Newborn at Risk NCLEX Questions

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist the newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.

1. Encourage the parents to touch their newborn.

A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? Select all that apply. 1. Flat breast tissue 2. Prominent clitoris 3. Abundant lanugo 4. Wrinkled skin

1. Flat breast tissue 4. Wrinkled skin

The nurse has been assigned to care for a neonate just delivered who has gastroschisis. Which concern should the nurse address in the client's plan of care? 1. Infection 2. Poor body image 3. Decreased urinary elimination 4. Cracking oral mucous membranes

1. Infection

The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect? 1. Low-set ears 2. Vernix caseosa 3. A 5-cm anterior fontanel 4. A heart rate of 130 beats per minute

1. Low-set ears

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction? 1. "A balance of rest and activity is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. "I can apply lotion or powder to the incision if it is itchy."

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome? 1. Length of 19 inches 2. Abnormal palmar creases 3. Birth weight of 6 lb, 14 oz (3120 g) 4. Head circumference appropriate for gestational age

2. Abnormal palmar creases

The nurse is preparing to administer exogenous surfactant to a premature infant who has respiratory distress syndrome. The nurse prepares to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2. Intratracheal

The nurse is monitoring a newborn born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn? 1. Flaccidity 2. Irritability 3. Poor feeding 4. Minimal response to stimuli

2. Irritability

Which neonate is at highest risk for cold stress syndrome? 1. Infant of a diabetic mother 2. Postdate neonate 3. Infant with Rh incompatibility 4. Down syndrome neonate

2. Postdate neonate

The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which findings should the nurse expect to note during the assessment of this newborn? Select all that apply. 1. Lethargy 2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort 6. Cuddles when being held

2. Sleepiness 3. Irritability 4. Constant crying 5. Difficult to comfort

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching? 1. "Quiet activities are allowed." 2. "The child should play inside for now." 3. "Visitors are not allowed for 1 month." 4. "The regular schedule for naps is resumed."

3. "Visitors are not allowed for 1 month."

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? 1. Anxiety 2. A temper tantrum 3. A hypercyanotic episode 4. The need for immediate primary health care provider notification

3. A hypercyanotic episode

The clinic nurse reviews the record of a child just seen by the pediatrician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Activity intolerance 4. Gastrointestinal disturbances

3. Activity intolerance

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Notify the primary health care provider.

3. Administer the medication.

The nurse is caring for a post-term, small for gestational age (SGA) newborn infant immediately after admission to the nursery. What should the nurse monitor as the priority? 1. Urinary output 2. Total bilirubin levels 3. Blood glucose levels 4. Hemoglobin and hematocrit levels

3. Blood glucose levels

A baby has just been admitted to the NICU with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. 1. Gestational diabetes 2. Hyperopia 3. Chronic hypertension 4. Advanced maternal age 5. Substance abuse

3. Chronic hypertension 4. Advanced maternal age 5. Substance abuse

The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure? 1. Paleness of the skin 2. Strong sucking reflex 3. Diaphoresis during feeding 4. Slow and shallow breathing

3. Diaphoresis during feeding

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation? 1. Warming the crib pad 2. Closing the doors to the room 3. Drying the infant with a warm blanket 4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket

The clinic nurse reviews the record of a child just seen by a primary health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3. Exercise intolerance

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition. 1. Aortic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect

3. Patent ductus arteriosus

A pediatric nurse educator provides a teaching session to the nursing staff regarding phenylketonuria. Which statement should the nurse educator include in the session? 1. "Treatment includes dietary restriction of tyramine." 2. "Phenylketonuria is an autosomal dominant disorder." 3. "Phenylketonuria primarily affects the gastrointestinal system." 4. "All 50 states require routine screening of all newborn infants for phenylketonuria."

4. "All 50 states require routine screening of all newborn infants for phenylketonuria."

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "If more than 1 dose is missed, I will call the pediatrician." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose."

The nurse provides instructions to the parent of a newborn to bring the infant to the well-baby clinic for a phenylketonuria rescreening blood test. The nurse determines that the parent understands the need for the test when which statement is made? 1. "It can detect heart disease in my baby." 2. "It will discover the presence of cancer in my baby." 3. "It will check for the presence of a genetic condition in my infant." 4. "It will allow me to institute measures to prevent complications if the level is elevated."

4. "It will allow me to institute measures to prevent complications if the level is elevated."

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother? 1. "The child may return to school in 1 week." 2. "The child will not be able to return to school during this academic year." 3. "The child may return to school in 1 week but needs to go half-days for the first 2 weeks." 4. "The child may return to school in 3 weeks but needs to go half-days for the first few days."

4. "The child may return to school in 3 weeks but needs to go half-days for the first few days."

