Newborn Saunders NCLEX questions with 100% Verified Answers
1. The nurse assisted with the delivery of a 3
newborn. Which nursing action is most ef-
fective in preventing heat loss by evapora- Evaporation of moisture from a
tion? wet body dissipates heat along
with the moisture. Keeping the
1. newborn dry by drying the wet
Warming the crib pad newborn at birth prevents hy-
pothermia via evaporation. Hy-
2. pothermia caused by conduc-
Closing the doors to the room tion occurs when the newborn
is on a cold surface, such as
3. a cold pad or mattress, and
Drying the infant with a warm blanket heat from the newborn's body
is transferred to the colder ob-
4. ject (direct contact). Warming
Turning on the overhead radiant warmer the crib pad assists in prevent-
ing hypothermia by conduc-
tion. Convection occurs as air
moves across the newborn's
skin from an open door and
heat is transferred to the air.
Radiation occurs when heat
from the newborn radiates to
a colder surface (indirect con-
tact).
2. The mother of a newborn calls the clinic 1
and reports that when cleaning the umbil-
ical cord, she noticed that the cord was Symptoms of umbilical cord in-
moist and that discharge was present. fection are moistness, oozing,
What is the most appropriate nursing in- discharge, and a reddened
struction for this mother? base around the cord. If symp-
toms of infection occur, the
1. client should be instructed to
Bring the infant to the clinic. notify a health care provider
(HCP). If these symptoms oc-
2. cur, antibiotics may be neces-
This is a normal occurrence. sary. Options 2, 3, and 4 are in-
appropriate nursing interven-
,Newborn Saunders NCLEX questions with 100% Verified Answers
3. tions for the description given
Increase the number of times that the cord in the question.
is cleaned per day.
4.
Monitor the cord for another 24 to 48 hours
and call the clinic if the discharge contin-
ues.
3. The nurse is assessing a newborn after cir- 3
cumcision and notes that the circumcised
area is red with a small amount of bloody The penis is normally red dur-
drainage. Which nursing action is most ap- ing the healing process after
propriate? circumcision. A yellow exudate
may be noted in 24 hours, and
1. this is part of normal heal-
Apply gentle pressure. ing. The nurse would expect
that the area would be red
2. with a small amount of bloody
Reinforce the dressing. drainage. Only if the bleed-
ing were excessive would the
3. nurse apply gentle pressure
Document the findings. with a sterile gauze. If bleed-
ing cannot be controlled, the
4. blood vessel may need to be
Contact the health care provider (HCP). ligated, and the nurse would
notify the health care provider.
Because the findings identified
in the question are normal, the
nurse would document the as-
sessment findings.
4. The nurse in a newborn nursery is monitor- 1
ing a preterm newborn for respiratory dis-
tress syndrome. Which assessment find- A newborn infant with respi-
ings would alert the nurse to the possibility ratory distress syndrome may
of this syndrome? present with clinical signs of
cyanosis, tachypnea or apnea,
1. nasal flaring, chest wall re-
,Newborn Saunders NCLEX questions with 100% Verified Answers
Tachypnea and retractions tractions, or audible grunts.
Acrocyanosis, a bluish discol-
2. oration of the hands and feet,
Acrocyanosis and grunting is associated with immature
peripheral circulation, and is
3. common in the first few hours
Hypotension and bradycardia of life. Options 2, 3, and 4 do
not indicate clinical signs of
4. respiratory distress syndrome.
Presence of a barrel chest and acro-
cyanosis
5. The postpartum nurse is providing instruc- 2
tions to the mother of a newborn with hy-
perbilirubinemia who is being breast-fed. Hyperbilirubinemia is an ele-
The nurse should provide which most ap- vated serum bilirubin level. At
propriate instruction to the mother? any serum bilirubin level, the
appearance of jaundice during
1. the first day of life indicates
Feed the newborn less frequently. a pathological process. Ear-
ly and frequent feeding has-
2. tens the excretion of bilirubin.
