NEWBORN NURSING CARE AND ASSESSMENT NCLEX
QUESTIONS EXAM 2026 QUESTIONS WITH ANSWERS
EXAM 2026 LATEST EDITION SOLVED QUESTIONS &
ANSWERS VERIFIED
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.)
The primary critical observation for Apgar scoring is the:
A. Heart rate
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B. Respiratory rate
C. Presence of meconium
D. Evaluation of the Moro reflex
A. Heart rate
(The heart rate is vital for life and is the most critical observation in Apgar scoring.
Respiratory effect rather than rate is included in the Apgar score; the rate is very
erratic.)
When performing a newborn assessment, the nurse should measure the vital
signs in the following sequence:
A. Pulse, respirations, temperature
B. Temperature, pulse, respirations
C. Respirations, temperature, pulse
D. Respirations, pulse, temperature
D. Respirations, pulse, temperature
(This sequence is least disturbing. Touching with the stethoscope and inserting the
thermometer increase anxiety and elevate vital signs.)
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Within three (3) minutes after birth the normal heart rate of the infant may
range between:
A. 100 and 180
B. 130 and 170
C. 120 and 160
D. 100 and 130
C. 120 and 160
(The heart rate varies with activity; crying will increase the rate, whereas deep sleep
will lower it; a rate between 120 and 160 is expected.)
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The expected respiratory rate of a neonate within three (3) minutes of birth
may be as high as:
A. 50
B. 60
C. 80
D. 100
B. 60
(The respiratory rate is associated with activity and can be as rapid as 60 breaths
per minute; over 60 breaths per minute are considered tachypneic in the infant.)
The nurse is aware that a healthy newborn's respirations are:
A. Regular, abdominal, 40-50 per minute, deep
B. Irregular, abdominal, 30-60 per minute, shallow
C. Irregular, initiated by chest wall, 30-60 per minute, deep
D. Regular, initiated by the chest wall, 40-60 per minute, shallow
B. Irregular, abdominal, 30-60 per minute, shallow
(Normally the newborn's breathing is abdominal and irregular in-depth and rhythm;
the rate ranges from 30-60 breaths per minute.)
To help limit the development of hyperbilirubinemia in the neonate, the plan of
care should include:
A. Monitoring for the passage of meconium each shift
B. Instituting phototherapy for 30 minutes every 6 hours
C. Substituting breastfeeding for formula during the 2nd day after birth
D. Supplementing breastfeeding with glucose water during the first 24 hours
A. Monitoring for the passage of meconium each shift
(Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is
reabsorbed.)
A newborn has small, whitish, pinpoint spots over the nose, which the nurse
knows are caused by retained sebaceous secretions. When charting this
observation, the nurse identifies it as:
A. Milia
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B. Lanugo
C. Whiteheads
D. Mongolian spots
A. Milia
(Milia occurs commonly, are not indicative of any illness, and eventually disappear.)
The nurse decides on a teaching plan for a new mother and her infant. The
plan should include:
A. Discussing the matter with her in a non-threatening manner
B. Showing by example and explanation how to care for the infant
C. Setting up a schedule for teaching the mother how to care for her baby
D. Supplying the emotional support to the mother and encouraging her
independence
B. Showing by example and explanation how to care for the infant
(Teaching the mother by example is a non-threatening approach that allows her to
proceed at her own pace.)
Which action best explains the main role of surfactant in the neonate?
A. Assists with ciliary body maturation in the upper airways
B. Helps maintain a rhythmic breathing pattern
C. Promotes clearing mucus from the respiratory tract
D. Helps the lungs remain expanded after the initiation of breathing
D. Helps the lungs remain expanded after the initiation of breathing
(Surfactant works by reducing surface tension in the lung. Surfactant allows the lung
to remain slightly expanded, decreasing the amount of work required for inspiration.)
While assessing a 2-hour old neonate, the nurse observes the neonate to have
acrocyanosis. Which of the following nursing actions should be performed
initially?
A. Activate the code blue or emergency system
B. Do nothing because acrocyanosis is normal in the neonate
C. Immediately take the newborn's temperature according to hospital policy
D. Notify the physician of the need for a cardiac consult