RNC - Low Risk Neonatal Nursing Exam with all Correct & 100%
Verified Answers |Actual Complete Update |Already Graded A+
Normal skin assessment ✔Correct Answer-Acrocyanosis with decreased peripheral pulses,
facial bruising and/or petechiae
Normal head assessment ✔Correct Answer-Large in relation to body size, cranial molding,
caput succedaneum
Normal newborn lung assessment ✔Correct Answer-RR 40-60/min, coarse rales, prolonged
expiration phase
Normal newborn heart assessment ✔Correct Answer-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 ✔Correct Answer-Bowel sounds will likely appear within
15 minutes of birth, meconium passage within 24 hrs of birth
Normal newborn kidneys ✔Correct Answer-Urine passage within 24 hrs of birth
Normal newborn limb assessment ✔Correct Answer-Positional oddities from intrauterine
positioning (e.g., legs up in frank breech position)
Newborn S/S of Hypoglycemia ✔Correct Answer-Apnea, Pallor, Jittery, Irritability, Weak high-
pitched cry, Hypothermia, Labile temps, Lethargy, Poor feeding, Vomiting, Cyanosis, Seizures
Causes of Hypoglycemia ✔Correct Answer-(Other than delayed feeding): IUGR or prematurity,
Inborn errors of metabolism or glycogen storage disease, Hypothermia or polycythemia,
Adrenal hemorrhage, CHF, Hyperinsulinism
HELLP Syndrome ✔Correct Answer-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 ✔Correct Answer-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) ✔Correct Answer-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? ✔Correct
Answer-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? ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct
Answer-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:
✔Correct Answer-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: ✔Correct Answer-
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? ✔Correct Answer-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: ✔Correct Answer-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? ✔Correct Answer-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: ✔Correct Answer-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)? ✔Correct Answer-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?
✔Correct Answer-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: ✔Correct Answer-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?
✔Correct Answer-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:
✔Correct Answer-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: ✔Correct
Answer-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? ✔Correct Answer-Cool lower limbs
with diminished pulses
Feedback
Verified Answers |Actual Complete Update |Already Graded A+
Normal skin assessment ✔Correct Answer-Acrocyanosis with decreased peripheral pulses,
facial bruising and/or petechiae
Normal head assessment ✔Correct Answer-Large in relation to body size, cranial molding,
caput succedaneum
Normal newborn lung assessment ✔Correct Answer-RR 40-60/min, coarse rales, prolonged
expiration phase
Normal newborn heart assessment ✔Correct Answer-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 ✔Correct Answer-Bowel sounds will likely appear within
15 minutes of birth, meconium passage within 24 hrs of birth
Normal newborn kidneys ✔Correct Answer-Urine passage within 24 hrs of birth
Normal newborn limb assessment ✔Correct Answer-Positional oddities from intrauterine
positioning (e.g., legs up in frank breech position)
Newborn S/S of Hypoglycemia ✔Correct Answer-Apnea, Pallor, Jittery, Irritability, Weak high-
pitched cry, Hypothermia, Labile temps, Lethargy, Poor feeding, Vomiting, Cyanosis, Seizures
Causes of Hypoglycemia ✔Correct Answer-(Other than delayed feeding): IUGR or prematurity,
Inborn errors of metabolism or glycogen storage disease, Hypothermia or polycythemia,
Adrenal hemorrhage, CHF, Hyperinsulinism
HELLP Syndrome ✔Correct Answer-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 ✔Correct Answer-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) ✔Correct Answer-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? ✔Correct
Answer-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? ✔Correct Answer-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? ✔Correct Answer-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? ✔Correct
Answer-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:
✔Correct Answer-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: ✔Correct Answer-
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? ✔Correct Answer-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: ✔Correct Answer-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? ✔Correct Answer-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: ✔Correct Answer-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)? ✔Correct Answer-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?
✔Correct Answer-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: ✔Correct Answer-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?
✔Correct Answer-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:
✔Correct Answer-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: ✔Correct
Answer-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? ✔Correct Answer-Cool lower limbs
with diminished pulses
Feedback
