NCLEX 3000-Maternal-The Neonate QUESTIONS AND ANSWERS 100% CORRECT
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic ointment 0.5% to a
neonate born 30 minutes ago. How should the nurse proceed? ANS: (1) Clean the eyes before
administration (2) Put on gloves.(4) Open the eyes by putting a thumb and finger at the corner of each
lid and gently pressing on the periorbital ridges. (5) Spread the ointment from the inner canthus of the
eye to the outer canthus. (6) Wipe excess ointment from the eyes after waiting 1 minute.
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of
the following responses is most appropriate to address the mother's concerns regarding her neonate's
breast-feeding behavior? ANS: "Breast milk is ideal for your baby, so his stomach will digest it quickly,
which requires more feedings."
A postpartum client plans to breast-feed her first child, a full-term neonate. She asks the nurse, "How
will I know if my baby is getting enough to eat?" The nurse informs her that nutritional intake is
adequate if the neonate: ANS: exhibits a steady weight gain.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the
nurse should recognize as indicating hypoglycemia in a neonate is: ANS: lethargy
An appropriate-for-gestational-age neonate should weigh: ANS: between the 10th and the 99th
percentiles for age.
A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-
feeding within 30 minutes of the neonate's birth because: ANS: the neonate will be responsive and
eager to suck at this time.
Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?
ANS: A neonate who's in good condition
It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:
ANS: normal progression into the sleep cycle.
Which finding in a neonate suggests hypothermia? ANS: Bradycardia
A client is concerned that her 2-day-old, breast-feeding neonate isn't gaining weight. The nurse should
teach the client that breast-feeding is effective if: ANS: the neonate latches onto the areola and
swallows audibly.
At birth, a neonate weighs 7 lb, 3 oz. When assessing the neonate 1 day later, the nurse obtains a weight
of 7 lb and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The
neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should
expect which nursing diagnosis to be added to the plan of care? ANS: Risk for injury related to
hyperbilirubinemia
, Which of the following measurements reflects normal calorie intake for a neonate? ANS: 110 to 130
calories per kg
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or
more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find in
the neonate? ANS: Upturned nose
Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body
requirements related to poor sucking? ANS: A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two
stools and wets four diapers per day
While discharging a neonate, the nurse notices that the parents have placed the infant in a child car
seat. Which action takes priority? ANS: Pointing out that an infant car seat is safest and arranging for
them to rent one
Which of the following explanations describes the rationale for administering vitamin K to every
neonate? ANS: The neonate lacks intestinal flora to make the vitamin.
Which sign indicates respiratory distress in a neonate? ANS: Nasal flaring
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38
weeks and delivers a baby boy. Which priority intervention should be included in the plan of care for the
baby during his first 24 hours? ANS: Provide frequent early feedings with formula.
A neonate's pulse rate drops below 60 beats/minute. How should the nurse intervene? Rank in
chronological order. Use all the options. ANS: 2. Gently shake the neonates shoulders, 3. Call for Help, 1.
Place the neonate on a firm, flat surface, 4. Us the hand-tilt-chin-lift method, 5. Assess breathing, and
then give 2 slow breaths 6. Give compressions
Which of the following describes a preterm neonate? ANS: A neonate born at less than 37 weeks'
gestation regardless of weight
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar
score, the nurse assesses the neonate's: ANS: respiration.
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is
very irritable. The nurse interprets this as which of the following? ANS: This is a normal adverse effect of
phototherapy.
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F
(35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which
nursing diagnosis takes highest priority at this time? ANS: Hypothermia related to heat loss
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term
neonate. Which needle should the nurse use? ANS: 25G, 5/8" needle
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic ointment 0.5% to a
neonate born 30 minutes ago. How should the nurse proceed? ANS: (1) Clean the eyes before
administration (2) Put on gloves.(4) Open the eyes by putting a thumb and finger at the corner of each
lid and gently pressing on the periorbital ridges. (5) Spread the ointment from the inner canthus of the
eye to the outer canthus. (6) Wipe excess ointment from the eyes after waiting 1 minute.
