a vasectomy.”

• Sterility is delayed until the proximal portion of the vas deferens is cleared of all remaining

sperm (20 ejaculations). Alternate forms of birth control is needed

B. “The menstrual cycle is shorter after a tubal ligation.”

• It is the same/longer after tubal ligation

C. “Most sterilization procedures are considered irreversible.”

• Female sterilization is irreversible but male is reversible (not always successful)