Newborn Nursing Care and Assessment NCLEX Questions

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss? A. Conduction B. Convection C. Evaporation D. Radiation

B. Convection (Convection heat loss is the flow of heat from the body surface to the cooler air.)

When performing an assessment on a neonate, which assessment finding is most suggestive of hypothermia? A. Bradycardia B. Hyperglycemia C. Metabolic alkalosis D. Shivering

A. Bradycardia (Hypothermic neonates become bradycardic proportional to the degree of core temperature. Hypoglycemia is seen in hypothermic neonates.)

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: A. Connect the resuscitation bag to the oxygen outlet B. Turn on the apnea and cardiorespiratory monitors C. Set up the intravenous line with 5% dextrose in water D. Set the radiant warmer control temperature at 36.5* C (97.6*F)

A. Connect the resuscitation bag to the oxygen outlet (The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment.)

A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which of the following nursing actions would be most appropriate? A. Document the findings B. Contact the physician C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes D. Reinforce the dressing

A. Document the findings (Close observation of the circumcision site during the first few hours is necessary to determine if there is a complication. A yellow exudate may be noted after 24 hours, and this is a part of normal healing. This should not be washed away because it serves a protective function. The nurse would expect that the area would be red with a small amount of bloody drainage. Because the findings identified in the question are normal, the nurse would document the assessment. Additionally, document if the infant is voiding after the procedure to ascertain that the urethra is not occluded. Instruct the parents to keep the site free from feces and covered in petrolatum until healing is complete. If the infant cries constantly and if there is redness or tenderness due to pain, it should be reported to the physician.)

A baby is born precipitously in the ER. The nurse's initial action should be to: A. Establish an airway for the baby B. Ascertain the condition of the fundus C. Quickly tie and cut the umbilical cord D. Move mother and baby to the birthing unit

A. Establish an airway for the baby (The nurse should position the baby with head lower than chest and rub the infant's back to stimulate crying to promote oxygenation.)

The primary critical observation for Apgar scoring is the: A. Heart rate B. Respiratory rate C. Presence of meconium D. Evaluation of the Moro reflex

A. Heart rate (The heart rate is vital for life and is the most critical observation in Apgar scoring. Respiratory effect rather than rate is included in the Apgar score; the rate is very erratic.)

A neonate is admitted to a hospital's central nursery. The neonate's vital signs are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is: A. Ineffective thermoregulation related to fluctuating environmental temperatures. B. Potential for infection related to lack of immunity. C. Altered nutrition, less than body requirements related to diminished sucking reflex. D. Altered elimination pattern related to lack of nourishment.

A. Ineffective thermoregulation related to fluctuating environmental temperatures. (Normal newborn temperature is around 97.8 to 98.8 F (axillary). Newborns have very small bodies and don't produce much heat themselves, but they readily absorb heat when they are held. Most cooling of the newborn occurs immediately after birth. During the first 10 to 20 minutes, the newborn may lose enough heat for the body temperature to fall by 2-4°C if appropriate measures are not taken. Continued heat loss will occur in the following hours if proper care is not provided. The temperature of the environment during delivery and the postnatal period has a significant effect on the risk to the newborn of developing hypothermia.)

A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained sebaceous secretions. When charting this observation, the nurse identifies it as: A. Milia B. Lanugo C. Whiteheads D. Mongolian spots

A. Milia (Milia occurs commonly, are not indicative of any illness, and eventually disappear.)

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: A. Monitoring for the passage of meconium each shift B. Instituting phototherapy for 30 minutes every 6 hours C. Substituting breastfeeding for formula during the 2nd day after birth D. Supplementing breastfeeding with glucose water during the first 24 hours

A. Monitoring for the passage of meconium each shift (Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.)

The nurse manager is presenting education to her staff to promote consistency in the interventions used with lactating mothers. She emphasizes that the optimum time to initiate lactation is: A. as soon as possible after the infant's birth. B. after the mother has rested for 4-6 hours. C. during the infant's second period of reactivity. D. after the infant has taken sterile water without complications.

A. as soon as possible after the infant's birth. (Early and uninterrupted skin-to-skin contact between mothers and infants should be facilitated and encouraged as soon as possible after birth. All mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery.)

The expected respiratory rate of a neonate within three (3) minutes of birth may be as high as: A. 50 B. 60 C. 80 D. 100

B. 60 (The respiratory rate is associated with activity and can be as rapid as 60 breaths per minute; over 60 breaths per minute are considered tachypneic in the infant.)

The nurse instructs a primipara about safety considerations for the neonate. The nurse determines that the client does not understand the instructions when she says: A. "All neonates should be in an approved car seat when in an automobile." B. "It's acceptable to prop the infant's bottle once in a while." C. "Pillows should not be used in the infant's crib." D. "Infants should never be left unattended on an unguarded surface."

