PN 131 NEWBORN NORMAL & COMPLICATIONS EXAM
QUESTIONS WITH CORRECT ANSWERS
What is the duration of the first period of reactivity (Phase 1) after birth? -
ANSWER 0 to 30 minutes
During Phase 1 of neonatal transition, the infant's heart rate initially shows
what? - ANSWER Tachycardia
Why is Phase 1 of neonatal transition the best time to initiate breastfeeding? -
ANSWER The sucking reflex is present and the infant is alert.
What is the duration of the 'decreased responsiveness' phase (Phase 2) of
neonatal transition? - ANSWER 30 minutes to 2 hours after birth
How does an infant's motor activity change during Phase 2 of neonatal
transition? - ANSWER There is a marked decrease in motor activity or the infant
sleeps.
What characterizes the bowel sounds during Phase 2 of neonatal transition? -
ANSWER Audible bowel sounds
What is the duration of the second period of reactivity (Phase 3)? - ANSWER 2 to
8 hours after birth
Which waste product is typically passed during Phase 3 of neonatal transition? -
ANSWER Meconium
Why might a newborn gag during Phase 3 of neonatal transition? - ANSWER
Increased mucus production
What is the number one priority of care for the newborn immediately after birth?
- ANSWER Airway maintenance
What is the second priority of care for the newborn immediately after birth? -
ANSWER Maintaining body temperature (thermoregulation)
At what two specific time intervals is APGAR scoring performed? - ANSWER 1
minute and 5 minutes after birth
In the APGAR mnemonic, what does the first 'A' stand for? - ANSWER
Appearance (Skin Color)
, In the APGAR mnemonic, what does 'P' stand for? - ANSWER Pulse Rate
In the APGAR mnemonic, what does 'G' stand for? - ANSWER Grimace (Reflex
Irritability)
In the APGAR mnemonic, what does the second 'A' stand for? - ANSWER Activity
(Muscle Tone)
In the APGAR mnemonic, what does 'R' stand for? - ANSWER Respiratory Effort
An infant with an APGAR score of 4 to 7 requires what nursing intervention? -
ANSWER Gentle stimulation such as rubbing the back
What intervention is required for a newborn with an APGAR score below 3? -
ANSWER Active resuscitation
What APGAR score range indicates an infant requires no action other than
continued observation? - ANSWER 8 to 10
Case Study: 1-minute APGAR. No noise, no breathing, blue hands, heart rate 50.
What is the score? - ANSWER 1 (Pulse < 100 = 1; all others = 0)
Case Study: 5-minute APGAR. Cries when stimulated, irregular breathing, pink
all over, heart rate 124. What is the score? - ANSWER 8 (Appearance 2, Pulse 2,
Grimace 2, Activity [not stated, assume 1], Resp 1)
Case Study: 1-minute APGAR. Blue hands/feet, crying, moving all extremities,
HR 110, pulling away from stimulus. What is the score? - ANSWER 9
(Appearance 1, all others 2)
In what order should the newborn's airway be suctioned with a bulb syringe? -
ANSWER Mouth first, then the nose
What must the nurse do to the bulb syringe before placing it into the baby's
mouth or nose? - ANSWER Compress the bulb
What percentage of birth weight is normal for a newborn to lose in the first 3 to 4
days? - ANSWER Up to 10%
What is the purpose of Vitamin K prophylaxis in the newborn? - ANSWER To
prevent bleeding/hemorrhage (clotting factor support)
What is the preferred site for Vitamin K and Hepatitis B vaccine administration in
a newborn? - ANSWER Vastus lateralis muscle
QUESTIONS WITH CORRECT ANSWERS
What is the duration of the first period of reactivity (Phase 1) after birth? -
ANSWER 0 to 30 minutes
During Phase 1 of neonatal transition, the infant's heart rate initially shows
what? - ANSWER Tachycardia
Why is Phase 1 of neonatal transition the best time to initiate breastfeeding? -
ANSWER The sucking reflex is present and the infant is alert.
What is the duration of the 'decreased responsiveness' phase (Phase 2) of
neonatal transition? - ANSWER 30 minutes to 2 hours after birth
How does an infant's motor activity change during Phase 2 of neonatal
transition? - ANSWER There is a marked decrease in motor activity or the infant
sleeps.
What characterizes the bowel sounds during Phase 2 of neonatal transition? -
ANSWER Audible bowel sounds
What is the duration of the second period of reactivity (Phase 3)? - ANSWER 2 to
8 hours after birth
Which waste product is typically passed during Phase 3 of neonatal transition? -
ANSWER Meconium
Why might a newborn gag during Phase 3 of neonatal transition? - ANSWER
Increased mucus production
What is the number one priority of care for the newborn immediately after birth?
- ANSWER Airway maintenance
What is the second priority of care for the newborn immediately after birth? -
ANSWER Maintaining body temperature (thermoregulation)
At what two specific time intervals is APGAR scoring performed? - ANSWER 1
minute and 5 minutes after birth
In the APGAR mnemonic, what does the first 'A' stand for? - ANSWER
Appearance (Skin Color)
, In the APGAR mnemonic, what does 'P' stand for? - ANSWER Pulse Rate
In the APGAR mnemonic, what does 'G' stand for? - ANSWER Grimace (Reflex
Irritability)
In the APGAR mnemonic, what does the second 'A' stand for? - ANSWER Activity
(Muscle Tone)
In the APGAR mnemonic, what does 'R' stand for? - ANSWER Respiratory Effort
An infant with an APGAR score of 4 to 7 requires what nursing intervention? -
ANSWER Gentle stimulation such as rubbing the back
What intervention is required for a newborn with an APGAR score below 3? -
ANSWER Active resuscitation
What APGAR score range indicates an infant requires no action other than
continued observation? - ANSWER 8 to 10
Case Study: 1-minute APGAR. No noise, no breathing, blue hands, heart rate 50.
What is the score? - ANSWER 1 (Pulse < 100 = 1; all others = 0)
Case Study: 5-minute APGAR. Cries when stimulated, irregular breathing, pink
all over, heart rate 124. What is the score? - ANSWER 8 (Appearance 2, Pulse 2,
Grimace 2, Activity [not stated, assume 1], Resp 1)
Case Study: 1-minute APGAR. Blue hands/feet, crying, moving all extremities,
HR 110, pulling away from stimulus. What is the score? - ANSWER 9
(Appearance 1, all others 2)
In what order should the newborn's airway be suctioned with a bulb syringe? -
ANSWER Mouth first, then the nose
What must the nurse do to the bulb syringe before placing it into the baby's
mouth or nose? - ANSWER Compress the bulb
What percentage of birth weight is normal for a newborn to lose in the first 3 to 4
days? - ANSWER Up to 10%
What is the purpose of Vitamin K prophylaxis in the newborn? - ANSWER To
prevent bleeding/hemorrhage (clotting factor support)
What is the preferred site for Vitamin K and Hepatitis B vaccine administration in
a newborn? - ANSWER Vastus lateralis muscle
