g
NEWBORN ASSESSMENT: NCLEX
QUESTIONS WITH VERIFIED
SOLUTIONS
The gnurse gassisted gwith gthe gdelivery gof ga gnewborn. gWhich gnursing gaction gis
gmost geffective gin gpreventing gheat gloss gby gevaporation?
g1.Warming gthe gcrib gpad
g2.Closing gthe gdoors gto gthe groom
g3.Drying gthe ginfant gwith ga gwarm gblanket
g4.Turning gon gthe goverhead gradiant gwarmer g- gcorrect ganswers g-3
Evaporation gof gmoisture gfrom ga gwet gbody gdissipates gheat galong gwith gthe
gmoisture. gKeeping gthe gnewborn gdry gby gdrying gthe gwet gnewborn gat gbirth
gprevents ghypothermia gvia gevaporation. gHypothermia gcaused gby gconduction
goccurs gwhen gthe gnewborn gis gon ga gcold gsurface, gsuch gas ga gcold gpad gor
gmattress, gand gheat gfrom gthe gnewborn's gbody gis gtransferred gto gthe gcolder
,gobject g(direct gcontact). gWarming gthe gcrib gpad gassists gin gpreventing
ghypothermia gby gconduction. gConvection goccurs gas gair gmoves gacross gthe
gnewborn's gskin gfrom gan gopen gdoor gand gheat gis gtransferred gto gthe gair.
gRadiation goccurs gwhen gheat gfrom gthe gnewborn gradiates gto ga gcolder gsurface
g(indirect gcontact).
The gmother gof ga gnewborn gcalls gthe gclinic gand greports gthat gwhen gcleaning
gthe gumbilical gcord, gshe gnoticed gthat gthe gcord gwas gmoist gand gthat gdischarge
gwas gpresent. gWhat gis gthe gmost gappropriate gnursing ginstruction gfor gthis
gmother?
g1.Bring gthe ginfant gto gthe gclinic.
g2.This gis ga gnormal goccurrence.
g3.Increase gthe gnumber gof gtimes gthat gthe gcord gis gcleaned gper gday.
g4.Monitor gthe gcord gfor ganother g24 gto g48 ghours gand gcall gthe gclinic gif gthe
gdischarge gcontinues. g- gcorrect ganswers g-1
Symptoms gof gumbilical gcord ginfection gare gmoistness, goozing, gdischarge, gand
ga greddened gbase garound gthe gcord. gIf gsymptoms gof ginfection goccur, gthe
gclient gshould gbe ginstructed gto gnotify ga ghealth gcare gprovider g(HCP). gIf gthese
gsymptoms goccur, gantibiotics gmay gbe gnecessary. gOptions g2, g3, gand g4 gare
ginappropriate gnursing ginterventions gfor gthe gdescription ggiven gin gthe gquestion.
The gnurse gis gassessing ga gnewborn gafter gcircumcision gand gnotes gthat gthe
gcircumcised garea gis gred gwith ga gsmall gamount gof gbloody gdrainage. gWhich
gnursing gaction gis gmost gappropriate?
g1.Apply ggentle gpressure.
g2.Reinforce gthe gdressing.
g3.Document gthe gfindings.
g4.Contact gthe ghealth gcare gprovider g(HCP). g- gcorrect ganswers g-3
The gpenis gis gnormally gred gduring gthe ghealing gprocess gafter gcircumcision. gA
gyellow gexudate gmay gbe gnoted gin g24 ghours, gand gthis gis gpart gof gnormal
ghealing. gThe gnurse gwould gexpect gthat gthe garea gwould gbe gred gwith ga gsmall
gamount gof gbloody gdrainage. gOnly gif gthe gbleeding gwere gexcessive gwould gthe
gnurse gapply ggentle gpressure gwith ga gsterile ggauze. gIf gbleeding gcannot gbe
gcontrolled, gthe gblood gvessel gmay gneed gto gbe gligated, gand gthe gnurse gwould
gnotify gthe ghealth gcare gprovider. gBecause gthe gfindings gidentified gin gthe
gquestion gare gnormal, gthe gnurse gwould gdocument gthe gassessment gfindings.
