A nurse is assessing a newborn infant following circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which of the
following nursing actions would be most appropriate?
1. Document the findings
2. Contact the physician
3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing - ANSWER 1. Document the findings - The penis is
normally red during the healing process. A yellow exudate may be noted in 24 hours,
and this is a part of normal healing. The nurse would expect that the area would be
red with a small amount of bloody drainage. If the bleeding is excessive, the nurse
would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the
blood vessel may need to be ligated, and the nurse would contact the physician.
Because the findings identified in the question are normal, the nurse would
document the assessment.
A nurse in a delivery room is assisting with the delivery of a newborn infant. After
the delivery, the nurse prepares to prevent heat loss in the newborn resulting from
evaporation by:
1. Warming the crib pad
2. Turning on the overhead radiant warmer
3. Closing the doors to the room
4. Drying the infant in a warm blanket - ANSWER 4. Drying the infant in a warm
blanket - Evaporation of moisture from a wet body dissipates heat along with the
moisture. Keeping the newborn dry by drying the wet newborn infant will prevent
hypothermia via evaporation.
A nurse in the newborn nursery is monitoring a preterm newborn infant for
respiratory distress syndrome. Which assessment signs if noted in the newborn
infant would alert the nurse to the possibility of this syndrome?
1. Hypotension and Bradycardia
2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest with grunting - ANSWER 2. Tachypnea and
retractions - The infant with respiratory distress syndrome may present with signs of
cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
A nurse in a newborn nursery is performing an assessment of a newborn infant. The
nurse is preparing to measure the head circumference of the infant. The nurse would
most appropriately:
1. Wrap the tape measure around the infant's head and measure just above the
eyebrows.
2. Place the tape measure under the infants head at the base of the skull and wrap
around to the front just above the eyes
3. Place the tape measure under the infants head, wrap around the occiput, and
measure just above the eyes
4. Place the tape measure at the back of the infant's head, wrap around across the
ears, and measure across the infant's mouth. - ANSWER 3. To measure the head
circumference, the nurse should place the tape measure under the infant's head,
wrap the tape around the occiput, and measure just above the eyebrows so that the
largest area of the occiput is included.
, A postpartum nurse is providing instructions to the mother of a newborn infant with
hyperbilirubinemia who is being breastfed. The nurse provides which most
appropriate instructions to the mother?
1. Switch to bottle feeding the baby for 2 weeks
2. Stop the breast feedings and switch to bottle-feeding permanently
3. Feed the newborn infant less frequently
4. Continue to breast-feed every 2-4 hours - ANSWER 4. Continue to breast-feed
every 2-4 hours - Breast feeding should be initiated within 2 hours after birth and
every 2-4 hours thereafter. The other options are not necessary.
A nurse on the newborn nursery floor is caring for a neonate. On assessment the
infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting.
Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant
replacement therapy. The nurse would prepare to administer this therapy by:
1. Subcutaneous injection
2. Intravenous injection
3. Instillation of the preparation into the lungs through an endotracheal tube
4. Intramuscular injection - ANSWER 3. The aim of therapy in RDS is to support the
disease until the disease runs its course with the subsequent development of
surfactant. The infant may benefit from surfactant replacement therapy. In surfactant
replacement, an exogenous surfactant preparation is instilled into the lungs through
an endotracheal tube.
A nurse is assessing a newborn infant who was born to a mother who is addicted to
drugs. Which of the following assessment findings would the nurse expect to note
during the assessment of this newborn?
1. Sleepiness
2. Cuddles when being held
3. Lethargy
4. Incessant crying - ANSWER 4. Incessant crying - A newborn infant born to a
woman using drugs is irritable. The infant is overloaded easily by sensory
stimulation. The infant may cry incessantly and posture rather than cuddle when
being held.
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother
asks the nurse why her newborn infant needs the injection. The best response by the
nurse would be:
1. "You infant needs vitamin K to develop immunity."
2. "The vitamin K will protect your infant from being jaundiced."
3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant
from abnormal bleeding."
4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of
bacteria in the bowel." - ANSWER 3. Vitamin K is necessary for the body to
synthesize coagulation factors. Vitamin K is administered to the newborn infant to
prevent abnormal bleeding. Newborn infants are vitamin K deficient because the
bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K.
The infant's bowel does not have support the production of vitamin K until bacteria
adequately colonizes it by food ingestion.
circumcised area is red with a small amount of bloody drainage. Which of the
following nursing actions would be most appropriate?
