2025 Nursing Care Of The Newborn Questions,
Answers And Rationales
1.A mother and her newborn have just been transferred to the postpartum unit from labor and
delivery. Which infant safety education should be provided as soon as mom and baby are
settled into their room? Select all that apply.
A. "Wash your hands before touching the newborn."
B. "Send the newborn to nursery to be monitored during the night."
C. "All client identification bands should remain in place until discharge."
D. "Do not let anyone remove the infant from your sight while you are in the hospital."
E. "Check the identification of staff, and if there is a question of validity, call the nursing station."
---Correct---Ans.A. "Wash your hands before touching the newborn."
C. "All client identification bands should remain in place until discharge."
E. "Check the identification of staff, and if there is a question of validity, call the nursing station."
Mothers, significant others or persons of the mother's choice, and the infant must continue to
wear identification bands during the entire hospital stay. These bands show which baby belongs
to which mother. The mother should call the nursing station to verify any person appearing to
be staff if she has any question about who the person is. Proper identification must be worn by
staff at all times. Washing hands before touching the newborn will decrease the chance of
infectious transfer of microorganisms to newborn. Safety is the most important concern. There
may be times when procedures, assessments, showering, and other activities involve the
newborn being taken from the mother's room. Only well-identified staff members caring for the
client should be allowed to take the infant out of the mother's sight. It is not necessary to send
the newborn to the nursery during the night; the mother may keep the baby at her side during
this time.
2.The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby
is in a bed with a radiant warmer. How does the nurse explain the increased risk for
hypothermia in preterm infants?
,A. Have a smaller body surface area than full-term newborns
B. Lack the subcutaneous fat that usually provides insulation
C. Perspire excessively, causing a constant loss of body heat
D. Have a limited ability to produce antibodies against infections ---Correct---Ans.B. Lack the
subcutaneous fat that usually provides insulation
Much of a full-term infant's birth weight (almost a third) is gained during the last month of
gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves
as insulation; the preterm infant did not have enough time to grow in the uterus and therefore
has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a
relatively larger surface area per body weight than does a term infant. Depressed antibody
production is unrelated to maintenance of body temperature.
3.In specific situations gloves are used to handle newborns whether or not they are positive for
human immunodeficiency virus (HIV). When is it unnecessary for the nurse to wear gloves while
caring for a newborn?
A. Offering a feeding
B. Changing the diaper
C. Giving an admission bath
D. Suctioning the nasopharynx ---Correct---Ans.A. Offering a feeding
Standard precautions do not include the use of gloves for feeding. Wearing clean gloves for
diaper changes of newborns is standard protocol. Clean gloves should be worn for all admission
baths, because the nurse will be exposed to blood and amniotic fluid. Clean gloves should also
be worn while the nurse suctions an infant.
, 4.In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however,
the baby soon goes back to sleep. What is the most appropriate nursing action in response to
this behavior?
A. Documenting an intact reflex
B. Assessing the infant's vital signs
C. Testing the infant's ability to hear
D. Stimulating the infant's respirations ---Correct---Ans.A. Documenting an intact reflex
The initial response is a reflection of the startle reflex; when the stimulus is repetitive, the
response to the stimulus decreases. This decrease in response is called habituation and is
expected. Assessing the infant's vital signs and stimulating the infant's respirations are not
necessary because the neonate's response is expected. The infant is responding to noise and
therefore hears.
5.A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex
elicited?
A. Striking the surface of the crib suddenly
B. Stroking the outer sole of the foot from the heel to the little toe
C. Maintaining the supine position and applying pressure to the soles of the feet
D. Holding the infant's body upright and allowing the feet to touch the surface of the crib ---
Correct---Ans.B. Stroking the outer sole of the foot from the heel to the little toe
Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or
plantar reflex; all of the toes hyperextend. Jarring the crib produces a startle response (Moro
reflex); the legs and arms extend and the fingers fan out, and the thumb and forefinger form a
C. Applying pressure against the soles of the feet produces the magnet reflex; the legs extend in
response to the pressure on the soles of the feet. Having the feet touch the surface of the crib
Answers And Rationales
1.A mother and her newborn have just been transferred to the postpartum unit from labor and
delivery. Which infant safety education should be provided as soon as mom and baby are
settled into their room? Select all that apply.