Continue to breast-feed every 2 to 4 hours. Breast-feeding should be initi-
ated within 2 hours after birth
3. and every 2 to 4 hours there-
Switch to bottle-feeding the infant for 2 after. The infant should not be
weeks. fed less frequently. Switching
to bottle-feeding for 2 weeks or
4. stopping breast-feeding per-
Stop breast-feeding and switch to bot- manently is unnecessary.
tle-feeding permanently.
6. The nurse is assessing a newborn who was 3
born to a mother who is addicted to drugs.
Which assessment finding would the nurse A newborn of a woman using
expect to note during the assessment of drugs is irritable. The infant is
this newborn? overloaded easily by sensory
stimulation. The infant may cry
1. incessantly and be difficult to
, Newborn Saunders NCLEX questions with 100% Verified Answers
Lethargy console. The infant would hy-
perextend and posture rather
2. than cuddle when being held.
Sleepiness
3.
Constant crying
4.
Cuddles when being held
7. The nurse notes hypotonia, irritability, and 2
a poor sucking reflex in a full-term newborn
on admission to the nursery. The nurse Fetal alcohol syndrome is
suspects fetal alcohol syndrome and is caused by maternal alcohol
aware that which additional sign would be use during pregnancy. Fea-
consistent with this syndrome? tures of newborns diagnosed
with fetal alcohol syndrome in-
1. clude craniofacial abnormal-
Length of 19 inches ities, intrauterine growth re-
striction, cardiac abnormali-
2. ties, abnormal palmar creas-
Abnormal palmar creases es, and respiratory distress.
Options 1, 3, and 4 are nor-
3. mal assessment findings in
Birth weight of 6 lb, 14 oz the full-term newborn infant.
4.
Head circumference appropriate for gesta-
tional age
8. The nurse is preparing a plan of care for a 4
newborn with fetal alcohol syndrome. The
nurse should include which priority inter- Fetal alcohol syndrome is
vention in the plan of care? caused by maternal alcohol
use during pregnancy. A pri-
1. mary nursing goal for the new-
Allow the newborn to establish own born diagnosed with fetal al-
sleep-rest pattern. cohol syndrome is to establish
1. The nurse assisted with the delivery of a 3
newborn. Which nursing action is most ef-
fective in preventing heat loss by evapora- Evaporation of moisture from a
tion? wet body dissipates heat along
with the moisture. Keeping the
1. newborn dry by drying the wet
Warming the crib pad newborn at birth prevents hy-
pothermia via evaporation. Hy-
2. pothermia caused by conduc-
Closing the doors to the room tion occurs when the newborn
is on a cold surface, such as
3. a cold pad or mattress, and
Drying the infant with a warm blanket heat from the newborn's body
is transferred to the colder ob-
4. ject (direct contact). Warming
Turning on the overhead radiant warmer the crib pad assists in prevent-
ing hypothermia by conduc-
tion. Convection occurs as air
moves across the newborn's
skin from an open door and
heat is transferred to the air.
Radiation occurs when heat
from the newborn radiates to
a colder surface (indirect con-
tact).
2. The mother of a newborn calls the clinic 1
and reports that when cleaning the umbil-
ical cord, she noticed that the cord was Symptoms of umbilical cord in-
moist and that discharge was present. fection are moistness, oozing,
What is the most appropriate nursing in- discharge, and a reddened
struction for this mother? base around the cord. If symp-
toms of infection occur, the
1. client should be instructed to
Bring the infant to the clinic. notify a health care provider
(HCP). If these symptoms oc-
2. cur, antibiotics may be neces-
This is a normal occurrence. sary. Options 2, 3, and 4 are in-
appropriate nursing interven-
,Newborn Saunders NCLEX questions with 100% Verified Answers
3. tions for the description given
Increase the number of times that the cord in the question.
is cleaned per day.
4.
Monitor the cord for another 24 to 48 hours
and call the clinic if the discharge contin-
ues.
