NURS 306 Quiz 9 V1 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
9) | West Coast University
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider as a potential sign of respiratory distress?
A. Acrocyanosis in the hands and feet
B. Nasal flaring and substernal retractions
C. Respiratory rate of 45 breaths per minute
D. Occasional periods of apnea lasting 5 seconds
Answer: B
Rationale: Nasal flaring and substernal retractions are classic clinical indicators of
respiratory distress in the neonate. While acrocyanosis is a normal finding in the first 24 to
48 hours, central cyanosis or accessory muscle use requires immediate intervention. The
nurse must monitor the infant closely for worsening signs such as grunting or a decrease in
oxygen saturation.
2. A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following actions should the nurse include in the plan of care?
A. Apply lotion to the newborn’s skin twice daily
B. Keep the newborn in a diaper and t-shirt
,C. Cover the newborn’s eyes with an opaque mask
D. Discontinue breastfeeding to limit fluid intake
Answer: C
Rationale: Protecting the newborn’s retina from the high-intensity light of phototherapy is
a critical safety measure. The nurse should ensure the mask is secure but not too tight to
prevent pressure on the eyes or nose. Frequent assessment of the skin under the mask and
ensuring the eyes remain closed under the shield is necessary to prevent corneal abrasions.
3. A nurse is performing a physical assessment of a newborn and notes a soft, fluctuant mass
on the scalp that does not cross the suture lines. The nurse should document this as:
A. Caput succedaneum
B. Molding
C. Cephalohematoma
D. Subgaleal hemorrhage
Answer: C
Rationale: A cephalohematoma is a collection of blood between the periosteum and the
skull bone, which is why it does not cross suture lines. In contrast, caput succedaneum is
generalized edema of the scalp that does cross suture lines. The nurse should monitor the
newborn for jaundice as the blood within the hematoma is reabsorbed and broken down.
,4. A nurse is assessing a newborn for Neonatal Abstinence Syndrome (NAS) following
maternal opioid use. Which of the following findings should the nurse expect?
A. Hypotonia and lethargy
B. Excessive sleeping between feedings
C. Low-pitched, weak cry
D. Exaggerated Moro reflex and tremors
Answer: D
Rationale: Newborns with NAS typically display central nervous system irritability, which
manifests as tremors, hypertonicity, and an exaggerated Moro reflex. They often have high-
pitched cries and difficulty self-soothing or sleeping. Managing these symptoms often
involves swaddling, reducing environmental stimuli, and potentially pharmacological
support.
5. A nurse is preparing to administer Vitamin K (Phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To prevent neonatal sepsis
B. To promote blood clotting and prevent Vitamin K Deficiency Bleeding (VKDB)
C. To stimulate the production of red blood cells
D. To assist with the digestion of breast milk
Answer: B
, Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta well and the sterile gut cannot synthesize it. Administering Vitamin K shortly after
birth provides the necessary factors for the liver to produce clotting factors II, VII, IX, and X.
This intervention is standard practice to prevent potentially life-threatening hemorrhagic
disease of the newborn.
6. Which of the following interventions is a priority for a newborn experiencing cold stress?
A. Administer an initial bath to warm the skin
B. Check the newborn’s blood glucose level
C. Increase the flow of oxygen
D. Measure the abdominal circumference
Answer: B
Rationale: Cold stress increases the newborn’s metabolic rate, which rapidly consumes
glucose stores and can lead to hypoglycemia. The nurse must prioritize monitoring blood
sugar while implementing warming measures like skin-to-skin contact or a radiant
warmer. Untreated cold stress can also lead to metabolic acidosis and respiratory distress.
7. A nurse is teaching a new mother about umbilical cord care. Which instruction should the
nurse include?
A. Apply povidone-iodine to the cord at every diaper change
B. Fold the diaper down below the cord stump
C. Keep the diaper covering the cord to keep it warm
Actual Q&A with Rationale (NURS306 Quiz
9) | West Coast University
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider as a potential sign of respiratory distress?
