NCLEX 3000-Maternal-The Neonate Exam
Questions And Answers
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic
ointment 0.5% to a neonate 30 minutes old. Which of the following is the nurse's next
action? - ANSWER (1) Cleanse the eyes prior to instillation (2) Don gloves.(4) To open
the eyes, the nurse places a thumb and finger at the corner of each lid and applies
gentle pressure to the periorbital ridges. (5) The ointment should be spread from the
inner angle of the eye up to the outer angle. (6) After 1 minute, wipe off extra ointment
leaking into the eyes.
A new mother is worried because her breast-feeding neonate "wants to nurse all of the
time." Which of the following is the most appropriate response to the concern of this
mother about her neonate's pattern of breast-feeding? - ANSWER "Breast milk is perfect
for your baby, so his stomach will digest it quickly, necessitating more feedings."
A postpartum client intends 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 responds
that nutritional intake is adequate if the neonate: - ANSWER demonstrates a progressive
weight gain.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An
early sign the nurse should recognize as indicating hypoglycemia in a neonate is: -
ANSWER lethargy
A appropriate-for-gestational-age neonate should weigh: - ANSWER between the 10th
and the 99th percentiles for age.
A client is going to breast-feed her healthy, full-term neonate. The nurse instructs her to
start breast-feeding within 30 minutes of the neonate's birth because: - ANSWER the
neonate will be alert and ready to suck at this time.
, The nurse interprets a neonate's Apgar score of 8 at 5 minutes as: - ANSWER A neonate
who's in good condition
It is difficult to arouse a neonate 3 hours after birth. The nurse recognizes this behavior
reflects: - ANWER normal transition into the sleep cycle.
Which of the following neonatal findings reflects hypothermia? - ANWER Bradycardia
A client states she is worried that her 2-day-old, breast-feeding neonate is not gaining
weight. The nurse should teach the client that breastfeeding is going well if: - ANWER
the neonate latches onto the areola and hears audible swallowing sounds.
At birth, the neonate weighed 7 lb, 3 oz. On day 1 assessment of the neonate, the nurse
measures a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and observes
that the sclerae are slightly yellow. The neonate has been breastfeeding once every 2 to
3 hours. Based on these findings, which nursing diagnosis does the nurse expect to be
added to the plan of care? - ANSWER Risk for injury related to hyperbilirubinemia
Which of the following measurements reflects normal calorie intake for a neonate? -
ANSWER 110 to 130 calories per kg
The nurse is performing an assessment on a neonate. Health history findings reveal that
the mother consumed 3 oz (89 ml) or more of alcohol daily during the pregnancy. What
characteristic does the nurse expect to find in the neonate? - ANSWER Upturned nose
Which of the following neonates is most at risk for the nursing diagnosis Imbalanced
nutrition: Less than body requirements related to poor sucking? ANSWER A bottle-fed,
7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day
When preparing to discharge a neonate, the nurse discovers that the parents have
placed the baby in a child car seat. Which of the following actions is the priority? -
ANSWER Telling them that an infant car seat is safest and making arrangements for
them to rent one
Questions And Answers
(SELECT ALL THAT APPLY) The nurse must administer erythromycin ophthalmic
ointment 0.5% to a neonate 30 minutes old. Which of the following is the nurse's next
action? - ANSWER (1) Cleanse the eyes prior to instillation (2) Don gloves.(4) To open
the eyes, the nurse places a thumb and finger at the corner of each lid and applies
gentle pressure to the periorbital ridges. (5) The ointment should be spread from the
inner angle of the eye up to the outer angle. (6) After 1 minute, wipe off extra ointment
leaking into the eyes.
A new mother is worried because her breast-feeding neonate "wants to nurse all of the
time." Which of the following is the most appropriate response to the concern of this
mother about her neonate's pattern of breast-feeding? - ANSWER "Breast milk is perfect
for your baby, so his stomach will digest it quickly, necessitating more feedings."
A postpartum client intends 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 responds
that nutritional intake is adequate if the neonate: - ANSWER demonstrates a progressive
weight gain.
The neonate of a client with type 1 diabetes mellitus is at high risk for hypoglycemia. An
early sign the nurse should recognize as indicating hypoglycemia in a neonate is: -
ANSWER lethargy
A appropriate-for-gestational-age neonate should weigh: - ANSWER between the 10th
and the 99th percentiles for age.
A client is going to breast-feed her healthy, full-term neonate. The nurse instructs her to
start breast-feeding within 30 minutes of the neonate's birth because: - ANSWER the
neonate will be alert and ready to suck at this time.
, The nurse interprets a neonate's Apgar score of 8 at 5 minutes as: - ANSWER A neonate
who's in good condition
It is difficult to arouse a neonate 3 hours after birth. The nurse recognizes this behavior
reflects: - ANWER normal transition into the sleep cycle.
Which of the following neonatal findings reflects hypothermia? - ANWER Bradycardia
A client states she is worried that her 2-day-old, breast-feeding neonate is not gaining
weight. The nurse should teach the client that breastfeeding is going well if: - ANWER
the neonate latches onto the areola and hears audible swallowing sounds.
At birth, the neonate weighed 7 lb, 3 oz. On day 1 assessment of the neonate, the nurse
measures a weight of 7 lb and an axillary temperature of 98° F (36.7° C) and observes
that the sclerae are slightly yellow. The neonate has been breastfeeding once every 2 to
3 hours. Based on these findings, which nursing diagnosis does the nurse expect to be
added to the plan of care? - ANSWER Risk for injury related to hyperbilirubinemia
Which of the following measurements reflects normal calorie intake for a neonate? -
ANSWER 110 to 130 calories per kg
The nurse is performing an assessment on a neonate. Health history findings reveal that
the mother consumed 3 oz (89 ml) or more of alcohol daily during the pregnancy. What
characteristic does the nurse expect to find in the neonate? - ANSWER Upturned nose
Which of the following neonates is most at risk for the nursing diagnosis Imbalanced
nutrition: Less than body requirements related to poor sucking? ANSWER A bottle-fed,
7-lb, 2-oz (3.2-kg) neonate who produces two stools and wets four diapers per day
When preparing to discharge a neonate, the nurse discovers that the parents have
placed the baby in a child car seat. Which of the following actions is the priority? -
ANSWER Telling them that an infant car seat is safest and making arrangements for
them to rent one
