ANSWERS|LATEST!!!!2025/2026|GUARANTEED
A couple arrives at the newborn nursery asking to take their newborn grandson to his
mother's room. What is the best response by the nurse? - ANSWER 1
"I'll get your grandchild. You must be very excited."
Correct2
"Please go on to see your daughter. I'll bring the baby to her room."
3
"Show me your identification. I need to see it before I can give you the baby."
4
"Only the mother can ask for the baby. Have her call us to bring the baby to her."
Telling the couple that the baby will be brought to the client's room maintains the nurse's
legal responsibility of providing for the infant's safety while still promoting a positive
interaction with the client's family. Giving the infant to another person without the mother's
knowledge or consent is illegal. Legally the nurse may not give the infant to the
grandparents. Although insisting that only the mother can ask for the infant may follow legal
policy, it is an abrupt nontherapeutic response to the grandparents.
The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a
preterm gestational age? - ANSWER Correct1
Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo:
abundant
2
Skin: parchment/wrinkled; breasts: flat areolae, no buds; plantar creases: cover entire sole;
lanugo: absent
1
,3
Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: covering the entire
sole; lanugo: abundant
4
Skin: cracking/few veins; breasts: raised areolae (3- to 4-mm buds); plantar creases: covering
the anterior two thirds of the sole; lanugo: thinning
The characteristics of preterm, term, and postterm gestational age are based on
assessments of physical maturity such as the Ballard or Dubowitz assessment. A preterm
infant's skin is translucent, with many visible veins. A term infant has some cracking of the
skin and some visible veins, depending on gestational age. Term is any gestation after 38
weeks; veins are less visible at 40 weeks' gestation. The postterm infant typically has dry,
leathery, parchmentlike skin with numerous deep wrinkles. The areolae of a preterm infant
are flat, without buds, and they become more raised during development, averaging 3 to 4
mm at term and 5 to 10 mm in the postterm infant. The plantar creases develop on the foot
during gestation, beginning smooth, then covering two thirds at term, and finally covering
the entire sole after term. Lanugo is the fine downy hair that diminishes as the infant
develops gestationally.
A newborn is found to have a diaphragmatic hernia. What is the immediate intervention
after the neonate is admitted to the neonatal intensive care unit? - ANSWER Hydrating
the infant with isotonic enemas
2
Limiting formula feedings to small amounts
3
Placing the infant in the Trendelenburg position
Correct4
Providing gastric decompression via nasogastric tube
When a diaphragmatic hernia is present, intra-abdominal pressure must be minimized; this
is accomplished with the use of gastric decompression. Hydrating the infant with isotonic
enemas is not beneficial. These infants are not fed orally; intravenous fluids are given with
careful measurement of electrolytes and intake and output to guide replacement therapy.
2
,The Trendelenburg position is contraindicated; the abdominal organs will increase pressure
on the diaphragm.
A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate
nursing care of this newborn include? - ANSWER Correct1
Assessing respirations, keeping him warm, and identifying him
2
Applying an antibiotic to the eyes, administering vitamin K, and bathing him
3
Aspirating the oropharynx, rushing him to the nursery, and stimulating him often
4
Weighing him, placing him in a crib, and waiting until the mother is ready to hold him
Establishing a patent airway, diminishing cold stress, and identifying the newborn are the
priorities. Application of eye prophylaxis and administration of vitamin K are often delayed
to allow the parents to bond with the infant; a bath at this time will increase the risk of cold
stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently
are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a
healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready
to hold him are not the priority care for a newborn.
A new mother asks the nurse why her baby seems to have a bowel movement after every
feeding. While preparing a response to explain why this is an expected occurrence, the nurse
remembers that this regularity indicates that what function is adequate? - ANSWER 1
Fluid intake
2
Cardiac sphincter
3
Pancreatic amylase level
Correct4
Gastrocolic reflex response
3
, The gastrocolic reflex is stimulated when the newborn's stomach begins to fill with fluid; this
causes an increase in peristalsis, resulting in the passage of stool during or after a feeding.
Six to 10 voidings a day of pale straw-colored urine are indicative of adequate fluid intake,
not the frequency of bowel movements. The cardiac sphincter is unrelated to bowel
movements; the cardiac sphincter, located between the esophagus and the stomach, is
immature in the newborn and is the reason for the newborn's tendency to regurgitate some
of the feedings. Although pancreatic amylase is a digestive enzyme, it does not stimulate
bowel movements after feedings.
An infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor
when crying. In light of these assessment findings, which actions should the nurse consider
taking next? - ANSWER 1
Taking no specific action, because both signs are expected in a newborn until 2 weeks of age
Correct2
Notifying the health care provider, because circumoral pallor may signal a cardiac problem
3
Taking no specific action, because circumoral pallor is a common finding for the first 72 to 96
hours
4
Notifying the health care provider, because cyanosis usually accompanies increased
intracranial pressure
Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign.
Circumoral pallor is not expected in a healthy newborn, or in a person of any age. Cyanosis
does not indicate increased intracranial pressure.
A nursing instructor provides education for the students on thermoregulation in the nursery.
What do the students determine produces heat in the healthy full-term neonate? -
ANSWER 1
Shivering when chilled
Correct2
4
A couple arrives at the newborn nursery asking to take their newborn grandson to his
mother's room. What is the best response by the nurse? - ANSWER 1
"I'll get your grandchild. You must be very excited."
Correct2
"Please go on to see your daughter. I'll bring the baby to her room."