1. Document the findings
2. Contact the physician
3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing - ANSWER 1. Document the findings - The penis is
normally red during the healing process. A yellow exudate may be noted in 24 hours,
and this is a part of normal healing. The nurse would expect that the area would be
red with a small amount of bloody drainage. If the bleeding is excessive, the nurse
would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the
blood vessel may need to be ligated, and the nurse would contact the physician.
Because the findings identified in the question are normal, the nurse would
document the assessment.
A nurse in a delivery room is assisting with the delivery of a newborn infant. After
the delivery, the nurse prepares to prevent heat loss in the newborn resulting from
evaporation by:
1. Warming the crib pad
2. Turning on the overhead radiant warmer
3. Closing the doors to the room
4. Drying the infant in a warm blanket - ANSWER 4. Drying the infant in a warm
blanket - Evaporation of moisture from a wet body dissipates heat along with the
moisture. Keeping the newborn dry by drying the wet newborn infant will prevent
hypothermia via evaporation.
A nurse in the newborn nursery is monitoring a preterm newborn infant for
respiratory distress syndrome. Which assessment signs if noted in the newborn
infant would alert the nurse to the possibility of this syndrome?
1. Hypotension and Bradycardia
2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest with grunting - ANSWER 2. Tachypnea and
retractions - The infant with respiratory distress syndrome may present with signs of
cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
A nurse in a newborn nursery is performing an assessment of a newborn infant. The
nurse is preparing to measure the head circumference of the infant. The nurse would
most appropriately:
1. Wrap the tape measure around the infant's head and measure just above the
eyebrows.
2. Place the tape measure under the infants head at the base of the skull and wrap
around to the front just above the eyes
3. Place the tape measure under the infants head, wrap around the occiput, and
measure just above the eyes
4. Place the tape measure at the back of the infant's head, wrap around across the
ears, and measure across the infant's mouth. - ANSWER 3. To measure the head
circumference, the nurse should place the tape measure under the infant's head,
wrap the tape around the occiput, and measure just above the eyebrows so that the
largest area of the occiput is included.
, A postpartum nurse is providing instructions to the mother of a newborn infant with
hyperbilirubinemia who is being breastfed. The nurse provides which most
appropriate instructions to the mother?
1. Switch to bottle feeding the baby for 2 weeks
2. Stop the breast feedings and switch to bottle-feeding permanently
3. Feed the newborn infant less frequently
4. Continue to breast-feed every 2-4 hours - ANSWER 4. Continue to breast-feed
every 2-4 hours - Breast feeding should be initiated within 2 hours after birth and
every 2-4 hours thereafter. The other options are not necessary.
A nurse on the newborn nursery floor is caring for a neonate. On assessment the
infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting.
Respiratory distress syndrome is diagnosed, and the physician prescribes surfactant
replacement therapy. The nurse would prepare to administer this therapy by:
1. Subcutaneous injection
2. Intravenous injection
3. Instillation of the preparation into the lungs through an endotracheal tube
4. Intramuscular injection - ANSWER 3. The aim of therapy in RDS is to support the
disease until the disease runs its course with the subsequent development of
surfactant. The infant may benefit from surfactant replacement therapy. In surfactant
replacement, an exogenous surfactant preparation is instilled into the lungs through
an endotracheal tube.
A nurse is assessing a newborn infant who was born to a mother who is addicted to
drugs. Which of the following assessment findings would the nurse expect to note
during the assessment of this newborn?
1. Sleepiness
2. Cuddles when being held
3. Lethargy
4. Incessant crying - ANSWER 4. Incessant crying - A newborn infant born to a
woman using drugs is irritable. The infant is overloaded easily by sensory
stimulation. The infant may cry incessantly and posture rather than cuddle when
being held.
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother
asks the nurse why her newborn infant needs the injection. The best response by the
nurse would be:
1. "You infant needs vitamin K to develop immunity."
2. "The vitamin K will protect your infant from being jaundiced."
3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant
from abnormal bleeding."
4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of
bacteria in the bowel." - ANSWER 3. Vitamin K is necessary for the body to
synthesize coagulation factors. Vitamin K is administered to the newborn infant to
prevent abnormal bleeding. Newborn infants are vitamin K deficient because the
bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K.
The infant's bowel does not have support the production of vitamin K until bacteria
adequately colonizes it by food ingestion.