The gnurse gin ga gnewborn gnursery gis gmonitoring ga gpreterm gnewborn gfor
grespiratory gdistress gsyndrome. gWhich gassessment gfindings gwould galert gthe
gnurse gto gthe gpossibility gof gthis gsyndrome?
g1.Tachypnea gand gretractions
g2.Acrocyanosis gand ggrunting
3.Hypotension gand gbradycardia
4.Presence gof ga gbarrel gchest gand gacrocyanosis g- gcorrect ganswers g-1
, A gnewborn ginfant gwith grespiratory gdistress gsyndrome gmay gpresent gwith gclinical
gsigns gof gcyanosis, gtachypnea gor gapnea, gnasal gflaring, gchest gwall gretractions,
gor gaudible ggrunts. gAcrocyanosis, ga gbluish gdiscoloration gof gthe ghands gand
gfeet, gis gassociated gwith gimmature gperipheral gcirculation, gand gis gcommon gin
gthe gfirst gfew ghours gof glife. gOptions g2, g3, gand g4 gdo gnot gindicate gclinical
gsigns gof grespiratory gdistress gsyndrome.
The gpostpartum gnurse gis gproviding ginstructions gto gthe gmother gof ga gnewborn
gwith ghyperbilirubinemia gwho gis gbeing gbreast-fed. gThe gnurse gshould gprovide
gwhich gmost gappropriate ginstruction gto gthe gmother?
g1.Feed gthe gnewborn gless gfrequently
g2.Continue gto gbreast-feed gevery g2 gto g4 ghours.
g3.Switch gto gbottle-feeding gthe ginfant gfor g2 gweeks.
g4.Stop gbreast-feeding gand gswitch gto gbottle-feeding gpermanently. g- gcorrect
ganswers g-2
Hyperbilirubinemia gis gan gelevated gserum gbilirubin glevel. gAt gany gserum gbilirubin
glevel, gthe gappearance gof gjaundice gduring gthe gfirst gday gof glife gindicates ga
gpathological gprocess. gEarly gand gfrequent gfeeding ghastens gthe gexcretion gof
gbilirubin. gBreast-feeding gshould gbe ginitiated gwithin g2 ghours gafter gbirth gand
gevery g2 gto g4 ghours gthereafter. gThe ginfant gshould gnot gbe gfed gless
gfrequently. gSwitching gto gbottle-feeding gfor g2 gweeks gor gstopping gbreast-feeding
gpermanently gis gunnecessary.
The gnurse gis gassessing ga gnewborn gwho gwas gborn gto ga gmother gwho gis
gaddicted gto gdrugs. gWhich gassessment gfinding gwould gthe gnurse gexpect gto
gnote gduring gthe gassessment gof gthis gnewborn?
g1.Lethargy
g2.Sleepiness
g3.Constant gcrying
g4.Cuddles gwhen gbeing gheld g- gcorrect ganswers g-3
A gnewborn gof ga gwoman gusing gdrugs gis girritable. gThe ginfant gis goverloaded
geasily gby gsensory gstimulation. gThe ginfant gmay gcry gincessantly gand gbe
gdifficult gto gconsole. gThe ginfant gwould ghyperextend gand gposture grather gthan
gcuddle gwhen gbeing gheld.