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the primary health care provider? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure 4. A weight gain of 1 lb (0.5 kg) in 1 day

4. A weight gain of 1 lb (0.5 kg) in 1 day

The nurse is preparing to care for an infant who has esophageal atresia with tracheoesophageal fistula. Surgery is scheduled to be performed in 1 hour. Intravenous fluids have been initiated, and a nasogastric (NG) tube has been inserted by the primary health care provider. The nurse plans care, knowing that which intervention is of highest priority during this preoperative period? 1. Monitor the temperature. 2. Monitor the blood pressure. 3. Reposition the infant frequently. 4. Aspirate the NG tube every 5 to 10 minutes.

4. Aspirate the NG tube every 5 to 10 minutes.

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia? 1. Tachypnea 2. Tachycardia 3. Sucking on the fingers 4. Clubbing of the fingers

4. Clubbing of the fingers

On assessment, a newborn is exhibiting cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the primary health care provider (PHCP) prescribes surfactant replacement therapy. Through which route should the nurse prepare to administer this medication? 1. Orally mixed in water 2. Intravenously through a burette 3. Subcutaneously in the anterior thigh 4. Endotracheally through the endotracheal tube

4. Endotracheally through the endotracheal tube

A just-delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism? 1. Radiation 2. Convection 3. Conduction 4. Evaporation

4. Evaporation

The nurse is creating a plan of care for a newborn diagnosed with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care? 1. Allow the newborn to establish own sleep-rest pattern. 2. Maintain the newborn in a brightly lighted area of the nursery. 3. Encourage frequent handling of the newborn by staff and parents. 4. Monitor the newborn's response to feedings and weight gain pattern.

4. Monitor the newborn's response to feedings and weight gain pattern.

To prevent heat loss by conduction during physical examination of a newborn infant, which action should the nurse implement? 1. Dry the newborn's head thoroughly. 2. Turn the thermostat in the room to 70º F. 3. Place the newborn near the nursery window. 4. Place a warm blanket on the examining table before placing the newborn on the table.

4. Place a warm blanket on the examining table before placing the newborn on the table.

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse? 1. Notify the nursing supervisor. 2. Contact the respiratory therapist. 3. Place the infant in a prone position. 4. Place the infant in a knee-chest position.

4. Place the infant in a knee-chest position.

The nurse is initiating nasogastric tube feedings in a child. What is the nurse's best action? 1. Microwave the formula. 2. Place the child in a prone position. 3. Encourage the child to point the head downward. 4. Position the child with the head slightly hyperflexed.

4. Position the child with the head slightly hyperflexed.

A 42 week gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is critical at this time? 1. Ophthalmic assessment to check for conjunctival irritation 2. Rectal temperature to assess for septic hyperthermia 3. Bath to remove meconium-contaminated fluid from the skin 4. Respiratory evaluation to monitor for respiratory distress

4. Respiratory evaluation to monitor for respiratory distress

The nurse caring for an infant with a congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? 1. Hypertension, cyanosis, bradycardia 2. Angina, oliguria, dysrhythmias 3. Irritability, hypotension, palpitations 4. Tachypnea, tachycardia, diaphoresis

4. Tachypnea, tachycardia, diaphoresis

The nursery room nurse is assessing a newborn infant who was born to a mother who abuses alcohol. Which assessment finding should the nurse expect to note? Select all that apply. 1. Tremors 2. Lethargy 3. Irritability 4. Poor feeding 5. Higher-than-normal birth weight 6. A greater-than-normal appetite when feeding

1. Tremors 3. Irritability 4. Poor feeding

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a urinary catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

1. Weighing the diapers

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Check the blood pressure and then administer the medication. 4. Check the respiratory rate and then administer the medication.

1. Withhold the medication.

A mother brings her 2-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation? 1. It is positive. 2. It is negative. 3. It is inconclusive. 4. It requires rescreening at age 6 weeks.

2. It is negative.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position? 1. Prone position 2. Knee-chest position 3. High-Fowler's position 4. Reverse Trendelenburg's position

2. Knee-chest position

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding? 1. Severe bradycardia 2. Asymptomatic after feeding 3. Bluish discoloration of the skin 4. Higher than normal body weight

3. Bluish discoloration of the skin

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

3. Choking with feedings

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

3. Tachycardia

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take? 1. Retake the apical pulse. 2. Administer the medication. 3. Withhold the medication for 1 hour. 4. Withhold the medication and notify the primary health care provider.

4. Withhold the medication and notify the primary health care provider.

Which action would the NICU nurse expect to perform when caring for a neonate with esophageal atresia and tracheoesophageal fistula (TEF)? 1. Give small frequent feedings 2. Maintain low nasogastric suction 3. Place on hypothermia blanket 4. Place the baby flat on left side

2. Maintain low nasogastric suction

The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn? 1. Developmental delays because of excessive size 2. Maintaining safety because of low blood glucose levels 3. Choking because of impaired suck and swallow reflexes 4. Elevated body temperature because of excess fat and glycogen

2. Maintaining safety because of low blood glucose levels

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication? 1. Prevents blue (tet) spells 2. Maintains adequate cardiac output 3. Maintains an adequate hormonal level 4. Maintains the position of the great arteries

