nclex exam newborn nursing care (50 items)

7/23/2019 NCLEX Exam Newborn Nursing Care (50 Items)

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NCLEX Exam: Newborn Nursing Care (50 Items)

1. A nurse in a delier! room is assisting wit" t"e delier! o# a newborn in#ant. A#ter t"e delier!$ t"e nurse %re%ares to

%reent "eat loss in t"e newborn resulting #rom ea%oration b!:

1. Warming the crib pad

2. Turning on the overhead radiant warmer

3. Closing the doors to the room

4. Drying the infant in a warm blanet

&. A nurse is assessing a newborn in#ant #ollowing 'ir'um'ision and notes t"at t"e 'ir'um'ised area is red wit" a small amount

o# blood! drainage. "i'" o# t"e #ollowing nursing a'tions would be most a%%ro%riate

1. Document the findings2. Contact the physician

3. Circle the amount of bloody drainage on the dressing and reassess in 3! minutes

4. "einforce the dressing

*. A nurse in t"e newborn nurser! is monitoring a %reterm newborn in#ant #or res%irator! distress s!ndrome. "i'"assessment signs i# noted in t"e newborn in#ant would alert t"e nurse to t"e %ossibilit! o# t"is s!ndrome

1. #ypotension and $radycardia

2. Tachypnea and retractions

3. %crocyanosis and grunting4. The presence of a barrel chest with grunting

+. A nurse in a newborn nurser! is %er#orming an assessment o# a newborn in#ant. ,"e nurse is %re%aring to measure t"e "ead

'ir'um#eren'e o# t"e in#ant. ,"e nurse would most a%%ro%riatel!:

1. Wrap the tape measure around the infant&s head and measure 'ust above the eyebrows.2. (lace the tape measure under the infants head at the base of the sull and wrap around to the front 'ust above the eyes

3. (lace the tape measure under the infants head) wrap around the occiput) and measure 'ust above the eyes

4. (lace the tape measure at the bac of the infant&s head) wrap around across the ears) and measure across the infant&s mouth.

5. A %ost%artum nurse is %roiding instru'tions to t"e mot"er o# a newborn in#ant wit" "!%erbilirubinemia w"o is being

breast#ed. ,"e nurse %roides w"i'" most a%%ro%riate instru'tions to t"e mot"er

1. *witch to bottle feeding the baby for 2 wees

2. *top the breast feedings and switch to bottle+feeding permanently

3. ,eed the newborn infant less fre-uently4. Continue to breast+feed every 2+4 hours

-. A nurse on t"e newborn nurser! #loor is 'aring #or a neonate. n assessment t"e in#ant is ex"ibiting signs o# '!anosis$

ta'"!%nea$ nasal #laring$ and grunting. /es%irator! distress s!ndrome is diagnosed$ and t"e %"!si'ian %res'ribes sur#a'tant

re%la'ement t"era%!. ,"e nurse would %re%are to administer t"is t"era%! b!:

1. *ubcutaneous in'ection

2. ntravenous in'ection



3. nstillation of the preparation into the lungs through an endotracheal tube

4. ntramuscular in'ection

. A nurse is assessing a newborn in#ant w"o was born to a mot"er w"o is addi'ted to drugs. "i'" o# t"e #ollowing assessment

#indings would t"e nurse ex%e't to note during t"e assessment o# t"is newborn

1. *leepiness

2. Cuddles when being held3. /ethargy4. ncessant crying

. A nurse %re%ares to administer a itamin 2 in3e'tion to a newborn in#ant. ,"e mot"er as4s t"e nurse w"! "er newborn

in#ant needs t"e in3e'tion. ,"e best res%onse b! t"e nurse would be:

1. 0ou infant needs vitamin to develop immunity.2. 0The vitamin will protect your infant from being 'aundiced.

3. 0ewborn infants are deficient in vitamin ) and this in'ection prevents your infant from abnormal bleeding.

4. 0ewborn infants have sterile bowels) and vitamin promotes the growth of bacteria in the bowel.