B. "It's acceptable to prop the infant's bottle once in a while." (It is not advisable to prop or leave the bottle in the baby's mouth. This can increase the baby's risk of choking, ear infections, and tooth decay. There is also the very real risk that babies simply end up consuming too much milk if it keeps flowing.)

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? A. Activate the code blue or emergency system B. Do nothing because acrocyanosis is normal in the neonate C. Immediately take the newborn's temperature according to hospital policy D. Notify the physician of the need for a cardiac consult

B. Do nothing because acrocyanosis is normal in the neonate (Acrocyanosis, or bluish discoloration of the hands and feet in the neonate (also called peripheral cyanosis), is a normal finding and shouldn't last more than 24 hours after birth.)

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication? A. Anemia B. Hypoglycemia C. Nitrogen loss D. Thrombosis

B. Hypoglycemia (Neonates of mothers with diabetes are at risk for hypoglycemia due to increased insulin levels. During gestation, an increased amount of glucose is transferred to the fetus across the placenta. The neonate's liver cannot initially adjust to the changing glucose levels after birth. This may result in an overabundance of insulin in the neonate, resulting in hypoglycemia.)

The nurse is aware that a healthy newborn's respirations are: A. Regular, abdominal, 40-50 per minute, deep B. Irregular, abdominal, 30-60 per minute, shallow C. Irregular, initiated by chest wall, 30-60 per minute, deep D. Regular, initiated by the chest wall, 40-60 per minute, shallow

B. Irregular, abdominal, 30-60 per minute, shallow (Normally the newborn's breathing is abdominal and irregular in-depth and rhythm; the rate ranges from 30-60 breaths per minute.)

The nurse decides on a teaching plan for a new mother and her infant. The plan should include: A. Discussing the matter with her in a non-threatening manner B. Showing by example and explanation how to care for the infant C. Setting up a schedule for teaching the mother how to care for her baby D. Supplying the emotional support to the mother and encouraging her independence

B. Showing by example and explanation how to care for the infant (Teaching the mother by example is a non-threatening approach that allows her to proceed at her own pace.)

A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? A. Hypotension and Bradycardia B. Tachypnea and retractions C. Acrocyanosis and grunting D. The presence of a barrel chest with grunting

B. Tachypnea and retractions (Infants who develop RDS have periods during the day when they are free of symptoms because of an initial release of surfactant. The initial signs of respiratory distress includes tachypnea (60 breaths per minute), sternal and subcostal retractions, nasal flaring, cyanotic mucous membranes.)

Which of the following behaviors would indicate that a client was bonding with her baby? A. The client asks her husband to give the baby a bottle of water. B. The client talks to the baby and picks him up when he cries. C. The client feeds the baby every three hours. D. The client asks the nurse to recommend a good child care manual.

B. The client talks to the baby and picks him up when he cries. (Maternal-infant bonding is the intense attachment that develops between parents and their baby. Mothers and infants are designed to stay close to each other. For this to happen, nature has provided a process of "bonding", so that normally a mother becomes attached to her particular baby, making her want to stay near him or her and respond to any crying or other signals.)

The nurse is preparing to discharge a multipara 24 hours after a vaginal delivery. The client is breastfeeding her newborn. The nurse instructs the client that if engorgement occurs the client should: A. wear a tight fitting bra or breast binder. B. apply warm, moist heat to the breasts. C. contact the nurse-midwife for a lactation suppressant. D. restrict fluid intake to 1000 ml daily.

B. apply warm, moist heat to the breasts. (Moist heat has this amazing ability to increase circulation, open milk ducts and stimulate let down - all of which encourage the milk to start flowing.)

A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be: A. "Your infant needs vitamin K to develop immunity." B. "Vitamin K will protect your infant from having jaundice." C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." D. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."

C. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding." (Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding.)

The nurse hears the mother of a 5-pound neonate telling a friend on the telephone, "As soon as I get home, I'll give him some cereal to get him to gain weight." The nurse recognizes the need for further instruction about infant feeding and tells her: A. "If you give the baby cereal, be sure to use Rice to prevent allergy." B. "The baby is not able to swallow cereal, because he is too small." C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." D. "If you want him to gain weight, just double his daily intake of formula."

C. "The infant's digestive tract cannot handle complex carbohydrates like cereal." (An infant's digestive system is still developing and is not yet ready to carry out the complex tasks of masticating (liquefying) and digesting (breaking down) foods. The breakdown of more complex starches occurs in the small intestine and involves an enzyme called pancreatic amylase. There are widely respected experts in pediatric gastroenterology, who assert that this essential enzyme does not appear until close to eighteen months of age and certainly not before twelve months. Feeding infants foods that they cannot digest properly merely leads to the decomposition of these foods in their intestines and the associated challenges which result.)

