Newborn Saunders NCLEX Test Questions with Verified Answers
The nurse assisted with the delivery of a newborn. Which 3
nursing action is most ettective in preventing heat loss by
evaporation? Evaporation of moisture from a wet body dissipates heat
along with the moisture. Keeping the newborn dry by
1. drying the wet newborn at birth prevents hypothermia via
Warming the crib pad evaporation. Hypothermia caused by conduction occurs
when the newborn is on a cold surface, such as a cold
2.
pad or mattress, and heat from the newborn's body is
Closing the doors to the room
transferred to the colder object (direct contact). Warming
the crib pad assists in preventing hypothermia by conduc-
3.
tion. Convection occurs as air moves across the newborn's
Drying the infant with a warm blanket
skin from an open door and heat is transferred to the air.
4. Radiation occurs when heat from the newborn radiates to
Turning on the overhead radiant warmer a colder surface (indirect contact).
The mother of a newborn calls the clinic and reports that
when cleaning the umbilical cord, she noticed that the
cord was moist and that discharge was present. What is
the most appropriate nursing instruction for this mother?
1
1.
Bring the infant to the clinic. Symptoms of umbilical cord infection are moistness, ooz-
ing, discharge, and a reddened base around the cord.
2.
If symptoms of infection occur, the client should be in-
This is a normal occurrence.
structed to notify a health care provider (HCP). If these
symptoms occur, antibiotics may be necessary. Options 2,
3.
3, and 4 are inappropriate nursing interventions for the
Increase the number of times that the cord is cleaned per
description given in the question.
day.
4.
Monitor the cord for another 24 to 48 hours and call the
clinic if the discharge continues.
,Newborn Saunders NCLEX Test Questions with Verified Answers
The nurse is assessing a newborn after circumcision and
notes that the circumcised area is red with a small amount 3
of bloody drainage. Which nursing action is most appro-
priate? The penis is normally red during the healing process after
circumcision. A yellow exudate may be noted in 24 hours,
1. and this is part of normal healing. The nurse would expect
Apply gentle pressure. that the area would be red with a small amount of bloody
drainage. Only if the bleeding were excessive would the
2.
nurse apply gentle pressure with a sterile gauze. If bleed-
Reinforce the dressing.
ing cannot be controlled, the blood vessel may need to
be ligated, and the nurse would notify the health care
3.
provider. Because the findings identified in the question
Document the findings.
are normal, the nurse would document the assessment
4. findings.
Contact the health care provider (HCP).
The nurse in a newborn nursery is monitoring a preterm
newborn for respiratory distress syndrome. Which assess-
ment findings would alert the nurse to the possibility of
this syndrome? 1
1. A newborn infant with respiratory distress syndrome may
Tachypnea and retractions present with clinical signs of cyanosis, tachypnea or ap-
nea, nasal flaring, chest wall retractions, or audible grunts.
2.
Acrocyanosis, a bluish discoloration of the hands and feet,
Acrocyanosis and grunting
is associated with immature peripheral circulation, and is
common in the first few hours of life. Options 2, 3, and 4 do
3.
not indicate clinical signs of respiratory distress syndrome.
Hypotension and bradycardia
4.
Presence of a barrel chest and acrocyanosis
,The postpartum nurse is providing instructions to the
mother of a newborn with hyperbilirubinemia who is
being breast-fed. The nurse should provide which most
appropriate instruction to the mother? 2
1. Hyperbilirubinemia is an elevated serum bilirubin level.
Feed the newborn less frequently. At any serum bilirubin level, the appearance of jaun-
dice during the first day of life indicates a pathological
2. process. Early and frequent feeding hastens the excretion
Continue to breast-feed every 2 to 4 hours. of bilirubin. Breast-feeding should be initiated within 2
hours after birth and every 2 to 4 hours thereafter. The
3. infant should not be fed less frequently. Switching to
Switch to bottle-feeding the infant for 2 weeks. bottle-feeding for 2 weeks or stopping breast-feeding
permanently is unnecessary.
4.
Stop breast-feeding and switch to bottle-feeding perma-
nently.
