RNC - LOW RISK NEONATAL NURSING QUESTIONS
AND ANSWERS
Normal skin assessment - Answers -Acrocyanosis with decreased peripheral pulses,
facial bruising and/or petechiae
Normal head assessment - Answers -Large in relation to body size, cranial molding,
caput succedaneum
Normal newborn lung assessment - Answers -RR 40-60/min, coarse rales, prolonged
expiration phase
Normal newborn heart assessment - Answers -HR 120-160, may peak up to 180 bpm
when stimulated, loud S2, split S2, soft systolic murmur (L —> R shunt from PDA)
Normal newborn GI tract assessment - Answers -Bowel sounds will likely appear within
15 minutes of birth, meconium passage within 24 hrs of birth
Normal newborn kidneys - Answers -Urine passage within 24 hrs of birth
Normal newborn limb assessment - Answers -Positional oddities from intrauterine
positioning (e.g., legs up in frank breech position)
Newborn S/S of Hypoglycemia - Answers -Apnea, Pallor, Jittery, Irritability, Weak high-
pitched cry, Hypothermia, Labile temps, Lethargy, Poor feeding, Vomiting, Cyanosis,
Seizures
Causes of Hypoglycemia - Answers -(Other than delayed feeding): IUGR or
prematurity, Inborn errors of metabolism or glycogen storage disease, Hypothermia or
polycythemia, Adrenal hemorrhage, CHF, Hyperinsulinism
HELLP Syndrome - Answers -May be associated with PIH; symptoms: hemolysis,
elevated liver enzymes, low platelet count; the client is at risk for hemorrhage,
pulmonary edema, and hepatic rupture
Gestational Hypertension - Answers -Transient elevation of blood pressure occurring
for the first time after mid-pregnancy without proteinuria or other signs of preeclampsia
(postpartum period: ends by 12 weeks: Gest HTN. beyond 12 weeks: Chronic HTN).
GBS (group B strep) - Answers -Group B streptococcus (GBS) is a type of bacterial
infection that can be found in a pregnant woman's vagina or rectum. This bacteria is
normally found in the vagina and/or rectum of about 25% of all healthy, adult women.
Women who test positive for GBS are said to be colonized
,The 30-week-gestation fetus of a primagravid mother has been diagnosed in utero with
an omphalocele. Which of the following procedures should the nurse anticipate? -
Answers -Karyotyping via amniocentesis; Omphalocele and gastroschisis are both
commonly associated with accompanying defects or chromosomal abnormalities. An
amniocentesis will likely be performed and karyotyping done to identify any
chromosomal abnormalities.
A 38-week-gestation newborn is vigorous at birth. The infant is dried, wrapped in warm
blankets and placed on the mother's chest. At 6 minutes of life, the infant still appears
cyanotic. According to recommended practice guidelines, which of the following should
the nurse perform FIRST? - Answers -Check the infant's pulse oximeter reading
Feedback
Recommended practice guidelines for neonatal resuscitation utilize pulse oximeter
readings to determine if an infant is within acceptable saturation range for minutes of
life. Use of 100% oxygen is discouraged.
A 39-week-gestation newborn male weighing 3.3 kg (7.3 lbs.) is admitted to the
newborn nursery following a cesarean section. How many kilocalories (kcal) should this
infant consume to meet the average daily requirement? - Answers -330 kcal/day
Feedback
Term newborns require approximately 100 kcal/kg/day. Premature infants require
approximately 120-150 kcal/kg/day.
A nurse is developing a teaching plan for the family of an infant being discharged home
with a gastrostomy tube (G-tube). Which of the following steps should be taken FIRST?
- Answers -Assess the family's current knowledge base
Feedback
Assessment is the first step in the nursing process. In order to facilitate learning, the
learner's knowledge and skills should be assessed before a teaching plan is formed.
A client has arrived at the labor and delivery unit in active labor. The nursing
assessment reveals a history of genital herpes with active lesions in the genital tract at
present. The nurse plans to: - Answers -Prepare the client for a cesarean delivery
Feedback
A cesarean delivery can reduce the risk of neonatal infection with a mother in labor who
has herpetic genital tract lesions. Standard precautions should be maintained.
A 3-day-old, former 35-week-gestation female infant born to a mother with a history of
methadone use is beginning to show signs of neonatal abstinence syndrome (NAS).
Nursing support measures for this infant should include all of the following EXCEPT: -
Answers -Encouraging bottle feeding
Feedback
Breastfeeding is encouraged for bonding, and may also help alleviate some of the
infant's symptoms of methadone withdrawal. Bottle feeding should only be encouraged
if the infant is not demonstrating adequate weight gain with breastfeeding alone, or if the
,infant is showing other adverse reactions to breastfeeding. Breastfeeding should not be
encouraged when the mother has a history of illicit drug use.
