Assessment NCLEX ACTUAL EXAM 2026 LATEST
UPDATE WITH VERIFIED QUESTIONS AND CORRECT
ANSWERS|| LATEST VERSION WITHCOMPLETE
QUESTIONS & ANSWERS|| ALREADY GRADED A+ |
LATEST UPDATE 2026-2027
A neonate is admitted to a hospital's central nursery. The neonate's
vital signs are: temperature = 96.5 degrees F., heart rate = 120 bpm, and
respirations = 40/minute. The infant is pink with slight acrocyanosis. The
priority nursing diagnosis for the neonate is:
A. Ineffective thermoregulation related to fluctuating environmental
temperatures.
B. Potential for infection related to lack of immunity.
C. Altered nutrition, less than body requirements related to diminished
sucking reflex.
D. Altered elimination pattern related to lack of nourishment.
A. Ineffective thermoregulation related to fluctuating environmental
temperatures.
(Normal newborn temperature is around 97.8 to 98.8 F (axillary).
Newborns have very small bodies and don't produce much heat
themselves, but they readily absorb heat when they are held. Most
cooling of the newborn occurs immediately after birth. During the first
10 to 20 minutes, the newborn may lose enough heat for the body
temperature to fall by 2-4°C if appropriate measures are not taken.
Continued heat loss will occur in the following hours if proper care is
not provided. The temperature of the environment during delivery and
the postnatal period has a significant effect on the risk to the newborn
of developing hypothermia.)
,A nurse in a newborn nursery receives a phone call to prepare for the
admission of a 43-week-gestation newborn with Apgar scores of 1
and 4. In planning for the admission of this infant, the nurse's highest
priority should be to:
A. Connect the resuscitation bag to the oxygen outlet
B. Turn on the apnea and cardiorespiratory monitors
C. Set up the intravenous line with 5% dextrose in water
D. Set the radiant warmer control temperature at 36.5 C (97.6F)
A. Connect the resuscitation bag to the oxygen outlet
(The highest priority on admission to the nursery for a newborn with
low Apgar scores is airway, which would involve preparing respiratory
resuscitation equipment.)
, Vitamin K is prescribed for a neonate. A nurse prepares to administer
the medication in which muscle site?
A. Deltoid
B. Triceps
C. Vastus lateralis
D. Biceps
C. Vastus lateralis
(Vitamin K is given as a prophylaxis for hemorrhagic disease. It is
administered intramuscular (IM) in the vastus lateralis muscle. The
vastus lateralis muscle lies lateral to the midline of the thigh and wraps
about 1/4 the distance around the thigh.)
A baby is born precipitously in the ER. The nurse's initial action should
be to:
A. Establish an airway for the baby
B. Ascertain the condition of the fundus
C. Quickly tie and cut the umbilical cord
D. Move mother and baby to the birthing unit
A. Establish an airway for the baby
(The nurse should position the baby with head lower than chest and
rub the infant's back to stimulate crying to promote oxygenation.)