NCLEX: Newborn

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

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

The nurse in the delivery room is performing an assessment on a newborn to determine the Apgar score. The nurse notes a heart rate of 92, a weak cry, some flexion of extremities, grimacing with stimulation, and pink body with blue extremities. On the basis of this score, what should the nurse determine? 1. The newborn requires vigorous resuscitation. 2. The newborn is adjusting well to extrauterine life. 3. The newborn requires some resuscitative interventions. 4. The newborn is having some difficulty adjusting to extrauterine life.

3. The newborn requires some resuscitative interventions.

The home care nurse is visiting a mother 1 week after she gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the mother about the signs and symptoms of this disorder, the nurse instructs the mother to monitor the infant for which findings? Select all that apply. 1. Loose stools 2. High-pitched cry 3. Vigorous feeding habits 4. A copper-colored skin rash 5. Mucopurulent nasal drainage (snuffles)

4. A copper-colored skin rash 5. Mucopurulent nasal drainage (snuffles)

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.

Hypoglycemia Fractured clavicle Congenital heart defect

The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?

The client begins to wash the newborn by starting with the eyes and face.

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.

Tremors Tachycardia Exaggerated startle reflex

The nurse is preparing to instruct a client on how to bathe a newborn. Which statement should the nurse include in the instruction? 1. "Begin with the eyes and face." 2. "Begin with the feet and work upward." 3. "Do the back side first, and then the front side." 4. "Start with the chest, move to the face, and then finish the rest of the body."

1. "Begin with the eyes and face."

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

Which newborn is most at risk for a brachial plexus injury?

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

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?

Palpate the clavicles for a fracture.

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?

Elevates the gastrostomy tube

The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother?

Increase the frequency of the breast-feeding.

A new mother reports that her niece was diagnosed as an infant with gastroesophageal reflux (GER). The newborn's mother asks the nurse if her newborn also has this diagnosis. Which findings should the nurse identify as potential indicators of GER? Select all that apply

Irritability Failure to thrive Choking with feeding Spitting up and regurgitation

Which medication should the nurse plan to administer to a newborn by the intramuscular (IM) route?

Phytonadione (Vitamin K)

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?

Tachypnea and retractions

The nurse is performing an assessment on a newborn and is preparing to measure the head circumference of the newborn. Which item is essential to perform this assessment?

Tape measure

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's highest priority at this time is to perform which action?

Thoroughly dry the newborn.

The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which instruction to the mother? 1. Feed the newborn less frequently. 2. Continue to breast-feed every 2 to 4 hours. 3. Switch to bottle-feeding the infant for 2 weeks. 4. Stop breast-feeding and switch to bottle-feeding permanently.

2. Continue to breast-feed every 2 to 4 hours.

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

The nurse creates a plan of care for a woman with human immunodeficiency virus (HIV) infection and her newborn. The nurse should include which intervention in the plan of care? 1. Monitoring the newborn's vital signs routinely 2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems 4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2. Maintaining standard precautions at all times while caring for the newborn

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?

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

The nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to the nursery. The maternity nurse prepares for the arrival of the newborn and places which priority item at the newborn's bedside? 1. A rectal thermometer 2. A blood pressure cuff 3. A specific gravity urinometer 4. A bottle of sterile normal saline

4. A bottle of sterile normal saline

The nurse is monitoring a newborn born to a client who abuses alcohol. Which findings should the nurse expect to note when assessing this newborn? (Select all that apply.)

Irritability Minimal response to stimuli

The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect?

Low set ears

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only 2 red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply.

Phototherapy lights Intravenous (IV) pump

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother? 1. Bring the infant to the clinic. 2. This is a normal occurrence and no further action is needed. 3. Increase the number of times that the cord is cleaned per day. 4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1. Bring the infant to the clinic.

A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of her infant. Which client statement indicates the need for further instruction? 1. "I will be sure to wash my hands before and after bathroom use." 2. "I need to breast-feed, especially for the first 6 weeks postpartum." 3. "Support groups are available to assist me with understanding my diagnosis of HIV." 4. "My newborn infant should be on antiviral medications for the first 6 weeks after delivery."

2. "I need to breast-feed, especially for the first 6 weeks postpartum."

A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL (238 mcmol/L). The nurse should plan to include which instruction in the teaching plan of care during the home visit to the mother of the newborn? 1. Applying lotions to exposed newborn skin 2. Assessing skin integrity and fluid status of the newborn 3. Having minimal contact with the newborn to prevent stimulation 4. Advising the mother to limit the newborn's oral intake during phototherapy

2. Assessing skin integrity and fluid status of the newborn

The nurse is preparing to administer an injection of vitamin K to a newborn and provides the mother with information about the injection. Which information should the nurse provide? 1. "It's a single injection given by the intravenous route." 2. "The injection is given after birth and then again one month later." 3. "The injection is extremely important to prevent bleeding in your baby." 4. "It's fine if you want to refuse giving it to your baby. Once your baby starts on baby food vitamin K deficiency will be replaced."