A term infant is diagnosed with intrauterine growth restriction. Which of the following
would be a primary factor in determining if this infant's growth restriction is symmetrical
or asymmetrical? - Answers -Head circumference
Feedback
Symmetrical growth restriction results in head circumference proportional to infant body
size and usually represents fetal etiology that spans all trimesters. Asymmetrical growth
restriction is generally head-sparing and infants will have larger head circumference to
body size ratios. Asymmetrical growth restriction usually represents maternal etiologies
that affect third trimester growth and development.
An obstetric practitioner orders an indirect Coombs test to determine the possibility of
maternal-fetal blood interaction. The nurse should: - Answers -Draw the mother's blood
Feedback
An indirect Coombs test performed for obstetric purposes evaluates a mother's blood
(usually Rh negative) for free-flowing antibodies against foreign red blood cells (usually
those with positive Rh factor). A direct Coombs test is performed on the infant's blood.
A nurse is performing an assessment on a 43-week-gestation male infant. Which
physical characteristic should the nurse expect to observe? - Answers -Desquamation
Feedback
The post-term infant (born after the 42nd week of gestation) exhibits dry, peeling,
cracked, almost leather-like skin over the body, which is called desquamation.
A 39-week gestation newborn, weighing 4.8 kg (10.6 lbs.) with Apgar scores of 8 at 1
minute and 9 at 5 minutes following cesarean delivery, is exhibiting tremors of the
hands and feet and an increased respiratory rate. This infant is likely demonstrating: -
Answers -Symptoms of hypoglycemia
Feedback
Large infants require higher caloric intake to maintain their glycogen stores. Symptoms
of hypoglycemia can include limb tremors and tachypnea.
Based on maternal history and current presentation, a 6-day-old term infant is
suspected of having herpes simplex meningitis. Which of the following sets of findings is
likely to appear in this patient's cerebrospinal fluid (CSF)? - Answers -Elevated RBCs,
normal glucose, elevated protein
Feedback
Anticipated CSF findings for acute viral encephalitis include elevated WBCs and RBCs,
elevated protein, and normal or decreased glucose levels. Viral cultures are rarely
positive and should not be relied upon for diagnosis.
Which of the following neonatal factors is correlated with a higher risk of disorganized
infant behavioral states, developmental delays, and difficulties in mother-infant
relationships? - Answers -Lower-than-normal weight for gestational age
, Feedback
Small-for-gestational-age (SGA) infants are at higher risk for behavioral, developmental,
and relationship delays than infants at normal weights for their gestational age.
Extremely low birth weight (ELBW) infants are at even higher risk.
An infant is being placed prone on a radiant warmer. The most appropriate location on
the infant for the servocontrol thermistor is on the: - Answers -Left or right flank area
Feedback
A prone infant should have the radiant warmer thermistor positioned over either flank
area. The thermistor should not be positioned over bony areas or under the axilla.
A nurse is educating a set of parents on the importance of standard interventions
performed during and shortly after delivery of the newborn. Which of the following
complications is prevented by routine vitamin K administration to the newborn shortly
after delivery? - Answers -A nurse is educating a set of parents on the importance of
standard interventions performed during and shortly after delivery of the newborn.
Which of the following complications is prevented by routine vitamin K administration to
the newborn shortly after delivery?
A 2-day-old, former 37-week-gestation infant is diagnosed with congenital pneumonia.
When administering the prescribed antibiotic therapy, the nurse knows that this
condition is: - Answers -Most likely caused by Staphylococcus epidermidis
Feedback
Most cases of bacterial neonatal/congenital pneumonia are caused by Staphylococcus
epidermidis, Group B Streptococcus, E. coli, and Ureaplasma urealyticum. Congenital
pneumonia may also be caused by viruses, the most common of which are herpes
simplex (HSV) and human immunodeficiency virus (HIV).
A term infant has just been admitted to the NICU after experiencing asphyxia during
delivery. The nurse expects the laboratory results for this infant are most likely to show:
- Answers -Acidosis, hypobicarbonatemia, and hypoglycemia
Feedback
Asphyxia causes acidosis, low bicarbonate levels (from being used to buffer acidosis),
and hypoglycemia.
A nurse is assessing a 38-week-gestation infant at 2 hours of life. Which of the following
cardiac assessment details should be reported to the practitioner? - Answers -Cool
lower limbs with diminished pulses
Feedback
Cool, mottled lower extremities with diminished pulses could indicate a coarctation of
the aorta or other circulatory obstruction, and should be reported to the practitioner
immediately.
