Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The
nurse should plan to include which instruction in the teaching plan of care during the home visit
to the mother of the newborn?
1.Applying lotions to exposed newborn skin
2.Assessing skin integrity and fluid status of the newborn
3.Having minimal contact with the newborn to prevent stimulation
4.Advising the mother to limit the newborn's oral intake during phototherapy - ans2
Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the
newborn. Assessing skin integrity and fluid status of the newborn infant is an essential
component of phototherapy. Lotions are not used to ensure the therapeutic effect of light
exposure in subcutaneous tissue. Contact with the newborn infant is important. Adequate oral
fluids are essential to prevent dehydration because diarrhea is a common side effect of therapy.
In addition, safe care for the newborn infant during phototherapy requires shielding the eyes with
a soft eye shield to prevent retinal damage, keeping the newborn's skin exposed except for the
wearing of a diaper, and changing the newborn's position frequently.
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The
nurse provides instructions to help the client regarding care of her infant. Which client statement
indicates the need for further instruction?
1."I will be sure to wash my hands before and after bathroom use."
2."I need to breast-feed, especially for the first 6 weeks postpartum."
3."Support groups are available to assist me with understanding my diagnosis of HIV."
4."My newborn infant should be on antiviral medications for the first 6 weeks after delivery." -
ans2
The mode of perinatal transmission of human immunodeficiency virus (HIV) to the fetus or
neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum
period. HIV transmission can occur during breast-feeding. HIV-positive clients should be
encouraged to bottle-feed their infants per the health care provider's prescription. Frequent hand-
washing is encouraged. Support groups and community agencies can be identified to assist the
parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and
available financial resources. It is recommended that infants of HIV-positive clients receive
antiviral medications for the first 6 weeks of life.
,Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks
the nurse to explain the diagnosis. On what description should the nurse plan to base the
response?
1.Gastric contents regurgitate back into the esophagus.
2.The esophagus terminates before it reaches the stomach.
3.Abdominal contents herniate through an opening of the diaphragm.
4.A portion of the stomach protrudes through the esophageal hiatus of the diaphragm. - ans1
GER is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal
atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia.
A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested
for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is
performed, and the results are positive. Which is the correct interpretation of these results?
1.Positive for HIV
2.Indicates the presence of maternal infection
3.Indicates that the newborn will develop AIDS later in life
4.Positive for acquired immunodeficiency syndrome (AIDS) - ans2
A positive antibody test in a child younger than 18 months of age indicates only that the mother
is infected because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months
and, in some cases, as long as 18 months. A positive ELISA does not indicate true HIV infection
or the development of AIDS, nor does it indicate that the newborn will develop AIDS later in
life.
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn,
the nurse's priority is to perform which action?
1.Determine Apgar score.
2.Auscultate the heart rate.
,Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
3.Thoroughly dry the newborn.
4.Take the newborn's rectal temperature. - ans3
An optimal thermal environment is essential to the effective care of a neonate. If a newborn is
not thoroughly dried and placed in a warm environment immediately after delivery, cold stress
may result. Infants respond to cold stress through an increased need for oxygen and depletion of
glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although
auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart
rate via the umbilical cord can be done while drying the infant. Drying the infant should only
take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar
score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately
following delivery.
A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery
room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to
the nursery. The maternity nurse prepares for the arrival of the newborn and places which
priority item at the newborn's bedside?
1.A rectal thermometer
2.A blood pressure cuff
3.A specific gravity urinometer
4.A bottle of sterile normal saline - ans4
Spina bifida is a central nervous system defect that results from failure of the neural tube to close
during embryonic development. The newborn with spina bifida is at risk for infection before the
closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over
the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of
the skin integrity at the site. A thermometer will be needed to assess temperature, but in this
newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure
may be difficult to assess during the newborn period and is not the best indicator of infection.
Urine concentration is not well developed in the newborn stage of development.
A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn.
The nurse plans to explain to the parents that which is the purpose of the medication?
1.Help the newborn to see more clearly.
, Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
2.Ensure the sterility of the conjunctiva in the newborn.
