NCLEX-RN (NEWBORN) EXAM QUESTIONS AND CORRECT
ANSWERS VERIFIED 100%
A graduate nurse is caring for a client at 39 weeks gestation who is receiving
an oxytocin infusion. Oxytocin is infusing at 20 mU/min. Based on the
electronic fetal monitoring strip, which action by the graduate nurse would
cause the registered nurse to intervene?
1. Administer oxygen by face mask at 10 L/min
2. Decreases oxytocin to 10mU/min
3. Notifies the healthcare provider
4. Repositions the client in left lateral position
2. Decreases oxytocin to 10mU/min
The nurse is observing a student nurse care for a mother who has been
unsuccessful with breastfeeding her newborn infant. Which action by the
student would require the nurse to intervene?
1. Assesses the baby's position and sucking behavior during breastfeeding
2. Demonstrates to the mother how to use an electric breast pump
3. Provides supplemental formula feedings until improved breastfeeding
occurs
4. Shows the mother how to hand express breast milk
3. Provides supplemental formula feedings until improved breastfeeding
occurs
The nurse assesses a newborn with skin discoloration in the lumbar area.
What would be an appropriate action for the nurse to complete?
1. Assess the infant's hemoglobin, hematocrit and platelet levels
2. Measure and document the size and location of the markings
3. Notify the HCP of the markings immediately
4. Review the delivery record for evidence of a traumatic birth
2. Measure and document the size and location of the markings
** Mongolian spots are usually bluish gray and fade over the first 1-2 years of life.
,They are often misidentified as bruises and it is important for nurse to measure and
document area for reference during future health assessments.
What is an appropriate nursing intervention after the birth of a newborn with
anencephaly?
1. Instruct the parents that visitors should be restricted
2. Provide information to the parents about genetic counseling
3. Refer the parents to a perinatal loss support group
4. Wrap the newborn in warm blankets for the parents to hold
4. Wrap the newborn in warm blankets for the parents to hold
**Anencephaly is a severe neural tube defect resulting in little to no brain tissue or
skull formation in utero.
** Many are stillborn and those born alive are not compatible with life. Providing
comfort care for the newborn and emotional support for the family is priority at the
time of birth.
** Providing a therapeutic environment for grieving parents and providing newborn
comfort such as warmth and oxygen
The nurse is performing an APGAR assessment on a newborn client at 1
minute of life. The newborn is completely blue, has a heart rate of 110/min and
is emitting a weak cry. Active movement and flexion of extremities are noted
and the newborn grimaces when nares are suctioned. Which APGAR score
should the nurse assign this newborn?
1. APGAR score of 4
2. APGAR score of 5
3. APGAR score of 6
4. APGAR score of 8
3. APGAR score of 6
A (Appearance)
- Blue/Pale 0
- Body Pink Extremity Blue 1
- Completely Pink 2
P (Pulse)
- Absent 0
, - <100/min 1
- >100/min 2
G (Grimace)
- Absent 0
- Grimace/Whimper 1
- Cough/sneeze/cry 2
A (Activity/Muscle tone)
- Limp 0
- Some flexion 1
- Active/Spontaneous 2
R (Respiratory effort)
- Absent 0
- Slow, weak cry 1
- Regular, good cry 2
The precepting nurse is supervising a new obstetric nurse performing a labor
admission assessment on a client with suspected spontaneous rupture of
membranes. Which action by the new nurse would cause the precepting nurse
to intervene?
1. Documenting a positive nitrazine test result when the test strip turns blue
2. Donning nonsterile gloves and using soluble gel for vaginal examination
3. Palpating the client's abdomen before applying external fetal monitors
4. Providing the client with a variety of clear liquids to drink
2. Donning non-sterile gloves and using soluble gel for vaginal examination
** The nurse should use a sterile glove during vaginal examination in the presence of
ruptured membranes to prevent infection. Using non-sterile gloves increases the risk
of infection in the laboring client or fetus.
A laboring client reports feeling the need to have a bowel movement and
begins vomiting. The nurse notes that the client's legs are trembling. What
cervical examination finding would the nurse most expect this client to have?