The gnurse gnotes ghypotonia, girritability, gand ga gpoor gsucking greflex gin ga gfull-
term gnewborn gon gadmission gto gthe gnursery. gThe gnurse gsuspects gfetal galcohol
gsyndrome gand gis gaware gthat gwhich gadditional gsign gwould gbe gconsistent gwith
gthis gsyndrome?
g1.Length gof g19 ginches
g2.Abnormal gpalmar gcreases
g3.Birth gweight gof g6 glb, g14 goz
g4.Head gcircumference gappropriate gfor ggestational gage g- gcorrect ganswers g-2
NEWBORN ASSESSMENT: NCLEX
QUESTIONS WITH VERIFIED
SOLUTIONS
The gnurse gassisted gwith gthe gdelivery gof ga gnewborn. gWhich gnursing gaction gis
gmost geffective gin gpreventing gheat gloss gby gevaporation?
g1.Warming gthe gcrib gpad
g2.Closing gthe gdoors gto gthe groom
g3.Drying gthe ginfant gwith ga gwarm gblanket
g4.Turning gon gthe goverhead gradiant gwarmer g- gcorrect ganswers g-3
Evaporation gof gmoisture gfrom ga gwet gbody gdissipates gheat galong gwith gthe
gmoisture. gKeeping gthe gnewborn gdry gby gdrying gthe gwet gnewborn gat gbirth
gprevents ghypothermia gvia gevaporation. gHypothermia gcaused gby gconduction
goccurs gwhen gthe gnewborn gis gon ga gcold gsurface, gsuch gas ga gcold gpad gor
gmattress, gand gheat gfrom gthe gnewborn's gbody gis gtransferred gto gthe gcolder
,gobject g(direct gcontact). gWarming gthe gcrib gpad gassists gin gpreventing
ghypothermia gby gconduction. gConvection goccurs gas gair gmoves gacross gthe
gnewborn's gskin gfrom gan gopen gdoor gand gheat gis gtransferred gto gthe gair.
gRadiation goccurs gwhen gheat gfrom gthe gnewborn gradiates gto ga gcolder gsurface
g(indirect gcontact).
The gmother gof ga gnewborn gcalls gthe gclinic gand greports gthat gwhen gcleaning
gthe gumbilical gcord, gshe gnoticed gthat gthe gcord gwas gmoist gand gthat gdischarge
gwas gpresent. gWhat gis gthe gmost gappropriate gnursing ginstruction gfor gthis
gmother?
g1.Bring gthe ginfant gto gthe gclinic.
g2.This gis ga gnormal goccurrence.
g3.Increase gthe gnumber gof gtimes gthat gthe gcord gis gcleaned gper gday.
g4.Monitor gthe gcord gfor ganother g24 gto g48 ghours gand gcall gthe gclinic gif gthe
gdischarge gcontinues. g- gcorrect ganswers g-1
Symptoms gof gumbilical gcord ginfection gare gmoistness, goozing, gdischarge, gand
ga greddened gbase garound gthe gcord. gIf gsymptoms gof ginfection goccur, gthe
gclient gshould gbe ginstructed gto gnotify ga ghealth gcare gprovider g(HCP). gIf gthese
gsymptoms goccur, gantibiotics gmay gbe gnecessary. gOptions g2, g3, gand g4 gare
ginappropriate gnursing ginterventions gfor gthe gdescription ggiven gin gthe gquestion.
The gnurse gis gassessing ga gnewborn gafter gcircumcision gand gnotes gthat gthe
gcircumcised garea gis gred gwith ga gsmall gamount gof gbloody gdrainage. gWhich
gnursing gaction gis gmost gappropriate?
g1.Apply ggentle gpressure.
g2.Reinforce gthe gdressing.
g3.Document gthe gfindings.
g4.Contact gthe ghealth gcare gprovider g(HCP). g- gcorrect ganswers g-3
The gpenis gis gnormally gred gduring gthe ghealing gprocess gafter gcircumcision. gA
gyellow gexudate gmay gbe gnoted gin g24 ghours, gand gthis gis gpart gof gnormal
ghealing. gThe gnurse gwould gexpect gthat gthe garea gwould gbe gred gwith ga gsmall
gamount gof gbloody gdrainage. gOnly gif gthe gbleeding gwere gexcessive gwould gthe
gnurse gapply ggentle gpressure gwith ga gsterile ggauze. gIf gbleeding gcannot gbe
gcontrolled, gthe gblood gvessel gmay gneed gto gbe gligated, gand gthe gnurse gwould
gnotify gthe ghealth gcare gprovider. gBecause gthe gfindings gidentified gin gthe
gquestion gare gnormal, gthe gnurse gwould gdocument gthe gassessment gfindings.