3.Guard against infection acquired during intrauterine life.
4.Protect the newborn from contracting an eye infection during birth. - ans4
The use of eye prophylaxis with an agent such as erythromycin protects the newborn from
contracting a conjunctival infection during birth. This infection, called ophthalmia neonatorum,
results from maternal vaginal infection with chlamydia or gonorrhea. This prophylaxis is
mandatory in the United States. Options 1, 2, and 3 do not describe the purposes of this
medication.
A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the
infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated
with a foul-smelling drainage. Which is the priority nursing action?
1.Reinforce the dressing.
2.Document the findings.
3.Contact the health care provider.
4.Swab the drainage and send the sample to the laboratory for culture. - ans3
Complications after circumcision include bleeding, failure to urinate, displacement of the
Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs
of infection occur, the health care provider is notified. The nurse would change, not reinforce, the
dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical
site. The nurse would document the findings, but this is not the priority item. The health care
provider will prescribe a culture if it is necessary; it is not within the realm of nursing
responsibilities to prescribe a diagnostic test.
A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial
action should the nurse plan to best facilitate bonding between the newborn and the parents?
1.Encourage the parents to touch their newborn.
2.Identify specific caregiving tasks that may be assumed by the parents.
3.Explain the equipment that is used and how it functions to assist their newborn.
4.Give the parents pamphlets that will help them understand their newborn's condition. - ans1
Reviewed Edition..
A 4-day-old newborn is receiving phototherapy at home for a bilirubin level of 14 mg/dL. The
nurse should plan to include which instruction in the teaching plan of care during the home visit
to the mother of the newborn?
1.Applying lotions to exposed newborn skin
2.Assessing skin integrity and fluid status of the newborn
3.Having minimal contact with the newborn to prevent stimulation
4.Advising the mother to limit the newborn's oral intake during phototherapy - ans2
Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the
newborn. Assessing skin integrity and fluid status of the newborn infant is an essential
component of phototherapy. Lotions are not used to ensure the therapeutic effect of light
exposure in subcutaneous tissue. Contact with the newborn infant is important. Adequate oral
fluids are essential to prevent dehydration because diarrhea is a common side effect of therapy.
In addition, safe care for the newborn infant during phototherapy requires shielding the eyes with
a soft eye shield to prevent retinal damage, keeping the newborn's skin exposed except for the
wearing of a diaper, and changing the newborn's position frequently.
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The
nurse provides instructions to help the client regarding care of her infant. Which client statement
indicates the need for further instruction?
1."I will be sure to wash my hands before and after bathroom use."
2."I need to breast-feed, especially for the first 6 weeks postpartum."
3."Support groups are available to assist me with understanding my diagnosis of HIV."
4."My newborn infant should be on antiviral medications for the first 6 weeks after delivery." -
ans2
The mode of perinatal transmission of human immunodeficiency virus (HIV) to the fetus or
neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum
period. HIV transmission can occur during breast-feeding. HIV-positive clients should be
encouraged to bottle-feed their infants per the health care provider's prescription. Frequent hand-
washing is encouraged. Support groups and community agencies can be identified to assist the
parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and
available financial resources. It is recommended that infants of HIV-positive clients receive
antiviral medications for the first 6 weeks of life.
,Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
A newborn infant is diagnosed with gastroesophageal reflux (GER), and the infant's mother asks
the nurse to explain the diagnosis. On what description should the nurse plan to base the
response?
1.Gastric contents regurgitate back into the esophagus.
2.The esophagus terminates before it reaches the stomach.
3.Abdominal contents herniate through an opening of the diaphragm.
4.A portion of the stomach protrudes through the esophageal hiatus of the diaphragm. - ans1
GER is regurgitation of gastric contents back into the esophagus. Option 2 describes esophageal
atresia. Option 3 describes a congenital diaphragmatic hernia. Option 4 describes a hiatal hernia.
A newborn infant of a mother who has human immunodeficiency virus (HIV) infection is tested
for the presence of HIV antibodies. An enzyme-linked immunosorbent assay (ELISA) is
performed, and the results are positive. Which is the correct interpretation of these results?