A new mother is concerned because her breast-feeding neonate wants to "nurse all the time." Which of
the following responses is most appropriate to address the mother's concerns regarding her neonate's
breast-feeding behavior? ANS: "Breast milk is ideal for your baby, so his stomach will digest it quickly,
which requires more feedings."
A postpartum client plans to breast-feed her first child, a full-term neonate. She asks the nurse, "How
will I know if my baby is getting enough to eat?" The nurse informs her that nutritional intake is
adequate if the neonate: ANS: exhibits a steady weight gain.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An initial sign the
nurse should recognize as indicating hypoglycemia in a neonate is: ANS: lethargy
An appropriate-for-gestational-age neonate should weigh: ANS: between the 10th and the 99th
percentiles for age.
A client plans to breast-feed her healthy, full-term neonate. The nurse encourages her to start breast-
feeding within 30 minutes of the neonate's birth because: ANS: the neonate will be responsive and
eager to suck at this time.
Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes?
ANS: A neonate who's in good condition
It's difficult to awaken a neonate 3 hours after birth. The nurse recognizes that this behavior indicates:
ANS: normal progression into the sleep cycle.
Which finding in a neonate suggests hypothermia? ANS: Bradycardia
A client is concerned that her 2-day-old, breast-feeding neonate isn't gaining weight. The nurse should
teach the client that breast-feeding is effective if: ANS: the neonate latches onto the areola and
swallows audibly.
At birth, a neonate weighs 7 lb, 3 oz. When assessing the neonate 1 day later, the nurse obtains a weight
of 7 lb and an axillary temperature of 98° F (36.7° C) and notes that the sclerae are slightly yellow. The
neonate has been breast-feeding once every 2 to 3 hours. Based on these findings, the nurse should
expect which nursing diagnosis to be added to the plan of care? ANS: Risk for injury related to
hyperbilirubinemia
, Which of the following measurements reflects normal calorie intake for a neonate? ANS: 110 to 130
calories per kg
The nurse is assessing a neonate. Health history findings indicate that the mother drank 3 oz (89 ml) or
more of alcohol per day throughout pregnancy. Which characteristic should the nurse expect to find in
the neonate? ANS: Upturned nose
Which neonate is at greatest risk for the nursing diagnosis Imbalanced nutrition: Less than body
requirements related to poor sucking? ANS: A bottle-fed, 7-lb, 2-oz (3.2-kg) neonate who produces two
stools and wets four diapers per day
While discharging a neonate, the nurse notices that the parents have placed the infant in a child car
seat. Which action takes priority? ANS: Pointing out that an infant car seat is safest and arranging for
them to rent one
Which of the following explanations describes the rationale for administering vitamin K to every
neonate? ANS: The neonate lacks intestinal flora to make the vitamin.
Which sign indicates respiratory distress in a neonate? ANS: Nasal flaring
A client's gestational diabetes is poorly controlled throughout her pregnancy. She goes into labor at 38
weeks and delivers a baby boy. Which priority intervention should be included in the plan of care for the
baby during his first 24 hours? ANS: Provide frequent early feedings with formula.
A neonate's pulse rate drops below 60 beats/minute. How should the nurse intervene? Rank in
chronological order. Use all the options. ANS: 2. Gently shake the neonates shoulders, 3. Call for Help, 1.
Place the neonate on a firm, flat surface, 4. Us the hand-tilt-chin-lift method, 5. Assess breathing, and
then give 2 slow breaths 6. Give compressions
Which of the following describes a preterm neonate? ANS: A neonate born at less than 37 weeks'
gestation regardless of weight
A client gives birth to a neonate prematurely, at 28 weeks' gestation. To obtain the neonate's Apgar
score, the nurse assesses the neonate's: ANS: respiration.
While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is
very irritable. The nurse interprets this as which of the following? ANS: This is a normal adverse effect of
phototherapy.
When assessing a neonate 1 hour after delivery, the nurse measures an axillary temperature of 95.6° F
(35.3° C), an apical pulse of 110 beats/minute, and a respiratory rate of 64 breaths/minute. Which
nursing diagnosis takes highest priority at this time? ANS: Hypothermia related to heat loss
The nurse prepares to administer an I.M. injection of prophylactic vitamin K to a normal, full-term
neonate. Which needle should the nurse use? ANS: 25G, 5/8" needle