A. "Wash your hands before touching the newborn."
B. "Send the newborn to nursery to be monitored during the night."
C. "All client identification bands should remain in place until discharge."
D. "Do not let anyone remove the infant from your sight while you are in the hospital."
E. "Check the identification of staff, and if there is a question of validity, call the nursing station."
---Correct---Ans.A. "Wash your hands before touching the newborn."
C. "All client identification bands should remain in place until discharge."
E. "Check the identification of staff, and if there is a question of validity, call the nursing station."
Mothers, significant others or persons of the mother's choice, and the infant must continue to
wear identification bands during the entire hospital stay. These bands show which baby belongs
to which mother. The mother should call the nursing station to verify any person appearing to
be staff if she has any question about who the person is. Proper identification must be worn by
staff at all times. Washing hands before touching the newborn will decrease the chance of
infectious transfer of microorganisms to newborn. Safety is the most important concern. There
may be times when procedures, assessments, showering, and other activities involve the
newborn being taken from the mother's room. Only well-identified staff members caring for the
client should be allowed to take the infant out of the mother's sight. It is not necessary to send
the newborn to the nursery during the night; the mother may keep the baby at her side during
this time.
2.The parent of a preterm infant asks the nurse in the neonatal intensive care unit why the baby
is in a bed with a radiant warmer. How does the nurse explain the increased risk for
hypothermia in preterm infants?
,A. Have a smaller body surface area than full-term newborns
B. Lack the subcutaneous fat that usually provides insulation
C. Perspire excessively, causing a constant loss of body heat
D. Have a limited ability to produce antibodies against infections ---Correct---Ans.B. Lack the
subcutaneous fat that usually provides insulation
Much of a full-term infant's birth weight (almost a third) is gained during the last month of
gestation, and most of this final spurt is related to an increase in subcutaneous fat, which serves
as insulation; the preterm infant did not have enough time to grow in the uterus and therefore
has little of this insulating layer. Preterm infants do not shiver or sweat. The preterm infant has a
relatively larger surface area per body weight than does a term infant. Depressed antibody
production is unrelated to maintenance of body temperature.
3.In specific situations gloves are used to handle newborns whether or not they are positive for
human immunodeficiency virus (HIV). When is it unnecessary for the nurse to wear gloves while
caring for a newborn?
A. Offering a feeding
B. Changing the diaper
C. Giving an admission bath
D. Suctioning the nasopharynx ---Correct---Ans.A. Offering a feeding
Standard precautions do not include the use of gloves for feeding. Wearing clean gloves for
diaper changes of newborns is standard protocol. Clean gloves should be worn for all admission
baths, because the nurse will be exposed to blood and amniotic fluid. Clean gloves should also
be worn while the nurse suctions an infant.
, 4.In a noisy room a sleeping newborn initially startles and exhibits rapid movements; however,
the baby soon goes back to sleep. What is the most appropriate nursing action in response to
this behavior?
A. Documenting an intact reflex
B. Assessing the infant's vital signs
C. Testing the infant's ability to hear
D. Stimulating the infant's respirations ---Correct---Ans.A. Documenting an intact reflex
The initial response is a reflection of the startle reflex; when the stimulus is repetitive, the
response to the stimulus decreases. This decrease in response is called habituation and is
expected. Assessing the infant's vital signs and stimulating the infant's respirations are not
necessary because the neonate's response is expected. The infant is responding to noise and
therefore hears.
5.A nurse who is assessing a full-term newborn elicits the Babinski reflex. How is this reflex
elicited?
A. Striking the surface of the crib suddenly
B. Stroking the outer sole of the foot from the heel to the little toe
C. Maintaining the supine position and applying pressure to the soles of the feet
D. Holding the infant's body upright and allowing the feet to touch the surface of the crib ---
Correct---Ans.B. Stroking the outer sole of the foot from the heel to the little toe
Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or
plantar reflex; all of the toes hyperextend. Jarring the crib produces a startle response (Moro
reflex); the legs and arms extend and the fingers fan out, and the thumb and forefinger form a
C. Applying pressure against the soles of the feet produces the magnet reflex; the legs extend in
response to the pressure on the soles of the feet. Having the feet touch the surface of the crib