Within three (3) minutes after birth the normal heart rate of the infant may range between: A. 100 and 180 B. 130 and 170 C. 120 and 160 D. 100 and 130

C. 120 and 160 (The heart rate varies with activity; crying will increase the rate, whereas deep sleep will lower it; a rate between 120 and 160 is expected.)

A client has just given birth at 42 weeks' gestation. When assessing the neonate, which physical finding is expected? A. A sleepy, lethargic baby B. Lanugo covering the body C. Desquamation of the epidermis D. Vernix caseosa covering the body

C. Desquamation of the epidermis (Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.)

A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: A. Subcutaneous injection B. Intravenous injection C. Instillation of the preparation into the lungs through an endotracheal tube D. Intramuscular injection

C. Instillation of the preparation into the lungs through an endotracheal tube (The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.)

When teaching umbilical cord care to a new mother, the nurse would include which information? A. Apply peroxide to the cord with each diaper change B. Cover the cord with petroleum jelly after bathing C. Keep the cord dry and open to air D. Wash the cord with soap and water each day during a tub bath

C. Keep the cord dry and open to air (Keeping the cord dry and open to air helps reduce infection and hastens drying.)

After reviewing the client's maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate? A. Hypoglycemia B. Jitteriness C. Respiratory depression D. Tachycardia

C. Respiratory depression (Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and Bradycardia.)

Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site? A. Deltoid B. Triceps C. Vastus lateralis D. Biceps

C. Vastus lateralis (Vitamin K is given as a prophylaxis for hemorrhagic disease. It is administered intramuscular (IM) in the vastus lateralis muscle. The vastus lateralis muscle lies lateral to the midline of the thigh and wraps about 1/4 the distance around the thigh.)

Soon after delivery, a neonate is admitted to the central nursery. The nursery nurse begins the initial assessment by: A. auscultate bowel sounds. B. determining chest circumference. C. inspecting the posture, color, and respiratory effort. D. checking for identifying birthmarks.

C. inspecting the posture, color, and respiratory effort. (One of the first assessments is a baby's Apgar score. At one minute and five minutes after birth, infants are checked for heart and respiratory rates, muscle tone, reflexes, and color. This helps identify babies that have difficulty breathing or have other problems that need further care.)

A newborn's mother is alarmed to find small amounts of blood on her infant girl's diaper. When the nurse checks the infant's urine it is straw colored and has no offensive odor. Which explanation to the newborn's mother is most appropriate? A. "It appears your baby has a kidney infection" B. "Breast-fed babies often experience this type of bleeding problem due to lack of vitamin C in the breast milk" C. "The baby probably passed a small kidney stone" D. "Some infants experience menstruation like bleeding when hormones from the mother are not available"

D. "Some infants experience menstruation like bleeding when hormones from the mother are not available" (Most dramatically, at 2 or 3 days of age, a girl infant may have a little bit of bleeding from her vagina. This is perfectly normal; it is caused by the withdrawal of the hormones she was exposed to in the womb. It will be her first and last menstrual period for another decade or so.)

A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother? A. Switch to bottle-feeding the baby for 2 weeks B. Stop breastfeeding and switch to bottle-feeding permanently C. Feed the newborn infant less frequently D. Continue to breastfeed every 2-4 hours

D. Continue to breastfeed every 2-4 hours (Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. Early feeding of newborns with hyperbilirubinemia promotes intestinal movement and excretion of meconium which ultimately helps prevent indirect bilirubin buildup. The other options are not necessary.)

When performing nursing care for a neonate after birth, which intervention has the highest nursing priority? A. Obtain a dextrostix B. Give the initial bath C. Give the vitamin K injection D. Cover the neonates head with a cap

D. Cover the neonates head with a cap (Covering the neonate's head with a cap helps prevent cold stress due to excessive evaporative heat loss from the neonate's wet head.Option C: Vitamin K can be given up to 4 hours after birth.)

A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares to prevent heat loss in the newborn resulting from evaporation by: A. Warming the crib pad B. Turning on the overhead radiant warmer C. Closing the doors to the room D. Drying the infant in a warm blanket

D. Drying the infant in a warm blanket (Evaporation is the loss of heat through the conversion of liquid to vapor. Newborns are wet from the amniotic fluid when they are born, as the fluid evaporates from their skin, they can lose heat. Drying the infant using a warm blanket is an excellent measure to help conserve heat or prevent heat loss. Additionally, drying the face and hair, covering the hair with a cap, and laying the newborn on the mother's abdomen, effectively reduces heat loss through evaporation. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.)