3. "The injection is extremely important to prevent bleeding in your baby."

The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate? 1. Apply gentle pressure. 2. Reinforce the dressing. 3. Document the findings. 4. Contact the health care provider (HCP).

3. Document the findings.

The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the umbilical cord, the nurse observes only 2 vessels. How should the nurse interpret this finding? 1. Finding 2 vessels is the expected finding. 2. Finding 2 vessels is correlated to a high incidence of Down syndrome. 3. Finding 2 vessels may indicate an increased risk for other congenital anomalies. 4. Finding 2 vessels means the newborn has been stressed previously with fetal hypoxia.

3. Finding 2 vessels may indicate an increased risk for other congenital anomalies.

The nurse prepares to administer a phytonadione (vitamin K) injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provide? 1. "Your newborn needs the medicine to develop immunity." 2. "The medicine will protect your newborn from being jaundiced." 3. "Newborns have sterile bowels, and the medicine promotes the growth of bacteria in the bowel." 4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

The nurse is reviewing the record of a newborn infant in the nursery and notes that the health care provider (HCP) has documented the presence of a cephalohematoma. Based on this documentation, what should the nurse expect to note on assessment of the infant?

Edema resulting from bleeding below the periosteum of the cranium

The nurse is preparing to provide instructions to a new mother regarding cord care for a newborn infant. Which instructions would the nurse provide? Select all that apply.

"The cord needs to be kept clean and dry." "You need to do cord care until the cord dries up and falls off."

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 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

The nurse in the newborn nursery is performing admission vital signs on a newborn infant. The nurse notes that the respiratory rate of the newborn is 50 breaths per minute. Which action should the nurse take? 1. Document the findings. 2. Contact the health care provider (HCP). 3. Apply an oxygen mask to the newborn infant. 4. Cover the newborn infant with blankets and reassess the respiratory rate in 15 minutes.

1. Document the findings.

The nurse is performing Apgar scoring for a newborn infant immediately after birth. The nurse notes that the heart rate is greater than 100 beats/min, the respiratory effort is good, muscle tone is active, the newborn infant sneezes when suctioned by the bulb syringe, and the skin color is pink. On the basis of these findings, the nurse should document which Apgar score?

10

Which statement, if made by the mother of a 1-day-old newborn, indicates the understanding of gastrointestinal system functioning in the infant? Select all that apply.

10 to 20 mL is the stomach capacity of a 1-day-old newborn 90 to 150 mL is the stomach capacity of a 1-month-old infant

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 performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is less than 100 beats per minute, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. What should be the immediate nursing intervention for this newborn? 1. Continued monitoring of vital signs 2. Oxygen supplementation and suctioning 3. Initiating cardiopulmonary resuscitation 4. Documenting findings and notifying the health care provider (HCP)

2. Oxygen supplementation and suctioning

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? 1. "I should retract the foreskin and clean the penis every time I change the diaper." 2. "I need to retract the foreskin and clean the penis every time I give my infant a bath." 3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." 4. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

3. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions."

Which statement reflects a new mother's understanding of the teaching about the prevention of newborn abduction? 1. "I will place my baby's crib close to the door." 2. "Some health care personnel won't have name badges." 3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here." 4. "It's okay to allow the nurse assistant to carry my newborn to the nursery."

3. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

The nurse in the labor room measures the Apgar score in a newborn infant and notes that the score is 4. Which action by the nurse has highest priority? 1. Initiate an intravenous (IV) line on the newborn infant. 2. Place the newborn infant on a cardiorespiratory monitor. 3. Place the newborn infant in the radiant warmer incubator. 4. Administer oxygen via resuscitation bag to the newborn infant.

4. Administer oxygen via resuscitation bag to the newborn infant.

The nurse is providing instructions to a new mother regarding cord care for a newborn infant. Which statement, if made by the mother, indicates a need for further instructions? 1. "The cord will fall off in 1 to 2 weeks." 2. "Soap and water may be used to clean the cord." 3. "I should cleanse the cord 2 or 3 times a day." 4. "I need to fold the diaper above the cord to prevent infection."

4. "I need to fold the diaper above the cord to prevent infection."

The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches.

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/minute; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score?

9

The nurse is performing an assessment of a newborn admitted to the nursery after birth. On assessment of the newborn's head, what should the nurse anticipate to be the most likely findings related to the fontanels? Select all that apply.

A soft and flat anterior fontanel A triangular-shaped posterior fontanel

On delivery of a newborn, the nurse performs an initial assessment. When should the nurse plan to determine the Apgar score?

At 1 minute after birth and 5 minutes after birth

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?

Blood glucose levels

Which is considered a normal finding in a newborn less than 12 hours old?

Bluish discoloration of the hands and feet

The nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6°F (38.1°C)and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Contact the health care provider (HCP)

The nurse determines the apical heart rate of a 2-day-old newborn to be 140 beats/minute. Which intervention is most appropriate related to this finding?