The gnurse gin ga gnewborn gnursery gis gmonitoring ga gpreterm gnewborn gfor
grespiratory gdistress gsyndrome. gWhich gassessment gfindings gwould galert gthe
gnurse gto gthe gpossibility gof gthis gsyndrome?
g1.Tachypnea gand gretractions
g2.Acrocyanosis gand ggrunting
3.Hypotension gand gbradycardia
4.Presence gof ga gbarrel gchest gand gacrocyanosis g- gcorrect ganswers g-1
, A gnewborn ginfant gwith grespiratory gdistress gsyndrome gmay gpresent gwith gclinical
gsigns gof gcyanosis, gtachypnea gor gapnea, gnasal gflaring, gchest gwall gretractions,
gor gaudible ggrunts. gAcrocyanosis, ga gbluish gdiscoloration gof gthe ghands gand
gfeet, gis gassociated gwith gimmature gperipheral gcirculation, gand gis gcommon gin
gthe gfirst gfew ghours gof glife. gOptions g2, g3, gand g4 gdo gnot gindicate gclinical
gsigns gof grespiratory gdistress gsyndrome.
The gpostpartum gnurse gis gproviding ginstructions gto gthe gmother gof ga gnewborn
gwith ghyperbilirubinemia gwho gis gbeing gbreast-fed. gThe gnurse gshould gprovide
gwhich gmost gappropriate ginstruction gto gthe gmother?
g1.Feed gthe gnewborn gless gfrequently
g2.Continue gto gbreast-feed gevery g2 gto g4 ghours.
g3.Switch gto gbottle-feeding gthe ginfant gfor g2 gweeks.
g4.Stop gbreast-feeding gand gswitch gto gbottle-feeding gpermanently. g- gcorrect
ganswers g-2
Hyperbilirubinemia gis gan gelevated gserum gbilirubin glevel. gAt gany gserum gbilirubin
glevel, gthe gappearance gof gjaundice gduring gthe gfirst gday gof glife gindicates ga
gpathological gprocess. gEarly gand gfrequent gfeeding ghastens gthe gexcretion gof
gbilirubin. gBreast-feeding gshould gbe ginitiated gwithin g2 ghours gafter gbirth gand
gevery g2 gto g4 ghours gthereafter. gThe ginfant gshould gnot gbe gfed gless
gfrequently. gSwitching gto gbottle-feeding gfor g2 gweeks gor gstopping gbreast-feeding
gpermanently gis gunnecessary.
The gnurse gis gassessing ga gnewborn gwho gwas gborn gto ga gmother gwho gis
gaddicted gto gdrugs. gWhich gassessment gfinding gwould gthe gnurse gexpect gto
gnote gduring gthe gassessment gof gthis gnewborn?
g1.Lethargy
g2.Sleepiness
g3.Constant gcrying
g4.Cuddles gwhen gbeing gheld g- gcorrect ganswers g-3
A gnewborn gof ga gwoman gusing gdrugs gis girritable. gThe ginfant gis goverloaded
geasily gby gsensory gstimulation. gThe ginfant gmay gcry gincessantly gand gbe
gdifficult gto gconsole. gThe ginfant gwould ghyperextend gand gposture grather gthan
gcuddle gwhen gbeing gheld.
The gnurse gnotes ghypotonia, girritability, gand ga gpoor gsucking greflex gin ga gfull-
term gnewborn gon gadmission gto gthe gnursery. gThe gnurse gsuspects gfetal galcohol
gsyndrome gand gis gaware gthat gwhich gadditional gsign gwould gbe gconsistent gwith
gthis gsyndrome?
g1.Length gof g19 ginches
g2.Abnormal gpalmar gcreases
g3.Birth gweight gof g6 glb, g14 goz
g4.Head gcircumference gappropriate gfor ggestational gage g- gcorrect ganswers g-2