1. 2 cm dilated, 50% effaced, -2 station
2. 6 cm dilated, 70% effaced, -1 station
ANSWERS VERIFIED 100%
A graduate nurse is caring for a client at 39 weeks gestation who is receiving
an oxytocin infusion. Oxytocin is infusing at 20 mU/min. Based on the
electronic fetal monitoring strip, which action by the graduate nurse would
cause the registered nurse to intervene?
1. Administer oxygen by face mask at 10 L/min
2. Decreases oxytocin to 10mU/min
3. Notifies the healthcare provider
4. Repositions the client in left lateral position
2. Decreases oxytocin to 10mU/min
The nurse is observing a student nurse care for a mother who has been
unsuccessful with breastfeeding her newborn infant. Which action by the
student would require the nurse to intervene?
1. Assesses the baby's position and sucking behavior during breastfeeding
2. Demonstrates to the mother how to use an electric breast pump
3. Provides supplemental formula feedings until improved breastfeeding
occurs
4. Shows the mother how to hand express breast milk
3. Provides supplemental formula feedings until improved breastfeeding
occurs
The nurse assesses a newborn with skin discoloration in the lumbar area.
What would be an appropriate action for the nurse to complete?
1. Assess the infant's hemoglobin, hematocrit and platelet levels
2. Measure and document the size and location of the markings
3. Notify the HCP of the markings immediately
4. Review the delivery record for evidence of a traumatic birth
2. Measure and document the size and location of the markings
** Mongolian spots are usually bluish gray and fade over the first 1-2 years of life.
,They are often misidentified as bruises and it is important for nurse to measure and
document area for reference during future health assessments.
What is an appropriate nursing intervention after the birth of a newborn with
anencephaly?
1. Instruct the parents that visitors should be restricted
2. Provide information to the parents about genetic counseling
3. Refer the parents to a perinatal loss support group
4. Wrap the newborn in warm blankets for the parents to hold
4. Wrap the newborn in warm blankets for the parents to hold
**Anencephaly is a severe neural tube defect resulting in little to no brain tissue or
skull formation in utero.
** Many are stillborn and those born alive are not compatible with life. Providing
comfort care for the newborn and emotional support for the family is priority at the
time of birth.
** Providing a therapeutic environment for grieving parents and providing newborn
comfort such as warmth and oxygen
The nurse is performing an APGAR assessment on a newborn client at 1
minute of life. The newborn is completely blue, has a heart rate of 110/min and
is emitting a weak cry. Active movement and flexion of extremities are noted
and the newborn grimaces when nares are suctioned. Which APGAR score
should the nurse assign this newborn?
1. APGAR score of 4
2. APGAR score of 5
3. APGAR score of 6
4. APGAR score of 8
3. APGAR score of 6
A (Appearance)
- Blue/Pale 0
- Body Pink Extremity Blue 1
- Completely Pink 2
P (Pulse)
- Absent 0
, - <100/min 1
- >100/min 2
G (Grimace)
- Absent 0
- Grimace/Whimper 1
- Cough/sneeze/cry 2
A (Activity/Muscle tone)
- Limp 0
- Some flexion 1
- Active/Spontaneous 2
R (Respiratory effort)
- Absent 0
- Slow, weak cry 1
- Regular, good cry 2
The precepting nurse is supervising a new obstetric nurse performing a labor
admission assessment on a client with suspected spontaneous rupture of
membranes. Which action by the new nurse would cause the precepting nurse
to intervene?
1. Documenting a positive nitrazine test result when the test strip turns blue
2. Donning nonsterile gloves and using soluble gel for vaginal examination
3. Palpating the client's abdomen before applying external fetal monitors
4. Providing the client with a variety of clear liquids to drink
2. Donning non-sterile gloves and using soluble gel for vaginal examination
** The nurse should use a sterile glove during vaginal examination in the presence of
ruptured membranes to prevent infection. Using non-sterile gloves increases the risk
of infection in the laboring client or fetus.
A laboring client reports feeling the need to have a bowel movement and
begins vomiting. The nurse notes that the client's legs are trembling. What
cervical examination finding would the nurse most expect this client to have?
1. 2 cm dilated, 50% effaced, -2 station
2. 6 cm dilated, 70% effaced, -1 station
