1. The nurse is assessing the reflexes of a newborn. The nurse assesses which of the following
reflexes by placing a finger in the newborn’s mouth?
Sucking reflex
Rooting reflex
Moro reflex
Babinski reflex
About the correct answer: The sucking reflex is tested by placing something, such as a finger,
in the infant’s mouth and seeing if the infant begins to suck on the object. The Moro reflex is
tested by suddenly lowering the newborn’s body. The infant should demonstrate a bilateral arm
extension and leg flexion. The rooting reflex is tested by stroking the cheek. The infant may open
the mouth. The Babinski reflex is tested by firmly stroking the plantar surface. The anticipated
response is the incurving of the toes as in plantar the grasp, with uncurling and fanning out.
2. A full-term newborn was just born. Which nursing intervention is important for the nurse to
perform first?
Elicit the Moro reflex.
Remove wet blankets.
Assess Apgar score.
Insert eye prophylaxis.
About the correct answer: When newborns are wet they can become hypothermic from heat
loss resulting from evaporation. They may then develop cold stress syndrome.
About the correct answer: The first Apgar score is not done until 60 seconds after delivery. The
wet blankets should have been removed from the baby well before that time. Eye prophylaxis
can be delayed until after the parents have begun bonding with their baby. Although the baby’s
central nervous system must be carefully assessed, reflex assessment should be postponed until
after the baby is dried and is breathing on his or her own.
TIP: This is a prioritizing question. Every one of the actions will be performed after the birth of
the baby. The nurse must know which action is
performed first. Because hypothermia can compromise a neonate’s transition to extrauterine life,
it is essential to dry the baby immediately to minimize heat loss through evaporation. It is
important for the test taker to review cold stress syndrome.
3. The nursing history for a newborn suspected of having pyloric stenosis would MOST likely
reveal?
Frequent vomiting of bile-stained fluid
Absence of gastrointestinal peristalsis
Cyanosis and vomiting immediately after feedings
, Mild emesis progressing to projectile vomiting
About the correct answer: Mild regurgitation or emesis that progresses to projectile vomiting is
a pattern of vomiting associated with pyloric stenosis.
4. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following
actions by the nurse is appropriate?
Swaddle baby in blanket.
Apply pulse oximeter.
Administer oxygen.
Place child in isolette.
About the correct answer: The baby’s extremities are cyanotic as a result of the baby’s
immature circulatory system. Swaddling helps to warm the baby’s hands and feet.
There is no evidence in the stem that would warrant placing the child in an isolette.
Cyanotic hands and feet are not signs of hypoxia in the neonate.
There is no evidence in the stem that would warrant monitoring with the pulse oximeter.
TIP: The test taker must be familiar with the differences between normal findings of the newborn
and those of an older child or adult. Acrocyanosis,
bluish/cyanotic hands and feet, is normal in the very young neonate resulting from its immature
circulation to the extremities.
5. The nurse admitting a preterm newborn to the nursery should assess the newborn for which of
the following?
Shoulder dystocia
Palsies
Clavicle fracture
Respiratory distress
About the correct answer: Preterm newborns may not have adequate pulmonary surfactant.
This increases the work of breathing and may cause respiratory distress and failure. Shoulder
dystonia, clavicle fractures, and palsies are complications associated with larger newborns.
6. Which of the following neonates is at highest risk for cold stress syndrome?
Down syndrome neonate.
Infant with Rh incompatibility.
Infant of diabetic mother.
Postdates neonate.
,About the correct answer: Postdates babies are at high risk for cold stress syndrome because
while still in utero they often metabolize the brown adipose tissue for nourishment when the
placental function deteriorates.The test taker must know that cold stress syndrome results from a
neonate’s inability to create heat through metabolic means. Brown adipose tissue (BAT) and
glycogen stores in the liver are the primary substances used for thermogenesis. The test taker
must then deduce that the infant most likely to have poor supplies of BAT and glycogen is the
postdates infant.
Infants of diabetic mothers are often large-for-gestational age, but they are not especially at high
risk for cold stress syndrome. Infants born with Rh incompatibility are not especially at high risk
for cold stress syndrome. Down syndrome babies are hypotonic, but they are not especially at
high risk for cold stress syndrome.
7. The nurse is assessing a newborn on admission to the newborn nursery. Which of the
following findings should the nurse report to the neonatalogist?
Intracostal retractions.
Epstein’s pearls.
Harlequin sign.
Caput succedaneum.
About the correct answer: Intracostal retractions are a sign of respiratory distress.
