CORRECT WELL DETAILED
ANSWERS|LATEST!!!!2025/2026|GUARANTEED
What action should the nursery nurse take first in caring for the infant? - ANSWER Dry
the infant quickly with warm blankets
After clearing the airway with a bulb syringe and drying the infant with warming blankets,
the nurse assesses that the infant is breathing and has a HR of 124, but remains cyanotic.
What action should the nurse take? - ANSWER Prepare to give oxygen
At 1 minute the infant has a heart rate of 130, has a slow weak cry, is grimacing, and has
sluggish movements with acrocyanosis. What Apgar score should the nurse assign? -
ANSWER 6
After receiving the labor and delivery report, which information should direct the nurse to
further assessment of the infant's head? - ANSWER Low forceps delivery
Which action should the nurse take prior to weighing the infant? - ANSWER Place a
cover on the scale
Which part of infant care should the nurse delay? - ANSWER Giving eye prophylaxis
The infant's vitals include: T 96.8; HR 136 irregular w/ soft murmur; RR 42. Which action
should the nurse take? - ANSWER Document the finding in the electronic medical
record (EMR)
1
,What action should the nurse take when finding that the head measures 36cm and the chest
measures 35? - ANSWER Document the findings in the EMR
Upon examining the infant's extremities, which finding should the nurse report to the HCP? -
ANSWER Diminished movement in one arm
The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the
nurse perform the Moro reflex? - ANSWER Slightly raise the infant's head and trunk
and allow the infant to drop back 30 degrees
When the nurse conducts a gestational age assessment, which findings may indicate post-
maturity? - ANSWER - Peeling, parchment-like skin
- Thin with loose skin and little subcutaneous fat
- Deep creases at the base of the toes extending to the heels
While administering Vitamin K to infant, which action should the nurse take? -
ANSWER Select the middle part of the vastus lateralis for use.
The nurse next prepares to administer the erythromycin ointment (Ilotycin ophthalmic
ointment). Which approach should the nurse use to administer the ointment? -
ANSWER Cover entire lower conjunctiva with the ointment after gently retracting the
lid
Five hours after delivery, the infant's vital signs are stable and he is taken to his family. While
the nurse discusses care with Mrs. Ivy, the infant starts gagging. Which action should the
nurse implement first? - ANSWER Use bulb syringe to clear the mouth and nose
The nurse instructs the family about feeding the infant. The mother asks how often the
infant should be burped.Which is the best response by the nurse for how often the infant
should be burped? - ANSWER He needs burping at the start of the feeding and after
each ounce (30 mL) of formula
2
,When Mrs. Ivy finishes feeding the infant, she checks the diaper and it is dry. Mr. Ivy
expresses concern that he thinks the infant is becoming dehydrated. - ANSWER The
infant should have 1 or 2 voids per day
After receiving report from the day shift, the night nurse begins making rounds. Upon
entering the Ivy's room, the nurse finds Mrs. Ivy in the bathroom and the infant in the crib
with a bottle propped on a towel. What action should the nurse take? -
ANSWER Remove the bottle from the infant's mouth
The nurse conduct the change of shift assessment of the infant. Which finding by the nurse
is consistent with a cephalhematoma? - ANSWER Well-outlined swelling that does not
cross suture lines
The infant has a reddish papular rash across his face. How should the nurse respond when
Mrs. Ivy asks about the rash? - ANSWER A newborn rash is very common, but it will
disappear soon
One the second day, the nurse assesses the infant for jaundice.Which factor should alert the
nurse to assess for the risk of jaundice? - ANSWER Trauma at birth
The nurse observes that the infant is jaundiced on his face, head, and chest. What action
should the nurse take next? - ANSWER Obtain blood for laboratory analysis
The nurse prepares infant for placement under a bilirubin light. Which actions should the
nurse implement? - ANSWER -Remove the infant's clothing
-Turn off the lights and allow parents to hold infant for feedings
-Place eye patches on the infant
While infant receives phototherapy, his stools become loose and green. What action should
the nurse take? - ANSWER Document the findings in the EMR
3
, Phototherapy blanket. Which instructions should the nurse include in the discharge
planning? - ANSWER Holding the infant does not interrupt the phototherapy process
Mrs. Ivy asks how she will know the phototherapy is working. How should the nurse
respond? - ANSWER Serum bilirubin level decreases
The nurse places the infant under a radiant warmer and starts to dry him quickly. Why? -
ANSWER Convective heat loss from evaporation is reduced.
Rationale: Drying the infant quickly and placing him under a radiant warmer reduces heat
loss through evaporation and radiation.
At 1 minute of age, the infant is alert and active, and has a strong cry. He has a heart rate of
172 and a respiratory rate of 50. The infant's arms and legs are flexed, the color of his body
is pink, and the color of both feet is blue. The nurse continues a physical assessment of the
infant looking for normal and abnormal findings. Which APGAR score should the nurse
assign? - ANSWER One point is deducted for acrocyanosis.
The correct score is 9
Upon inspection of the umbilical cord, which finding should the nurse report to the
healthcare provider (HCP)? - ANSWER One artery and one vein are present
Two arteries and one vein should be present.
The infant's head is molded from the vaginal delivery. Upon seeing the baby, the parent says,
"Oh, he is so beautiful, but something is wrong with his head." How should the nurse
respond? - ANSWER "His head has been molded from delivery through the birth canal,
which is normal."