A term infant is being evaluated for tachypnea following delivery. The nurse caring for
the infant educates the parents by stating that the symptoms associated with TTN are
AND ANSWERS
Normal skin assessment - Answers -Acrocyanosis with decreased peripheral pulses,
facial bruising and/or petechiae
Normal head assessment - Answers -Large in relation to body size, cranial molding,
caput succedaneum
Normal newborn lung assessment - Answers -RR 40-60/min, coarse rales, prolonged
expiration phase
Normal newborn heart assessment - Answers -HR 120-160, may peak up to 180 bpm
when stimulated, loud S2, split S2, soft systolic murmur (L —> R shunt from PDA)
Normal newborn GI tract assessment - Answers -Bowel sounds will likely appear within
15 minutes of birth, meconium passage within 24 hrs of birth
Normal newborn kidneys - Answers -Urine passage within 24 hrs of birth
Normal newborn limb assessment - Answers -Positional oddities from intrauterine
positioning (e.g., legs up in frank breech position)
Newborn S/S of Hypoglycemia - Answers -Apnea, Pallor, Jittery, Irritability, Weak high-
pitched cry, Hypothermia, Labile temps, Lethargy, Poor feeding, Vomiting, Cyanosis,
Seizures
Causes of Hypoglycemia - Answers -(Other than delayed feeding): IUGR or
prematurity, Inborn errors of metabolism or glycogen storage disease, Hypothermia or
polycythemia, Adrenal hemorrhage, CHF, Hyperinsulinism
HELLP Syndrome - Answers -May be associated with PIH; symptoms: hemolysis,
elevated liver enzymes, low platelet count; the client is at risk for hemorrhage,
pulmonary edema, and hepatic rupture
Gestational Hypertension - Answers -Transient elevation of blood pressure occurring
for the first time after mid-pregnancy without proteinuria or other signs of preeclampsia
(postpartum period: ends by 12 weeks: Gest HTN. beyond 12 weeks: Chronic HTN).
GBS (group B strep) - Answers -Group B streptococcus (GBS) is a type of bacterial
infection that can be found in a pregnant woman's vagina or rectum. This bacteria is
normally found in the vagina and/or rectum of about 25% of all healthy, adult women.
Women who test positive for GBS are said to be colonized
,The 30-week-gestation fetus of a primagravid mother has been diagnosed in utero with
an omphalocele. Which of the following procedures should the nurse anticipate? -
Answers -Karyotyping via amniocentesis; Omphalocele and gastroschisis are both
commonly associated with accompanying defects or chromosomal abnormalities. An
amniocentesis will likely be performed and karyotyping done to identify any
chromosomal abnormalities.
A 38-week-gestation newborn is vigorous at birth. The infant is dried, wrapped in warm
blankets and placed on the mother's chest. At 6 minutes of life, the infant still appears
cyanotic. According to recommended practice guidelines, which of the following should
the nurse perform FIRST? - Answers -Check the infant's pulse oximeter reading
Feedback
Recommended practice guidelines for neonatal resuscitation utilize pulse oximeter
readings to determine if an infant is within acceptable saturation range for minutes of
life. Use of 100% oxygen is discouraged.
A 39-week-gestation newborn male weighing 3.3 kg (7.3 lbs.) is admitted to the
newborn nursery following a cesarean section. How many kilocalories (kcal) should this
infant consume to meet the average daily requirement? - Answers -330 kcal/day
Feedback
Term newborns require approximately 100 kcal/kg/day. Premature infants require
approximately 120-150 kcal/kg/day.
A nurse is developing a teaching plan for the family of an infant being discharged home
with a gastrostomy tube (G-tube). Which of the following steps should be taken FIRST?
- Answers -Assess the family's current knowledge base
Feedback
Assessment is the first step in the nursing process. In order to facilitate learning, the
learner's knowledge and skills should be assessed before a teaching plan is formed.
A client has arrived at the labor and delivery unit in active labor. The nursing
assessment reveals a history of genital herpes with active lesions in the genital tract at
present. The nurse plans to: - Answers -Prepare the client for a cesarean delivery
Feedback
A cesarean delivery can reduce the risk of neonatal infection with a mother in labor who
has herpetic genital tract lesions. Standard precautions should be maintained.
A 3-day-old, former 35-week-gestation female infant born to a mother with a history of
methadone use is beginning to show signs of neonatal abstinence syndrome (NAS).
Nursing support measures for this infant should include all of the following EXCEPT: -
Answers -Encouraging bottle feeding
Feedback
Breastfeeding is encouraged for bonding, and may also help alleviate some of the
infant's symptoms of methadone withdrawal. Bottle feeding should only be encouraged
if the infant is not demonstrating adequate weight gain with breastfeeding alone, or if the
,infant is showing other adverse reactions to breastfeeding. Breastfeeding should not be
encouraged when the mother has a history of illicit drug use.
