NUR 1211C MN QUESTIONS
REVISED.
Ruth Psetas
Questions on Newborn Assessment/ Nursing Care
1) For a newborn after birth, which intervention is the highest priority?
a) Initiating breastfeeding
b) Performing the initial bath
c) Giving the Vitamin K injection
d) Covering the head with a cap
Rationale: The greatest risk to the newborn is cold stress. Therefore the highest priority is to
intervention is to prevent heat loss. Covering the newborn’s head with a cap prevents cold stress
due to excessive evaporative heat loss.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 287)
2) Why is the Vitamin K (Aquamephyton) injection given?
a) It assists with clotting
b) It promotes maturation of the bowel
c) It is a preventative vaccine
d) It provides immunity
Rationale: Vitamin K is deficient in a newborn because the colon is sterile. Until bacteria are
present to stimulate Vitamin K production, the newborn is at risk for hemorrhagic disease.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 287)
3) Which of the following characteristics indicates that this infant is post-term?
a. Excess body fat
b. Flat areola without breast buds
c. Heels movable fully to ears
d. Leathery skin
Rationale: Excess body fat is seen in a macrosomic baby. Flat areolas without breast buds and
heels that move fully to ears are seen in preterm babies. Leathery, cracked, and wrinkled skin are
seen in newborns who are post-term due to placental insufficiency.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 343)
, 4) Which of the following findings supports neonatal abstinence syndrome?
a. Decreased muscle tone
b. Continuous high pitched cry
c. Sleeps for 2 hours after feedings
d. Mild tremors when disturbed
Rationale: In NAS, increased muscle tone, continuous high pitched crying, sleep pattern
disturbances, and moderate to severe tremors when disturbed are seen.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 344)
5) Which are proper instructions to a breastfeeding mother of a newborn with
hyperbilirubinemia?
a. Feed the newborn less frequently.
b. Continue to breastfeed every 2 to 4 hours.
c. Switch to bottle-feeding the infant for 2 weeks.
d. Switch to bottle feeding permanently.
Rationale: Early and frequent feeding hastens the excretion of bilirubin. Switching to bottle-
feeding is unnecessary.
Silvestri, L. A. (2011). Saunders Comprehensive Review for the NCLEX-RN examination (5th
ed.). St. Louis, MO: Elsevier. (PG 355)
6) Which shows appropriate instructions on how to care for the baby’s umbilical cord?
a. Cleanse it with hydrogen peroxide if it starts to smell.
b. Remove it with sterile tweezers at one week of age.
c. Call the doctor if greenish drainage appears.
d. Cover it with sterile dressings until it falls off.
Rationale: Hydrogen peroxide should not be used to clean it. The cord should fall off on its own,
usually within 7 to 10 days. There is no need to cover the umbilicus. Green drainage could be a
sign of infection and should be reported.
DeSevo, M. (2009). Maternal and Newborn Success (Davis's Success ). Philadelphia, PA: F.A.
Davis Company. (Pg 190)
7) The nurse is assessing a neonate. Which of the following should she report to
the physician?
a. The eyes cross and uncross when they are open.
b. The ears are positioned in alignment with the inner and outer canthus of the eyes.
c. Axillae and femoral folds of the baby are covered with a cheesy white substance.
d. The nostrils flare whenever the baby inhales.
REVISED.
Ruth Psetas
Questions on Newborn Assessment/ Nursing Care
1) For a newborn after birth, which intervention is the highest priority?
a) Initiating breastfeeding
b) Performing the initial bath
c) Giving the Vitamin K injection
d) Covering the head with a cap
Rationale: The greatest risk to the newborn is cold stress. Therefore the highest priority is to
intervention is to prevent heat loss. Covering the newborn’s head with a cap prevents cold stress
due to excessive evaporative heat loss.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 287)
2) Why is the Vitamin K (Aquamephyton) injection given?
a) It assists with clotting
b) It promotes maturation of the bowel
c) It is a preventative vaccine
d) It provides immunity
Rationale: Vitamin K is deficient in a newborn because the colon is sterile. Until bacteria are
present to stimulate Vitamin K production, the newborn is at risk for hemorrhagic disease.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 287)
3) Which of the following characteristics indicates that this infant is post-term?
a. Excess body fat
b. Flat areola without breast buds
c. Heels movable fully to ears
d. Leathery skin
Rationale: Excess body fat is seen in a macrosomic baby. Flat areolas without breast buds and
heels that move fully to ears are seen in preterm babies. Leathery, cracked, and wrinkled skin are
seen in newborns who are post-term due to placental insufficiency.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 343)
, 4) Which of the following findings supports neonatal abstinence syndrome?
a. Decreased muscle tone
b. Continuous high pitched cry
c. Sleeps for 2 hours after feedings
d. Mild tremors when disturbed
Rationale: In NAS, increased muscle tone, continuous high pitched crying, sleep pattern
disturbances, and moderate to severe tremors when disturbed are seen.
Sommer, S., Johnson, J., Roberts, K., Redding, S. R., & Churchill, L. (2013). RN Maternal
Newborn Nursing (9.0th ed.). Assessment Technologies Institute. (Pg. 344)
5) Which are proper instructions to a breastfeeding mother of a newborn with
hyperbilirubinemia?
a. Feed the newborn less frequently.
b. Continue to breastfeed every 2 to 4 hours.
c. Switch to bottle-feeding the infant for 2 weeks.
d. Switch to bottle feeding permanently.
Rationale: Early and frequent feeding hastens the excretion of bilirubin. Switching to bottle-
feeding is unnecessary.
Silvestri, L. A. (2011). Saunders Comprehensive Review for the NCLEX-RN examination (5th
ed.). St. Louis, MO: Elsevier. (PG 355)
6) Which shows appropriate instructions on how to care for the baby’s umbilical cord?
a. Cleanse it with hydrogen peroxide if it starts to smell.
b. Remove it with sterile tweezers at one week of age.
c. Call the doctor if greenish drainage appears.
d. Cover it with sterile dressings until it falls off.
Rationale: Hydrogen peroxide should not be used to clean it. The cord should fall off on its own,
usually within 7 to 10 days. There is no need to cover the umbilicus. Green drainage could be a
sign of infection and should be reported.
DeSevo, M. (2009). Maternal and Newborn Success (Davis's Success ). Philadelphia, PA: F.A.
Davis Company. (Pg 190)
7) The nurse is assessing a neonate. Which of the following should she report to
the physician?
a. The eyes cross and uncross when they are open.
b. The ears are positioned in alignment with the inner and outer canthus of the eyes.
c. Axillae and femoral folds of the baby are covered with a cheesy white substance.
d. The nostrils flare whenever the baby inhales.