Document the finding in the electronic health record.

The nurse is caring for a term newborn. Blood samples for serum chemistries are drawn, and the total calcium level is reported as 8.0 mg/dL (2 mmol/L). Based on this information, which nursing action should be implemented?

Document the finding in the electronic health record.

The nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding?

Document the findings in the electronic health record.

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?

Encourage the parents to touch their newborn.

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?

Evaporation

The nurse is assessing a newborn infant with a diagnosis of hiatal hernia. Which findings should the nurse most specifically expect to note in the infant? Select all that apply.

Failure to thrive Coughing, wheezing, and short periods of apnea

Which is considered a normal finding in a newborn less than 12 hours old?

Has not passed meconium yet

The nurse in the newborn nursery is determining admission vital signs for a newborn infant. The nurse documents that the vital signs are within normal range if which set of vital signs is noted on assessment?

Heart rate 130 beats/minute, respirations 46 breaths/minute

An infant is born to a mother with hepatitis B. Which prophylactic measure is indicated for the infant?

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

The nurse in the labor room is performing an initial assessment on a newborn infant. On assessment of the head, the nurse notes that the ears are low set. Which nursing action would be appropriate?

Notify the health care provider (HCP).

The nurse in a newborn nursery is performing an assessment of an infant. What procedure should the nurse use to measure the infant's head circumference?

Place the tape measure under the infant's head, wrap around the occiput, and measure just above the eyebrows.

The nurse is caring for a term newborn. Which assessment finding should alert the nurse to suspect the potential for jaundice in this infant?

Presence of a cephalhematoma

Which are considered normal findings in a newborn less than 12 hours old? Select all that apply.

Presence of vernix caseosa Anterior fontanelle measuring 5.0 cm Bluish discoloration of hands and feet

The nurse is admitting a newborn infant to the nursery and notes that the health care provider (HCP) has documented that the newborn has an omphalocele and will require a surgical procedure. Preoperative nursing care should include which nursing interventions? Select all that apply.

Protect defect from trauma. Maintain a thermoneutral environment Assess for associated birth defects such as cleft palate

The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the rooting reflex?

Stimulate the perioral cavity with a finger.

The nurse is performing an admission assessment on a newborn infant with the diagnosis of subdural hematoma after a difficult vaginal delivery. Which assessment technique assists to support the newborn's diagnosis?

Stimulating for reflex responses in the extremities

The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection, which site should the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The nurse is teaching the mother of a newborn infant measures to maintain the infant's health. The nurse identifies which as an example of primary prevention activities for the infant? 1. Selective placement of the infant 2. Periodic well-baby examinations 3. Phenylketonuria (PKU) testing at birth 4. Administration of an antibiotic for an umbilical cord staphylococcal infection

2. Periodic well-baby examinations

The nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. Which statement, if made by the mother, demonstrates understanding of why this medication is used?

"The medication will help protect my baby's eyes from certain infections transmitted during the labor and delivery process."

The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which action? 1. Make a loud, abrupt noise to startle the newborn. 2. Stimulate the ball of the foot of the newborn by firm pressure. 3. Stimulate the perioral cavity of the newborn infant with a finger. 4. Stimulate the pads of the newborn infant's hands by firm pressure.

1. Make a loud, abrupt noise to startle the newborn.

The nurse is preparing to teach a new mother how to sponge bathe a 1-day-old newborn. Which actions should the nurse take? Select all that apply.

1. Pat the baby dry gently. 3. Support the newborn's body during the bath. 4. Make sure that the room temperature is 75°F (23.9°C). 5. Cleanse one body area at a time keeping other body areas covered.

The postpartum nurse teaches a mother how to give a bath to the newborn infant and observes the mother performing the procedure. Which observation indicates a lack of understanding of the instructions? 1. The mother bathes the newborn infant after a feeding. 2. The mother states that she should gather all supplies before the bath is started. 3. The mother states that she should never leave the newborn infant in the tub of water alone. 4. The mother fills a clean basin or sink with 2 to 3 inches (5 to 7.5 cm) of water and then checks the temperature with her wrist.

1. The mother bathes the newborn infant after a feeding

A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is performed, and the results are positive. Which is the correct interpretation of these results? 1. Positive for HIV 2. Indicates the presence of maternal infection 3. Indicates that the newborn will develop acquired immunodeficiency syndrome (AIDS) later in life 4. Positive for AIDS

2. Indicates the presence of maternal infection

The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1. Document the findings. 2. Arrange for hearing testing. 3. Notify the health care provider. 4. Cover the ears with gauze pads.

3. Notify the health care provider.

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 70°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 administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis? 1. Protects the newborn's eyes from possible infections acquired while hospitalized. 2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella. 3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor. 4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.

4. Prevents an infection called ophthalmia neonatorum from occurring after birth in a newborn born to a woman with an untreated gonococcal infection.