A term infant is diagnosed with intrauterine growth restriction. Which of the following
would be a primary factor in determining if this infant's growth restriction is symmetrical
or asymmetrical? - Answers -Head circumference
Feedback
Symmetrical growth restriction results in head circumference proportional to infant body
size and usually represents fetal etiology that spans all trimesters. Asymmetrical growth
restriction is generally head-sparing and infants will have larger head circumference to
body size ratios. Asymmetrical growth restriction usually represents maternal etiologies
that affect third trimester growth and development.
An obstetric practitioner orders an indirect Coombs test to determine the possibility of
maternal-fetal blood interaction. The nurse should: - Answers -Draw the mother's blood
Feedback
An indirect Coombs test performed for obstetric purposes evaluates a mother's blood
(usually Rh negative) for free-flowing antibodies against foreign red blood cells (usually
those with positive Rh factor). A direct Coombs test is performed on the infant's blood.
A nurse is performing an assessment on a 43-week-gestation male infant. Which
physical characteristic should the nurse expect to observe? - Answers -Desquamation
Feedback
The post-term infant (born after the 42nd week of gestation) exhibits dry, peeling,
cracked, almost leather-like skin over the body, which is called desquamation.
A 39-week gestation newborn, weighing 4.8 kg (10.6 lbs.) with Apgar scores of 8 at 1
minute and 9 at 5 minutes following cesarean delivery, is exhibiting tremors of the
hands and feet and an increased respiratory rate. This infant is likely demonstrating: -
Answers -Symptoms of hypoglycemia
Feedback
Large infants require higher caloric intake to maintain their glycogen stores. Symptoms
of hypoglycemia can include limb tremors and tachypnea.
Based on maternal history and current presentation, a 6-day-old term infant is
suspected of having herpes simplex meningitis. Which of the following sets of findings is
likely to appear in this patient's cerebrospinal fluid (CSF)? - Answers -Elevated RBCs,
normal glucose, elevated protein
Feedback
Anticipated CSF findings for acute viral encephalitis include elevated WBCs and RBCs,
elevated protein, and normal or decreased glucose levels. Viral cultures are rarely
positive and should not be relied upon for diagnosis.
Which of the following neonatal factors is correlated with a higher risk of disorganized
infant behavioral states, developmental delays, and difficulties in mother-infant
relationships? - Answers -Lower-than-normal weight for gestational age
, Feedback
Small-for-gestational-age (SGA) infants are at higher risk for behavioral, developmental,
and relationship delays than infants at normal weights for their gestational age.
Extremely low birth weight (ELBW) infants are at even higher risk.
An infant is being placed prone on a radiant warmer. The most appropriate location on
the infant for the servocontrol thermistor is on the: - Answers -Left or right flank area
Feedback
A prone infant should have the radiant warmer thermistor positioned over either flank
area. The thermistor should not be positioned over bony areas or under the axilla.
A nurse is educating a set of parents on the importance of standard interventions
performed during and shortly after delivery of the newborn. Which of the following
complications is prevented by routine vitamin K administration to the newborn shortly
after delivery? - Answers -A nurse is educating a set of parents on the importance of
standard interventions performed during and shortly after delivery of the newborn.
Which of the following complications is prevented by routine vitamin K administration to
the newborn shortly after delivery?
A 2-day-old, former 37-week-gestation infant is diagnosed with congenital pneumonia.
When administering the prescribed antibiotic therapy, the nurse knows that this
condition is: - Answers -Most likely caused by Staphylococcus epidermidis
Feedback
Most cases of bacterial neonatal/congenital pneumonia are caused by Staphylococcus
epidermidis, Group B Streptococcus, E. coli, and Ureaplasma urealyticum. Congenital
pneumonia may also be caused by viruses, the most common of which are herpes
simplex (HSV) and human immunodeficiency virus (HIV).
A term infant has just been admitted to the NICU after experiencing asphyxia during
delivery. The nurse expects the laboratory results for this infant are most likely to show:
- Answers -Acidosis, hypobicarbonatemia, and hypoglycemia
Feedback
Asphyxia causes acidosis, low bicarbonate levels (from being used to buffer acidosis),
and hypoglycemia.
A nurse is assessing a 38-week-gestation infant at 2 hours of life. Which of the following
cardiac assessment details should be reported to the practitioner? - Answers -Cool
lower limbs with diminished pulses
Feedback
Cool, mottled lower extremities with diminished pulses could indicate a coarctation of
the aorta or other circulatory obstruction, and should be reported to the practitioner
immediately.
A term infant is being evaluated for tachypnea following delivery. The nurse caring for
the infant educates the parents by stating that the symptoms associated with TTN are