1.Positive for HIV
2.Indicates the presence of maternal infection
3.Indicates that the newborn will develop AIDS later in life
4.Positive for acquired immunodeficiency syndrome (AIDS) - ans2
A positive antibody test in a child younger than 18 months of age indicates only that the mother
is infected because maternal immunoglobulin G antibodies persist in infants for 6 to 9 months
and, in some cases, as long as 18 months. A positive ELISA does not indicate true HIV infection
or the development of AIDS, nor does it indicate that the newborn will develop AIDS later in
life.
A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn,
the nurse's priority is to perform which action?
1.Determine Apgar score.
2.Auscultate the heart rate.
,Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
3.Thoroughly dry the newborn.
4.Take the newborn's rectal temperature. - ans3
An optimal thermal environment is essential to the effective care of a neonate. If a newborn is
not thoroughly dried and placed in a warm environment immediately after delivery, cold stress
may result. Infants respond to cold stress through an increased need for oxygen and depletion of
glucose stores, resulting in an increased respiratory rate and possibly cyanosis. Although
auscultating the heart rate is essential in the initial assessment of the newborn, palpating the heart
rate via the umbilical cord can be done while drying the infant. Drying the infant should only
take a few seconds and auscultating the heart rate can be done immediately afterward. The Apgar
score is assessed at 1 and 5 minutes of life. Taking the temperature is not a priority immediately
following delivery.
A nurse employed in a neonatal intensive care nursery receives a telephone call from the delivery
room and is told that a newborn with spina bifida (myelomeningocele type) will be transported to
the nursery. The maternity nurse prepares for the arrival of the newborn and places which
priority item at the newborn's bedside?
1.A rectal thermometer
2.A blood pressure cuff
3.A specific gravity urinometer
4.A bottle of sterile normal saline - ans4
Spina bifida is a central nervous system defect that results from failure of the neural tube to close
during embryonic development. The newborn with spina bifida is at risk for infection before the
closure of the sac, which is done soon after birth. A sterile normal saline dressing is placed over
the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of
the skin integrity at the site. A thermometer will be needed to assess temperature, but in this
newborn the priority is to maintain sterile normal saline dressings over the sac. Blood pressure
may be difficult to assess during the newborn period and is not the best indicator of infection.
Urine concentration is not well developed in the newborn stage of development.
A nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn.
The nurse plans to explain to the parents that which is the purpose of the medication?
1.Help the newborn to see more clearly.
, Newborn Assessment NCLEX Questions And Answers Most Recent
Reviewed Edition..
2.Ensure the sterility of the conjunctiva in the newborn.
3.Guard against infection acquired during intrauterine life.
4.Protect the newborn from contracting an eye infection during birth. - ans4
The use of eye prophylaxis with an agent such as erythromycin protects the newborn from
contracting a conjunctival infection during birth. This infection, called ophthalmia neonatorum,
results from maternal vaginal infection with chlamydia or gonorrhea. This prophylaxis is
mandatory in the United States. Options 1, 2, and 3 do not describe the purposes of this
medication.
A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the
infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated
with a foul-smelling drainage. Which is the priority nursing action?
1.Reinforce the dressing.
2.Document the findings.
3.Contact the health care provider.
4.Swab the drainage and send the sample to the laboratory for culture. - ans3
Complications after circumcision include bleeding, failure to urinate, displacement of the
Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs
of infection occur, the health care provider is notified. The nurse would change, not reinforce, the
dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical
site. The nurse would document the findings, but this is not the priority item. The health care
provider will prescribe a culture if it is necessary; it is not within the realm of nursing
responsibilities to prescribe a diagnostic test.
A nurse is preparing to care for a newborn who has respiratory distress syndrome. Which initial
action should the nurse plan to best facilitate bonding between the newborn and the parents?
1.Encourage the parents to touch their newborn.
2.Identify specific caregiving tasks that may be assumed by the parents.
3.Explain the equipment that is used and how it functions to assist their newborn.
4.Give the parents pamphlets that will help them understand their newborn's condition. - ans1
