Assessment NCLEX Questions with
All Guaranteed Pass Solutions 2025-
2026 Updated.
A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery,
the nurse prepares to prevent heat loss in the newborn resulting from evaporation by:
A. Warming the crib pad
B. Turning on the overhead radiant warmer
C. Closing the doors to the room
D. Drying the infant in a warm blanket - Answer D. Drying the infant in a warm blanket
(Evaporation is the loss of heat through the conversion of liquid to vapor. Newborns are wet
from the amniotic fluid when they are born, as the fluid evaporates from their skin, they can
lose heat. Drying the infant using a warm blanket is an excellent measure to help conserve heat
or prevent heat loss. Additionally, drying the face and hair, covering the hair with a cap, and
laying the newborn on the mother's abdomen, effectively reduces heat loss through
evaporation. Keeping the newborn dry by drying the wet newborn infant will prevent
hypothermia via evaporation.)
A nurse is assessing a newborn infant following circumcision and notes that the circumcised
area is red with a small amount of bloody drainage. Which of the following nursing actions
would be most appropriate?
A. Document the findings
B. Contact the physician
C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
D. Reinforce the dressing - Answer A. Document the findings
(Close observation of the circumcision site during the first few hours is necessary to determine if
there is a complication. A yellow exudate may be noted after 24 hours, and this is a part of
normal healing. This should not be washed away because it serves a protective function. The
nurse would expect that the area would be red with a small amount of bloody drainage.
Because the findings identified in the question are normal, the nurse would document the
assessment. Additionally, document if the infant is voiding after the procedure to ascertain that
the urethra is not occluded. Instruct the parents to keep the site free from feces and covered in
petrolatum until healing is complete. If the infant cries constantly and if there is redness or
tenderness due to pain, it should be reported to the physician.)
, A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress
syndrome. Which assessment signs if noted in the newborn infant would alert the nurse to the
possibility of this syndrome?
A. Hypotension and Bradycardia
B. Tachypnea and retractions
C. Acrocyanosis and grunting
D. The presence of a barrel chest with grunting - Answer B. Tachypnea and retractions
(Infants who develop RDS have periods during the day when they are free of symptoms because
of an initial release of surfactant. The initial signs of respiratory distress includes tachypnea (60
breaths per minute), sternal and subcostal retractions, nasal flaring, cyanotic mucous
membranes.)
A postpartum nurse is providing instructions to the mother of a newborn infant with
hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate
instructions to the mother?
A. Switch to bottle-feeding the baby for 2 weeks
B. Stop breastfeeding and switch to bottle-feeding permanently
C. Feed the newborn infant less frequently
D. Continue to breastfeed every 2-4 hours - Answer D. Continue to breastfeed every 2-4
hours
(Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours thereafter.
Early feeding of newborns with hyperbilirubinemia promotes intestinal movement and
excretion of meconium which ultimately helps prevent indirect bilirubin buildup. The other
options are not necessary.)
A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is
exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress
syndrome is diagnosed, and the physician prescribes surfactant replacement therapy. The nurse
would prepare to administer this therapy by:
A. Subcutaneous injection
B. Intravenous injection
C. Instillation of the preparation into the lungs through an endotracheal tube
D. Intramuscular injection - Answer C. Instillation of the preparation into the lungs through
an endotracheal tube
(The aim of therapy in RDS is to support the disease until the disease runs its course with the
subsequent development of surfactant. The infant may benefit from surfactant replacement
therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the
lungs through an endotracheal tube.)