The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism? A. Candida albicans B. Chlamydia trachomatis C. Escherichia coli D. Group B beta-hemolytic streptococci

D. Group B beta-hemolytic streptococci (Transmission of Group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock.)

Which action best explains the main role of surfactant in the neonate? A. Assists with ciliary body maturation in the upper airways B. Helps maintain a rhythmic breathing pattern C. Promotes clearing mucus from the respiratory tract D. Helps the lungs remain expanded after the initiation of breathing

D. Helps the lungs remain expanded after the initiation of breathing (Surfactant works by reducing surface tension in the lung. Surfactant allows the lung to remain slightly expanded, decreasing the amount of work required for inspiration.)

A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition? A. It usually resolves in 3-6 weeks B. It doesn't cross the cranial suture line C. It's a collection of blood between the skull and the periosteum D. It involves swelling of tissue over the presenting part of the presenting head

D. It involves swelling of tissue over the presenting part of the presenting head (Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure; it resolves in 3-4 days.)

A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result? A. Negative Coombs test B. Bleeding from the nose and ear C. Jaundice after the first 24 hours of life D. Jaundice within the first 24 hours of life

D. Jaundice within the first 24 hours of life (The neonate with ABO blood incompatibility with its mother will have jaundice (pathologic) within the first 24 hours of life. The neonate would have a positive Coombs test result.)

Neonates of mothers with diabetes are at risk for which complication following birth? A. Atelectasis B. Microcephaly C. Pneumothorax D. Macrosomia

D. Macrosomia (Neonates of mothers with diabetes are at increased risk for macrosomia (excessive fetal growth) as a result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.)

A healthy term neonate born by C-section was admitted to the transitional nursery 30 minutes ago and placed under a radiant warmer. The neonate has an axillary temperature of 97.6ºF, a respiratory rate of 80 breaths/minute, and a heel stick glucose value of 60 mg/dl. Which action should the nurse take? A. Wrap the neonate warmly and place her in an open crib B. Administer an oral glucose feeding of 10% dextrose in water C. Increase the temperature setting on the radiant warmer D. Obtain an order for IV fluid administration

D. Obtain an order for IV fluid administration (Assessment findings indicate that the neonate is in respiratory distress—most likely from transient tachypnea, which is common after cesarean delivery. A neonate with a rate of 80 breaths a minute shouldn't be fed but should receive IV fluids until the respiratory rate returns to normal. To allow for close observation for worsening respiratory distress, the neonate should be kept unclothed in the radiant warmer.)

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: A. Pulse, respirations, temperature B. Temperature, pulse, respirations C. Respirations, temperature, pulse D. Respirations, pulse, temperature

D. Respirations, pulse, temperature (This sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.)

A mother of a term neonate asks what the thick, white, cheesy coating is on his skin. Which correctly describes this finding? A. Lanugo B. Milia C. Nevus flammeus D. Vernix

D. Vernix (Vernix caseosa or vernix is the waxy or cheese-like white substance found coating the skin of newborn human babies. It is produced by dedicated cells and is thought to have some protective roles during fetal development and for a few hours after birth.)

An insulin-dependent diabetic delivered a 10-pound male. When the baby is brought to the nursery, the priority of care is to: A. clean the umbilical cord with Betadine to prevent infection B. give the baby a bath C. call the laboratory to collect a PKU screening test D. check the baby's serum glucose level and administer glucose if < 40 mg/dL

D. check the baby's serum glucose level and administer glucose if < 40 mg/dL (Because the mother has diabetes, the baby is at risk for problems. The newborn baby may be large in size (macrosomia). Big babies are more likely to get hurt during delivery. These include shoulder injuries. The baby may also have low blood sugar (hypoglycemia), low blood calcium, low blood iron, and high levels of red blood cells and thickened blood. Hypoglycemia occurs if the mother's blood glucose levels have been consistently high, causing the fetus to have a high level of insulin in its circulation. The baby's blood glucose level is checked after birth, and if the level is too low, it may be necessary to give the baby glucose intravenously.)

The home health nurse visits the Cox family 2 weeks after hospital discharge. She observes that the umbilical cord has dried and fallen off. The area appears healed with no drainage or erythema present. The mother can be instructed to: A. cover the umbilicus with a band-aid. B. continue to clean the stump with alcohol for one week. C. apply an antibiotic ointment to the stump. D. give him a bath in an infant tub now.

D. give him a bath in an infant tub now. (The baby's umbilical cord stump dries out and eventually falls off — usually within one to three weeks after birth. After the cord has fallen off, the navel will gradually heal. It's normal for the center to look red at the point of separation. Sponge baths are recommended for a few more days or tub baths will be fine.)