Caput succedaneum is a normal finding in a neonate.
Epstein’s pearls are often seen in the mouths of neonates.
Harlequin sign, although odd-appearing, is a normal finding in a neonate.
TIP: Each of the normal findings is seen in newborns, although not seen later in life. The test
taker must be familiar with these age-specific normal findings. It is also important to remember
that, based on the hierarchy of needs, respiratory problems always take precedence.
8. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After
discussing the defect with the parents, the nurse should expect that?
Post-operative appearance will be normal
Circumcision can be performed at any time
Surgery will be performed in stages
Initial repair is delayed until ages 6-8
About the correct answer: Surgery will be performed in stages. Hypospadias, a condition in
which the urethral opening is located on the ventral surface or below the penis, is corrected in
, stages as soon as the infant can tolerate surgery.
9. A pre-term newborn is to be fed breast milk through nasogastric tube. The nurse recognizes
that breast milk is preferred to formula because it?
Contains less lactose
Has less fatty acid
Is higher in calories/ounce
Provides antibodies
About the correct answer: Breast milk is ideal for the preterm baby who needs additional
protection against infection through maternal antibodies.
10. Four babies with the following conditions are in the well-baby nursery. The baby with which
of the conditions is high risk for physiological jaundice?
Caput succedaneum.
Cephalhematoma.
Mongolian spotting.
Harlequin coloring.
About the correct answer: Red blood cells in the cephalhematoma will have to be broken down
and excreted. The by-product of the destruction—bilirubin—increases the baby’s risk for
physiological jaundice.
A caput is merely a collection of edematous fluid. There is no relation between the presence of a
caput and jaundice.
Harlequin coloration is related to the dilation of blood vessels on one side of the baby’s body.
There is no relation between the presence of harlequin coloring and jaundice.
Mongolian spots are hyperpigmented areas primarily seen on the buttocks. There is no relation
between the presence of mongolian spots and jaundice.
TIP: During the early newborn period, whenever a situation exists that results in the breakdown
of red blood cells, the baby is at high risk for hyperbilirubinemia and resulting jaundice. In this
case, the baby is at high risk from a cephalhematoma, a collection of blood between the skull and
the
periosteal membrane. In addition, the neonate is at high risk for hyperbilirubinemia because of
the immaturity of the newborn liver.
reflexes by placing a finger in the newborn’s mouth?
Sucking reflex
Rooting reflex
Moro reflex
Babinski reflex
About the correct answer: The sucking reflex is tested by placing something, such as a finger,
in the infant’s mouth and seeing if the infant begins to suck on the object. The Moro reflex is
tested by suddenly lowering the newborn’s body. The infant should demonstrate a bilateral arm
extension and leg flexion. The rooting reflex is tested by stroking the cheek. The infant may open
the mouth. The Babinski reflex is tested by firmly stroking the plantar surface. The anticipated
response is the incurving of the toes as in plantar the grasp, with uncurling and fanning out.
2. A full-term newborn was just born. Which nursing intervention is important for the nurse to
perform first?
Elicit the Moro reflex.
Remove wet blankets.
Assess Apgar score.
Insert eye prophylaxis.
About the correct answer: When newborns are wet they can become hypothermic from heat
loss resulting from evaporation. They may then develop cold stress syndrome.
About the correct answer: The first Apgar score is not done until 60 seconds after delivery. The
wet blankets should have been removed from the baby well before that time. Eye prophylaxis
can be delayed until after the parents have begun bonding with their baby. Although the baby’s
central nervous system must be carefully assessed, reflex assessment should be postponed until
after the baby is dried and is breathing on his or her own.
TIP: This is a prioritizing question. Every one of the actions will be performed after the birth of
the baby. The nurse must know which action is
performed first. Because hypothermia can compromise a neonate’s transition to extrauterine life,
it is essential to dry the baby immediately to minimize heat loss through evaporation. It is
important for the test taker to review cold stress syndrome.
3. The nursing history for a newborn suspected of having pyloric stenosis would MOST likely
reveal?
Frequent vomiting of bile-stained fluid
Absence of gastrointestinal peristalsis
Cyanosis and vomiting immediately after feedings
, Mild emesis progressing to projectile vomiting
About the correct answer: Mild regurgitation or emesis that progresses to projectile vomiting is
a pattern of vomiting associated with pyloric stenosis.
4. A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following
actions by the nurse is appropriate?
Swaddle baby in blanket.
Apply pulse oximeter.
Administer oxygen.
Place child in isolette.