3
"Show me your identification. I need to see it before I can give you the baby."
4
"Only the mother can ask for the baby. Have her call us to bring the baby to her."
Telling the couple that the baby will be brought to the client's room maintains the nurse's
legal responsibility of providing for the infant's safety while still promoting a positive
interaction with the client's family. Giving the infant to another person without the mother's
knowledge or consent is illegal. Legally the nurse may not give the infant to the
grandparents. Although insisting that only the mother can ask for the infant may follow legal
policy, it is an abrupt nontherapeutic response to the grandparents.
The nurse is caring for a 1-hour-old newborn. Which assessment characteristics represent a
preterm gestational age? - ANSWER Correct1
Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: absent; lanugo:
abundant
2
Skin: parchment/wrinkled; breasts: flat areolae, no buds; plantar creases: cover entire sole;
lanugo: absent
1
,3
Skin: thin, veins visible; breasts: flat areolae, no buds; plantar creases: covering the entire
sole; lanugo: abundant
4
Skin: cracking/few veins; breasts: raised areolae (3- to 4-mm buds); plantar creases: covering
the anterior two thirds of the sole; lanugo: thinning
The characteristics of preterm, term, and postterm gestational age are based on
assessments of physical maturity such as the Ballard or Dubowitz assessment. A preterm
infant's skin is translucent, with many visible veins. A term infant has some cracking of the
skin and some visible veins, depending on gestational age. Term is any gestation after 38
weeks; veins are less visible at 40 weeks' gestation. The postterm infant typically has dry,
leathery, parchmentlike skin with numerous deep wrinkles. The areolae of a preterm infant
are flat, without buds, and they become more raised during development, averaging 3 to 4
mm at term and 5 to 10 mm in the postterm infant. The plantar creases develop on the foot
during gestation, beginning smooth, then covering two thirds at term, and finally covering
the entire sole after term. Lanugo is the fine downy hair that diminishes as the infant
develops gestationally.
A newborn is found to have a diaphragmatic hernia. What is the immediate intervention
after the neonate is admitted to the neonatal intensive care unit? - ANSWER Hydrating
the infant with isotonic enemas
2
Limiting formula feedings to small amounts
3
Placing the infant in the Trendelenburg position
Correct4
Providing gastric decompression via nasogastric tube
When a diaphragmatic hernia is present, intra-abdominal pressure must be minimized; this
is accomplished with the use of gastric decompression. Hydrating the infant with isotonic
enemas is not beneficial. These infants are not fed orally; intravenous fluids are given with
careful measurement of electrolytes and intake and output to guide replacement therapy.
2
,The Trendelenburg position is contraindicated; the abdominal organs will increase pressure
on the diaphragm.
A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate
nursing care of this newborn include? - ANSWER Correct1
Assessing respirations, keeping him warm, and identifying him
2
Applying an antibiotic to the eyes, administering vitamin K, and bathing him
3
Aspirating the oropharynx, rushing him to the nursery, and stimulating him often
4
Weighing him, placing him in a crib, and waiting until the mother is ready to hold him
Establishing a patent airway, diminishing cold stress, and identifying the newborn are the
priorities. Application of eye prophylaxis and administration of vitamin K are often delayed
to allow the parents to bond with the infant; a bath at this time will increase the risk of cold
stress. Aspirating the oropharynx, rushing him to the nursery, and stimulating him frequently
are measures appropriate for a compromised newborn; an 8/9 Apgar score is indicative of a
healthy newborn. Weighing him, placing him in a crib, and waiting until the mother is ready
to hold him are not the priority care for a newborn.
A new mother asks the nurse why her baby seems to have a bowel movement after every
feeding. While preparing a response to explain why this is an expected occurrence, the nurse
remembers that this regularity indicates that what function is adequate? - ANSWER 1
Fluid intake
2
Cardiac sphincter
3
Pancreatic amylase level
Correct4
Gastrocolic reflex response
3
, The gastrocolic reflex is stimulated when the newborn's stomach begins to fill with fluid; this
causes an increase in peristalsis, resulting in the passage of stool during or after a feeding.
Six to 10 voidings a day of pale straw-colored urine are indicative of adequate fluid intake,
not the frequency of bowel movements. The cardiac sphincter is unrelated to bowel
movements; the cardiac sphincter, located between the esophagus and the stomach, is
immature in the newborn and is the reason for the newborn's tendency to regurgitate some
of the feedings. Although pancreatic amylase is a digestive enzyme, it does not stimulate
bowel movements after feedings.
An infant in the newborn nursery has cyanosis of the hands and feet and circumoral pallor
when crying. In light of these assessment findings, which actions should the nurse consider
taking next? - ANSWER 1
Taking no specific action, because both signs are expected in a newborn until 2 weeks of age
Correct2
Notifying the health care provider, because circumoral pallor may signal a cardiac problem
3
Taking no specific action, because circumoral pallor is a common finding for the first 72 to 96
hours
4
Notifying the health care provider, because cyanosis usually accompanies increased
intracranial pressure
Cardiac pathology can be detected at an early age, and circumoral pallor may be a sign.
Circumoral pallor is not expected in a healthy newborn, or in a person of any age. Cyanosis
does not indicate increased intracranial pressure.
A nursing instructor provides education for the students on thermoregulation in the nursery.
What do the students determine produces heat in the healthy full-term neonate? -
ANSWER 1
Shivering when chilled
Correct2
4