2. Maintains adequate cardiac output

A pediatric client with ventricular septal defect repair is placed on a maintenance dosage of digoxin. The dosage is 8 mcg/kg. The child's weight is 7.2 kg. The pediatrician prescribes digoxin to be given twice daily. The nurse prepares how many mcg of digoxin to administer at each dose? 1. 12.6 mcg 2. 21.4 mcg 3. 28.8 mcg 4. 32.2 mcg

3. 28.8 mcg

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings should alert the nurse to the possibility of this syndrome? Select all that apply. 1. Cyanosis 2. Tachypnea 3. Hypotension 4. Retractions 5. Audible grunts 6. Presence of a barrel chest

1. Cyanosis 2. Tachypnea 4. Retractions 5. Audible grunts

An infant returns to the nursing unit following surgery for a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous fluids and a gastrostomy tube is in place. Following assessment, the nurse positions the infant and performs which action? 1. Elevates the gastrostomy tube 2. Tapes the gastrostomy tube to the bed linens 3. Attaches the gastrostomy tube to low suction 4. Connects the gastrostomy tube to the feeding pump

1. Elevates the gastrostomy tube

Which newborn is most at risk for a brachial plexus injury? 1. A term infant with a history of a forceps-assisted delivery 2. A term infant delivered via primary cesarean section for malpresentation 3. A large for gestational age infant with a history of shoulder dystocia at delivery 4. A 36-week preterm infant delivered vaginally after preterm rupture of membranes

3. A large for gestational age infant with a history of shoulder dystocia at delivery

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action? 1. Retake the apical pulse. 2. Withhold the medication. 3. Administer the medication. 4. Notify the primary health care provider.

3. Administer the medication.

An initial assessment of a large for gestational age (LGA) newborn infant is being done. Which physical assessment technique should the nurse assist in performing to assess for evidence of birth trauma? 1. Palpate the clavicles for a fracture. 2. Auscultate the heart for a cardiac defect. 3. Blanch the skin for evidence of jaundice. 4. Perform Ortolani's maneuver for hip dysplasia.

1. Palpate the clavicles for a fracture.

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? 1. Polycythemia 2. Hyperglycemia 3. Thrombocytopenia 4. Neutropenia

1. Polycythemia

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest and acrocyanosis

1. Tachypnea and retractions

The nurse in the newborn nursery is assessing a neonate who was born of a mother addicted to cocaine. Which assessment findings should the nurse expect to note in the neonate? Select all that apply. 1. Tremors 2. Tachycardia 3. Flaccid muscles 4. Extreme lethargy 5. Exaggerated startle reflex

1. Tremors 2. Tachycardia 5. Exaggerated startle reflex

The nurse is caring for an infant client with tetralogy of Fallot who is experiencing a hypercyanotic spell. Place the actions the nurse should take in order of priority. All options must be used. 1. Administer 100% oxygen. 2. Place the infant in a knee-chest position. 3. Administer morphine sulfate as prescribed. 4. Document the occurrence, actions taken, and the infant's response. 5. Administer fluids intravenously.

2, 1, 3, 5, 4

The mother of a preterm newborn is comparing the appearance of her preterm baby to the nearby full-term babies. She asks why her baby's skin appears so different. What is the best response for the nurse to provide? 1. "A full term newborn has decreased brown fat stores." 2. "A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat." 3. "A preterm baby has additional subcutaneous fat beneath the skin that is lost between 38 to 40 weeks." 4. "The full term newborn has produced much more soft downy hair, giving the skin a more fuzzy appearance."

2. "A preterm newborn's skin appears more translucent due to decreased amounts of subcutaneous fat."

Which finding would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5F? 1. Blood glucose of 50 mg/dL 2. Oxygen saturation of 96% 3. Tachypnea 4. Acrocyanosis

3. Tachypnea

A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? 1. Provide needed stimulation for the baby 2. Feed the baby half-strength formula 3. Tightly swaddle the baby 4. Place the baby prone in the crib

3. Tightly swaddle the baby

A pediatrician has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing

4. When drawing blood for electrolyte level testing

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess for which of the following? 1. Webbed neck 2. Absent Moro reflex 3. Poor suck reflex 4. Ambiguous genitalia

3. Poor suck reflex

The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority? 1. Turn on the apnea and cardiorespiratory monitors. 2. Connect the resuscitation bag to the oxygen outlet. 3. Set up the intravenous line with 5% dextrose in water. 4. Set the radiant warmer control temperature at 36.5° C (97.6° F).

2. Connect the resuscitation bag to the oxygen outlet.

The nurse weighing a term newborn during the initial newborn assessment determines the infant's weight to be 4400 g. The nurse determines that this infant may be at risk for which complications? Select all that apply 1. Retinopathy 2. Hypoglycemia 3. Fractured clavicle 4. Hyperbilirubinemia 5. Congenital heart defect 6. Necrotizing enterocolitis

2. Hypoglycemia 3. Fractured clavicle 5. Congenital heart defect