The nurse is assessing a newborn who has just been delivered. Which of the following is the priority
physiological change?
Successful feeding.
Thermoregulation.
Gld
Extra-uterine circulatory shift.
Spontaneous respirations.
The nurse is caring for a newborn who was delivered 24 hours ago and is due to have an initial bath.
Which of the following interventions should the nurse include when bathing the newborn?
Place a hat on the newborn during bathing.
Utilize a cleanser with a neutral pH during bathing.
o @
Make sure the newborn is placed in hot water.
Use warm 0.9% sodium chloride (normal saline) during bathing.
The nurse is caring for a newborn who was born 30 minutes ago. The nurse recognizes which of the
following as a probable sign of respiratory distress?
P
e Chest retractions.
0. Respirations (R) of 58.
c. Short periods of apnea lasting 8 to 10 seconds.
d. Blue hands and feet.
The nurse is caring for a newborn immediately following birth. After ensuring a patent airway, which
of the following is the priority nursing action?
‘ Dry the skin.
f Administer eye prophylaxis
c. Administer vitamin K.
d. Place an identification bracelet.
The nurse is assessing a newborn who has just been admitted to the nursery. Which of the following
findings requires further assessment by the nurse?
An edematous area on the occiput of the scalp.
D. Head is 1/4 the total body length.
c. Transient rash with macules and papules.
d. lrregular shape of blue-grey pigmentation over the sacral area.
, The nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse
include in the plan of care to prevent jaundice?
a. Begin phototherapy.
Monitor with a transcutaneous bilirubinometry (TcB) monitor.
Initiate early feeding.
Prepare for an exchange blood transfusion.
A nurse is providing postpartum care to a mother with diabetes and her newborn. One and one-half
hours post-delivery, the nurse observed tremors of the newborn’s extremities. The blood glucose
level is obtained from a heel stick and the results are 50 mg/dL. Which of the following actions should
the nurse take next?
a. / Feed the newborn breastmilk or formula.
Place the newborn skin-to-skin with mother.
c. Recheck the blood glucose level.
d. Obtain a complete blood count (CBC) with differential.
The nurse is observing a new mother care for her newborn for the first time. Which of the following
observations requires the nurse to intervene?
a. Mother heating a bottle of formula in a pan of water.
b. Mother supporting the head when holding the newborn.
Mother keeping the diaper below the umbilical cord.
Mother cleaning the newborn's eyes from outer to inner canthus.
The nurse is teaching a postpartum client about the newborn’s Moro reflex. The nurse determines
teaching has been effective when the client reports that the newborn will
e move legs up and down when held on a firm surface.
extend both arms out and abduct them in an embracing motion.
G turn the head to the left, extend left extremity, and flex right extremity.
d. extend and abduct the arms and legs with the toes fanning out.
physiological change?
Successful feeding.
Thermoregulation.
Gld
Extra-uterine circulatory shift.
Spontaneous respirations.
The nurse is caring for a newborn who was delivered 24 hours ago and is due to have an initial bath.
Which of the following interventions should the nurse include when bathing the newborn?
Place a hat on the newborn during bathing.
Utilize a cleanser with a neutral pH during bathing.
o @
Make sure the newborn is placed in hot water.
Use warm 0.9% sodium chloride (normal saline) during bathing.
The nurse is caring for a newborn who was born 30 minutes ago. The nurse recognizes which of the
following as a probable sign of respiratory distress?
P
e Chest retractions.
0. Respirations (R) of 58.
c. Short periods of apnea lasting 8 to 10 seconds.
d. Blue hands and feet.
The nurse is caring for a newborn immediately following birth. After ensuring a patent airway, which
of the following is the priority nursing action?
‘ Dry the skin.
f Administer eye prophylaxis
c. Administer vitamin K.
d. Place an identification bracelet.
The nurse is assessing a newborn who has just been admitted to the nursery. Which of the following
findings requires further assessment by the nurse?
An edematous area on the occiput of the scalp.
D. Head is 1/4 the total body length.
c. Transient rash with macules and papules.
d. lrregular shape of blue-grey pigmentation over the sacral area.
, The nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse
include in the plan of care to prevent jaundice?
a. Begin phototherapy.
Monitor with a transcutaneous bilirubinometry (TcB) monitor.
Initiate early feeding.
Prepare for an exchange blood transfusion.
A nurse is providing postpartum care to a mother with diabetes and her newborn. One and one-half
hours post-delivery, the nurse observed tremors of the newborn’s extremities. The blood glucose
level is obtained from a heel stick and the results are 50 mg/dL. Which of the following actions should
the nurse take next?
a. / Feed the newborn breastmilk or formula.
Place the newborn skin-to-skin with mother.
c. Recheck the blood glucose level.
d. Obtain a complete blood count (CBC) with differential.
The nurse is observing a new mother care for her newborn for the first time. Which of the following
observations requires the nurse to intervene?
a. Mother heating a bottle of formula in a pan of water.
b. Mother supporting the head when holding the newborn.
Mother keeping the diaper below the umbilical cord.
Mother cleaning the newborn's eyes from outer to inner canthus.
The nurse is teaching a postpartum client about the newborn’s Moro reflex. The nurse determines
teaching has been effective when the client reports that the newborn will
e move legs up and down when held on a firm surface.
extend both arms out and abduct them in an embracing motion.
G turn the head to the left, extend left extremity, and flex right extremity.
d. extend and abduct the arms and legs with the toes fanning out.