4
ANSWERS|LATEST!!!!2025/2026|GUARANTEED
What action should the nursery nurse take first in caring for the infant? - ANSWER Dry
the infant quickly with warm blankets
After clearing the airway with a bulb syringe and drying the infant with warming blankets,
the nurse assesses that the infant is breathing and has a HR of 124, but remains cyanotic.
What action should the nurse take? - ANSWER Prepare to give oxygen
At 1 minute the infant has a heart rate of 130, has a slow weak cry, is grimacing, and has
sluggish movements with acrocyanosis. What Apgar score should the nurse assign? -
ANSWER 6
After receiving the labor and delivery report, which information should direct the nurse to
further assessment of the infant's head? - ANSWER Low forceps delivery
Which action should the nurse take prior to weighing the infant? - ANSWER Place a
cover on the scale
Which part of infant care should the nurse delay? - ANSWER Giving eye prophylaxis
The infant's vitals include: T 96.8; HR 136 irregular w/ soft murmur; RR 42. Which action
should the nurse take? - ANSWER Document the finding in the electronic medical
record (EMR)
1
,What action should the nurse take when finding that the head measures 36cm and the chest
measures 35? - ANSWER Document the findings in the EMR
Upon examining the infant's extremities, which finding should the nurse report to the HCP? -
ANSWER Diminished movement in one arm
The nurse performs a newborn assessment and evaluates the infant's reflexes. How does the
nurse perform the Moro reflex? - ANSWER Slightly raise the infant's head and trunk
and allow the infant to drop back 30 degrees
When the nurse conducts a gestational age assessment, which findings may indicate post-
maturity? - ANSWER - Peeling, parchment-like skin
- Thin with loose skin and little subcutaneous fat
- Deep creases at the base of the toes extending to the heels
While administering Vitamin K to infant, which action should the nurse take? -
ANSWER Select the middle part of the vastus lateralis for use.
The nurse next prepares to administer the erythromycin ointment (Ilotycin ophthalmic
ointment). Which approach should the nurse use to administer the ointment? -
ANSWER Cover entire lower conjunctiva with the ointment after gently retracting the
lid
Five hours after delivery, the infant's vital signs are stable and he is taken to his family. While
the nurse discusses care with Mrs. Ivy, the infant starts gagging. Which action should the
nurse implement first? - ANSWER Use bulb syringe to clear the mouth and nose
The nurse instructs the family about feeding the infant. The mother asks how often the
infant should be burped.Which is the best response by the nurse for how often the infant
should be burped? - ANSWER He needs burping at the start of the feeding and after
each ounce (30 mL) of formula
2
,When Mrs. Ivy finishes feeding the infant, she checks the diaper and it is dry. Mr. Ivy
expresses concern that he thinks the infant is becoming dehydrated. - ANSWER The
infant should have 1 or 2 voids per day
After receiving report from the day shift, the night nurse begins making rounds. Upon
entering the Ivy's room, the nurse finds Mrs. Ivy in the bathroom and the infant in the crib
with a bottle propped on a towel. What action should the nurse take? -
ANSWER Remove the bottle from the infant's mouth
The nurse conduct the change of shift assessment of the infant. Which finding by the nurse
is consistent with a cephalhematoma? - ANSWER Well-outlined swelling that does not
cross suture lines
The infant has a reddish papular rash across his face. How should the nurse respond when
Mrs. Ivy asks about the rash? - ANSWER A newborn rash is very common, but it will
disappear soon
One the second day, the nurse assesses the infant for jaundice.Which factor should alert the
nurse to assess for the risk of jaundice? - ANSWER Trauma at birth
The nurse observes that the infant is jaundiced on his face, head, and chest. What action
should the nurse take next? - ANSWER Obtain blood for laboratory analysis
The nurse prepares infant for placement under a bilirubin light. Which actions should the
nurse implement? - ANSWER -Remove the infant's clothing
-Turn off the lights and allow parents to hold infant for feedings
-Place eye patches on the infant
While infant receives phototherapy, his stools become loose and green. What action should
the nurse take? - ANSWER Document the findings in the EMR
3
, Phototherapy blanket. Which instructions should the nurse include in the discharge
planning? - ANSWER Holding the infant does not interrupt the phototherapy process
Mrs. Ivy asks how she will know the phototherapy is working. How should the nurse
respond? - ANSWER Serum bilirubin level decreases
The nurse places the infant under a radiant warmer and starts to dry him quickly. Why? -
ANSWER Convective heat loss from evaporation is reduced.
Rationale: Drying the infant quickly and placing him under a radiant warmer reduces heat
loss through evaporation and radiation.
At 1 minute of age, the infant is alert and active, and has a strong cry. He has a heart rate of
172 and a respiratory rate of 50. The infant's arms and legs are flexed, the color of his body
is pink, and the color of both feet is blue. The nurse continues a physical assessment of the
infant looking for normal and abnormal findings. Which APGAR score should the nurse
assign? - ANSWER One point is deducted for acrocyanosis.
The correct score is 9
Upon inspection of the umbilical cord, which finding should the nurse report to the
healthcare provider (HCP)? - ANSWER One artery and one vein are present
Two arteries and one vein should be present.
The infant's head is molded from the vaginal delivery. Upon seeing the baby, the parent says,
"Oh, he is so beautiful, but something is wrong with his head." How should the nurse
respond? - ANSWER "His head has been molded from delivery through the birth canal,
which is normal."
4