About the correct answer: The baby’s extremities are cyanotic as a result of the baby’s
immature circulatory system. Swaddling helps to warm the baby’s hands and feet.
There is no evidence in the stem that would warrant placing the child in an isolette.
Cyanotic hands and feet are not signs of hypoxia in the neonate.
There is no evidence in the stem that would warrant monitoring with the pulse oximeter.
TIP: The test taker must be familiar with the differences between normal findings of the newborn
and those of an older child or adult. Acrocyanosis,
bluish/cyanotic hands and feet, is normal in the very young neonate resulting from its immature
circulation to the extremities.
5. The nurse admitting a preterm newborn to the nursery should assess the newborn for which of
the following?
Shoulder dystocia
Palsies
Clavicle fracture
Respiratory distress
About the correct answer: Preterm newborns may not have adequate pulmonary surfactant.
This increases the work of breathing and may cause respiratory distress and failure. Shoulder
dystonia, clavicle fractures, and palsies are complications associated with larger newborns.
6. Which of the following neonates is at highest risk for cold stress syndrome?
Down syndrome neonate.
Infant with Rh incompatibility.
Infant of diabetic mother.
Postdates neonate.
,About the correct answer: Postdates babies are at high risk for cold stress syndrome because
while still in utero they often metabolize the brown adipose tissue for nourishment when the
placental function deteriorates.The test taker must know that cold stress syndrome results from a
neonate’s inability to create heat through metabolic means. Brown adipose tissue (BAT) and
glycogen stores in the liver are the primary substances used for thermogenesis. The test taker
must then deduce that the infant most likely to have poor supplies of BAT and glycogen is the
postdates infant.
Infants of diabetic mothers are often large-for-gestational age, but they are not especially at high
risk for cold stress syndrome. Infants born with Rh incompatibility are not especially at high risk
for cold stress syndrome. Down syndrome babies are hypotonic, but they are not especially at
high risk for cold stress syndrome.
7. The nurse is assessing a newborn on admission to the newborn nursery. Which of the
following findings should the nurse report to the neonatalogist?
Intracostal retractions.
Epstein’s pearls.
Harlequin sign.
Caput succedaneum.
About the correct answer: Intracostal retractions are a sign of respiratory distress.
Caput succedaneum is a normal finding in a neonate.
Epstein’s pearls are often seen in the mouths of neonates.
Harlequin sign, although odd-appearing, is a normal finding in a neonate.
TIP: Each of the normal findings is seen in newborns, although not seen later in life. The test
taker must be familiar with these age-specific normal findings. It is also important to remember
that, based on the hierarchy of needs, respiratory problems always take precedence.
8. The nurse is caring for a newborn who has just been diagnosed with hypospadias. After
discussing the defect with the parents, the nurse should expect that?
Post-operative appearance will be normal
Circumcision can be performed at any time
Surgery will be performed in stages
Initial repair is delayed until ages 6-8
About the correct answer: Surgery will be performed in stages. Hypospadias, a condition in
which the urethral opening is located on the ventral surface or below the penis, is corrected in
, stages as soon as the infant can tolerate surgery.
9. A pre-term newborn is to be fed breast milk through nasogastric tube. The nurse recognizes
that breast milk is preferred to formula because it?
Contains less lactose
Has less fatty acid
Is higher in calories/ounce
Provides antibodies
About the correct answer: Breast milk is ideal for the preterm baby who needs additional
protection against infection through maternal antibodies.
10. Four babies with the following conditions are in the well-baby nursery. The baby with which
of the conditions is high risk for physiological jaundice?
Caput succedaneum.
Cephalhematoma.
Mongolian spotting.
Harlequin coloring.
About the correct answer: Red blood cells in the cephalhematoma will have to be broken down
and excreted. The by-product of the destruction—bilirubin—increases the baby’s risk for
physiological jaundice.
A caput is merely a collection of edematous fluid. There is no relation between the presence of a
caput and jaundice.
Harlequin coloration is related to the dilation of blood vessels on one side of the baby’s body.
There is no relation between the presence of harlequin coloring and jaundice.
Mongolian spots are hyperpigmented areas primarily seen on the buttocks. There is no relation
between the presence of mongolian spots and jaundice.
TIP: During the early newborn period, whenever a situation exists that results in the breakdown
of red blood cells, the baby is at high risk for hyperbilirubinemia and resulting jaundice. In this
case, the baby is at high risk from a cephalhematoma, a collection of blood between the skull and
the
periosteal membrane. In addition, the neonate is at high risk for hyperbilirubinemia because of
the immaturity of the newborn liver.