3. The nurse is assessing a newborn after cir- 3
cumcision and notes that the circumcised
area is red with a small amount of bloody The penis is normally red dur-
drainage. Which nursing action is most ap- ing the healing process after
propriate? circumcision. A yellow exudate
may be noted in 24 hours, and
1. this is part of normal heal-
Apply gentle pressure. ing. The nurse would expect
that the area would be red
2. with a small amount of bloody
Reinforce the dressing. drainage. Only if the bleed-
ing were excessive would the
3. nurse apply gentle pressure
Document the findings. with a sterile gauze. If bleed-
ing cannot be controlled, the
4. blood vessel may need to be
Contact the health care provider (HCP). ligated, and the nurse would
notify the health care provider.
Because the findings identified
in the question are normal, the
nurse would document the as-
sessment findings.
4. The nurse in a newborn nursery is monitor- 1
ing a preterm newborn for respiratory dis-
tress syndrome. Which assessment find- A newborn infant with respi-
ings would alert the nurse to the possibility ratory distress syndrome may
of this syndrome? present with clinical signs of
cyanosis, tachypnea or apnea,
1. nasal flaring, chest wall re-
,Newborn Saunders NCLEX questions with 100% Verified Answers
Tachypnea and retractions tractions, or audible grunts.
Acrocyanosis, a bluish discol-
2. oration of the hands and feet,
Acrocyanosis and grunting is associated with immature
peripheral circulation, and is
3. common in the first few hours
Hypotension and bradycardia of life. Options 2, 3, and 4 do
not indicate clinical signs of
4. respiratory distress syndrome.
Presence of a barrel chest and acro-
cyanosis
5. The postpartum nurse is providing instruc- 2
tions to the mother of a newborn with hy-
perbilirubinemia who is being breast-fed. Hyperbilirubinemia is an ele-
The nurse should provide which most ap- vated serum bilirubin level. At
propriate instruction to the mother? any serum bilirubin level, the
appearance of jaundice during
1. the first day of life indicates
Feed the newborn less frequently. a pathological process. Ear-
ly and frequent feeding has-
2. tens the excretion of bilirubin.
Continue to breast-feed every 2 to 4 hours. Breast-feeding should be initi-
ated within 2 hours after birth
3. and every 2 to 4 hours there-
Switch to bottle-feeding the infant for 2 after. The infant should not be
weeks. fed less frequently. Switching
to bottle-feeding for 2 weeks or
4. stopping breast-feeding per-
Stop breast-feeding and switch to bot- manently is unnecessary.
tle-feeding permanently.
6. The nurse is assessing a newborn who was 3
born to a mother who is addicted to drugs.
Which assessment finding would the nurse A newborn of a woman using
expect to note during the assessment of drugs is irritable. The infant is
this newborn? overloaded easily by sensory
stimulation. The infant may cry
1. incessantly and be difficult to
, Newborn Saunders NCLEX questions with 100% Verified Answers
Lethargy console. The infant would hy-
perextend and posture rather
2. than cuddle when being held.
Sleepiness
3.
Constant crying
4.
Cuddles when being held
7. The nurse notes hypotonia, irritability, and 2
a poor sucking reflex in a full-term newborn
on admission to the nursery. The nurse Fetal alcohol syndrome is
suspects fetal alcohol syndrome and is caused by maternal alcohol
aware that which additional sign would be use during pregnancy. Fea-
consistent with this syndrome? tures of newborns diagnosed
with fetal alcohol syndrome in-
1. clude craniofacial abnormal-
Length of 19 inches ities, intrauterine growth re-
striction, cardiac abnormali-
2. ties, abnormal palmar creas-
Abnormal palmar creases es, and respiratory distress.
Options 1, 3, and 4 are nor-
3. mal assessment findings in
Birth weight of 6 lb, 14 oz the full-term newborn infant.
4.
Head circumference appropriate for gesta-
tional age
8. The nurse is preparing a plan of care for a 4
newborn with fetal alcohol syndrome. The
nurse should include which priority inter- Fetal alcohol syndrome is
vention in the plan of care? caused by maternal alcohol
use during pregnancy. A pri-
1. mary nursing goal for the new-
Allow the newborn to establish own born diagnosed with fetal al-
sleep-rest pattern. cohol syndrome is to establish