The nurse is assessing a newborn who was born to a
mother who is addicted to drugs. Which assessment find-
ing would the nurse expect to note during the assessment
of this newborn?
3
1.
Lethargy A newborn of a woman using drugs is irritable. The infant
is overloaded easily by sensory stimulation. The infant may
2.
cry incessantly and be diflcult to console. The infant would
Sleepiness
hyperextend and posture rather than cuddle when being
held.
3.
Constant crying
4.
Cuddles when being held
, The nurse notes hypotonia, irritability, and a poor sucking
reflex in a full-term newborn on admission to the nursery.
The nurse suspects fetal alcohol syndrome and is aware
that which additional sign would be consistent with this
syndrome? 2
1. Fetal alcohol syndrome is caused by maternal alcohol use
Length of 19 inches during pregnancy. Features of newborns diagnosed with
fetal alcohol syndrome include craniofacial abnormalities,
2. intrauterine growth restriction, cardiac abnormalities, ab-
Abnormal palmar creases normal palmar creases, and respiratory distress. Options
1, 3, and 4 are normal assessment findings in the full-term
3. newborn infant.
Birth weight of 6 lb, 14 oz
4.
Head circumference appropriate for gestational age
The nurse is preparing a plan of care for a newborn with
fetal alcohol syndrome. The nurse should include which
priority intervention in the plan of care? 4
1. Fetal alcohol syndrome is caused by maternal alcohol use
Allow the newborn to establish own sleep-rest pattern. during pregnancy. A primary nursing goal for the new-
born diagnosed with fetal alcohol syndrome is to establish
2.
nutritional balance after delivery. These newborns may
Maintain the newborn in a brightly lighted area of the
exhibit hyperirritability, vomiting, diarrhea, or an unco-
nursery.
ordinated sucking and swallowing ability. A quiet envi-
ronment with minimal stimuli and handling would help
3.
establish appropriate sleep-rest cycles in the newborn as
Encourage frequent handling of the newborn by statt and
well. Options 1, 2, and 3 are inappropriate interventions.
parents.
4.
The nurse assisted with the delivery of a newborn. Which 3
nursing action is most ettective in preventing heat loss by
evaporation? Evaporation of moisture from a wet body dissipates heat
along with the moisture. Keeping the newborn dry by
1. drying the wet newborn at birth prevents hypothermia via
Warming the crib pad evaporation. Hypothermia caused by conduction occurs
when the newborn is on a cold surface, such as a cold
2.
pad or mattress, and heat from the newborn's body is
Closing the doors to the room
transferred to the colder object (direct contact). Warming
the crib pad assists in preventing hypothermia by conduc-
3.
tion. Convection occurs as air moves across the newborn's
Drying the infant with a warm blanket
skin from an open door and heat is transferred to the air.
4. Radiation occurs when heat from the newborn radiates to
Turning on the overhead radiant warmer a colder surface (indirect contact).
The mother of a newborn calls the clinic and reports that
when cleaning the umbilical cord, she noticed that the
cord was moist and that discharge was present. What is
the most appropriate nursing instruction for this mother?
1
1.
Bring the infant to the clinic. Symptoms of umbilical cord infection are moistness, ooz-
ing, discharge, and a reddened base around the cord.
2.
If symptoms of infection occur, the client should be in-
This is a normal occurrence.
structed to notify a health care provider (HCP). If these
symptoms occur, antibiotics may be necessary. Options 2,
3.
3, and 4 are inappropriate nursing interventions for the
Increase the number of times that the cord is cleaned per
description given in the question.
day.
4.
Monitor the cord for another 24 to 48 hours and call the
clinic if the discharge continues.
,Newborn Saunders NCLEX Test Questions with Verified Answers
The nurse is assessing a newborn after circumcision and
notes that the circumcised area is red with a small amount 3
of bloody drainage. Which nursing action is most appro-
priate? The penis is normally red during the healing process after
circumcision. A yellow exudate may be noted in 24 hours,
1. and this is part of normal healing. The nurse would expect
Apply gentle pressure. that the area would be red with a small amount of bloody
drainage. Only if the bleeding were excessive would the
2.
nurse apply gentle pressure with a sterile gauze. If bleed-
Reinforce the dressing.
ing cannot be controlled, the blood vessel may need to
be ligated, and the nurse would notify the health care
3.
provider. Because the findings identified in the question
Document the findings.
are normal, the nurse would document the assessment
4. findings.