A. Acrocyanosis in the hands and feet
B. Nasal flaring and substernal retractions
C. Respiratory rate of 45 breaths per minute
D. Occasional periods of apnea lasting 5 seconds
Answer: B
Rationale: Nasal flaring and substernal retractions are classic clinical indicators of
respiratory distress in the neonate. While acrocyanosis is a normal finding in the first 24 to
48 hours, central cyanosis or accessory muscle use requires immediate intervention. The
nurse must monitor the infant closely for worsening signs such as grunting or a decrease in
oxygen saturation.
2. A nurse is caring for a newborn who has hyperbilirubinemia and is receiving phototherapy.
Which of the following actions should the nurse include in the plan of care?
A. Apply lotion to the newborn’s skin twice daily
B. Keep the newborn in a diaper and t-shirt
,C. Cover the newborn’s eyes with an opaque mask
D. Discontinue breastfeeding to limit fluid intake
Answer: C
Rationale: Protecting the newborn’s retina from the high-intensity light of phototherapy is
a critical safety measure. The nurse should ensure the mask is secure but not too tight to
prevent pressure on the eyes or nose. Frequent assessment of the skin under the mask and
ensuring the eyes remain closed under the shield is necessary to prevent corneal abrasions.
3. A nurse is performing a physical assessment of a newborn and notes a soft, fluctuant mass
on the scalp that does not cross the suture lines. The nurse should document this as:
A. Caput succedaneum
B. Molding
C. Cephalohematoma
D. Subgaleal hemorrhage
Answer: C
Rationale: A cephalohematoma is a collection of blood between the periosteum and the
skull bone, which is why it does not cross suture lines. In contrast, caput succedaneum is
generalized edema of the scalp that does cross suture lines. The nurse should monitor the
newborn for jaundice as the blood within the hematoma is reabsorbed and broken down.
,4. A nurse is assessing a newborn for Neonatal Abstinence Syndrome (NAS) following
maternal opioid use. Which of the following findings should the nurse expect?
A. Hypotonia and lethargy
B. Excessive sleeping between feedings
C. Low-pitched, weak cry
D. Exaggerated Moro reflex and tremors
Answer: D
Rationale: Newborns with NAS typically display central nervous system irritability, which
manifests as tremors, hypertonicity, and an exaggerated Moro reflex. They often have high-
pitched cries and difficulty self-soothing or sleeping. Managing these symptoms often
involves swaddling, reducing environmental stimuli, and potentially pharmacological
support.
5. A nurse is preparing to administer Vitamin K (Phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To prevent neonatal sepsis
B. To promote blood clotting and prevent Vitamin K Deficiency Bleeding (VKDB)
C. To stimulate the production of red blood cells
D. To assist with the digestion of breast milk
Answer: B
, Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta well and the sterile gut cannot synthesize it. Administering Vitamin K shortly after
birth provides the necessary factors for the liver to produce clotting factors II, VII, IX, and X.
This intervention is standard practice to prevent potentially life-threatening hemorrhagic
disease of the newborn.
6. Which of the following interventions is a priority for a newborn experiencing cold stress?
A. Administer an initial bath to warm the skin
B. Check the newborn’s blood glucose level
C. Increase the flow of oxygen
D. Measure the abdominal circumference
Answer: B
Rationale: Cold stress increases the newborn’s metabolic rate, which rapidly consumes
glucose stores and can lead to hypoglycemia. The nurse must prioritize monitoring blood
sugar while implementing warming measures like skin-to-skin contact or a radiant
warmer. Untreated cold stress can also lead to metabolic acidosis and respiratory distress.
7. A nurse is teaching a new mother about umbilical cord care. Which instruction should the
nurse include?
A. Apply povidone-iodine to the cord at every diaper change
B. Fold the diaper down below the cord stump
C. Keep the diaper covering the cord to keep it warm