Contact the health care provider (HCP).
The nurse in a newborn nursery is monitoring a preterm
newborn for respiratory distress syndrome. Which assess-
ment findings would alert the nurse to the possibility of
this syndrome? 1
1. A newborn infant with respiratory distress syndrome may
Tachypnea and retractions present with clinical signs of cyanosis, tachypnea or ap-
nea, nasal flaring, chest wall retractions, or audible grunts.
2.
Acrocyanosis, a bluish discoloration of the hands and feet,
Acrocyanosis and grunting
is associated with immature peripheral circulation, and is
common in the first few hours of life. Options 2, 3, and 4 do
3.
not indicate clinical signs of respiratory distress syndrome.
Hypotension and bradycardia
4.
Presence of a barrel chest and acrocyanosis
,The postpartum nurse is providing instructions to the
mother of a newborn with hyperbilirubinemia who is
being breast-fed. The nurse should provide which most
appropriate instruction to the mother? 2
1. Hyperbilirubinemia is an elevated serum bilirubin level.
Feed the newborn less frequently. At any serum bilirubin level, the appearance of jaun-
dice during the first day of life indicates a pathological
2. process. Early and frequent feeding hastens the excretion
Continue to breast-feed every 2 to 4 hours. of bilirubin. Breast-feeding should be initiated within 2
hours after birth and every 2 to 4 hours thereafter. The
3. infant should not be fed less frequently. Switching to
Switch to bottle-feeding the infant for 2 weeks. bottle-feeding for 2 weeks or stopping breast-feeding
permanently is unnecessary.
4.
Stop breast-feeding and switch to bottle-feeding perma-
nently.
The nurse is assessing a newborn who was born to a
mother who is addicted to drugs. Which assessment find-
ing would the nurse expect to note during the assessment
of this newborn?
3
1.
Lethargy A newborn of a woman using drugs is irritable. The infant
is overloaded easily by sensory stimulation. The infant may
2.
cry incessantly and be diflcult to console. The infant would
Sleepiness
hyperextend and posture rather than cuddle when being
held.
3.
Constant crying
4.
Cuddles when being held
, The nurse notes hypotonia, irritability, and a poor sucking
reflex in a full-term newborn on admission to the nursery.
The nurse suspects fetal alcohol syndrome and is aware
that which additional sign would be consistent with this
syndrome? 2
1. Fetal alcohol syndrome is caused by maternal alcohol use
Length of 19 inches during pregnancy. Features of newborns diagnosed with
fetal alcohol syndrome include craniofacial abnormalities,
2. intrauterine growth restriction, cardiac abnormalities, ab-
Abnormal palmar creases normal palmar creases, and respiratory distress. Options
1, 3, and 4 are normal assessment findings in the full-term
3. newborn infant.
Birth weight of 6 lb, 14 oz
4.
Head circumference appropriate for gestational age
The nurse is preparing a plan of care for a newborn with
fetal alcohol syndrome. The nurse should include which
priority intervention in the plan of care? 4
1. Fetal alcohol syndrome is caused by maternal alcohol use
Allow the newborn to establish own sleep-rest pattern. during pregnancy. A primary nursing goal for the new-
born diagnosed with fetal alcohol syndrome is to establish
2.
nutritional balance after delivery. These newborns may
Maintain the newborn in a brightly lighted area of the
exhibit hyperirritability, vomiting, diarrhea, or an unco-
nursery.
ordinated sucking and swallowing ability. A quiet envi-
ronment with minimal stimuli and handling would help
3.
establish appropriate sleep-rest cycles in the newborn as
Encourage frequent handling of the newborn by statt and
well. Options 1, 2, and 3 are inappropriate interventions.
parents.
4.