. A nurse in a newborn nurser! re'eies a %"one 'all to %re%are #or t"e admission o# a +*6wee46gestation newborn wit" A%gar

s'ores o# 1 and +. In %lanning #or t"e admission o# t"is in#ant$ t"e nurse7s "ig"est %riorit! s"ould be to:

1. Connect the resuscitation bag to the o5ygen outlet

2. Turn on the apnea and cardiorespiratory monitors

3. *et up the intravenous line with 67 de5trose in water 4. *et the radiant warmer control temperature at 38.69 C :;<.89,=

10. 8itamin 2 is %res'ribed #or a neonate. A nurse %re%ares to administer t"e medi'ation in w"i'" mus'le site

1. Deltoid

2. Triceps3. >astus lateralis

4. $iceps

11. A nursing instru'tor as4s a nursing student to des'ribe t"e %ro'edure #or administering er!t"rom!'in ointment into t"e

e!es i# a neonate. ,"e instru'tor determines t"at t"e student needs to resear'" t"is %ro'edure #urt"er i# t"e student states:

1. 0 will cleanse the neonate&s eyes before instilling ointment.

2. 0 will flush the eyes after instilling the ointment.3. 0 will instill the eye ointment into each of the neonate&s con'unctival sacs within one hour after birth.

4. 0%dministration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent+infant attachmentand bonding can occur.

1&. A bab! is born %re'i%itousl! in t"e E/. ,"e nurses initial a'tion s"ould be to:

1. ?stablish an airway for the baby

2. %scertain the condition of the fundus



3. @uicly tie and cut the umbilical cord

4. Aove mother and baby to the birthing unit

1*. ,"e %rimar! 'riti'al obseration #or A%gar s'oring is t"e:

1. #eart rate

2. "espiratory rate

3. (resence of meconium4. ?valuation of the Aoro refle5

1+. "en %er#orming a newborn assessment$ t"e nurse s"ould measure t"e ital signs in t"e #ollowing se9uen'e:

1. (ulse) respirations) temperature

2. Temperature) pulse) respirations

3. "espirations) temperature) pulse4. "espirations) pulse) temperature

15. it"in * minutes a#ter birt" t"e normal "eart rate o# t"e in#ant ma! range between:

1. 1!! and 1B!

2. 13! and 1<!3. 12! and 18!

4. 1!! and 13!

1-. ,"e ex%e'ted res%irator! rate o# a neonate wit"in * minutes o# birt" ma! be as "ig" as:

1. 6!

2. 8!3. B!

4. 1!!

1. ,"e nurse is aware t"at a "ealt"! newborn7s res%irations are:

1. "egular) abdominal) 4!+6! per minute) deep2. rregular) abdominal) 3!+8! per minute) shallow

3. rregular) initiated by chest wall) 3!+8! per minute) deep

4. "egular) initiated by the chest wall) 4!+8! per minute) shallow

1. ,o "el% limit t"e deelo%ment o# "!%erbilirubinemia in t"e neonate$ t"e %lan o# 'are s"ould in'lude:

1. Aonitoring for the passage of meconium each shift

2. nstituting phototherapy for 3! minutes every 8 hours

3. *ubstituting breastfeeding for formula during the 2nd day after birth

4. *upplementing breastfeeding with glucose water during the first 24 hours

1. A newborn "as small$ w"itis"$ %in%oint s%ots oer t"e nose$ w"i'" t"e nurse 4nows are 'aused b! retained seba'eous

se'retions. "en '"arting t"is obseration$ t"e nurse identi#ies it as:



1. Ailia

2. /anugo

3. Whiteheads4. Aongolian spots

&0. "en newborns "ae been on #ormula #or *-6+ "ours$ t"e! s"ould "ae a:

1. *creening for (2. >itamin in'ection3. Test for necrotiing enterocolitis

4. #eel stic for blood glucose level

&1. ,"e nurse de'ides on a tea'"ing %lan #or a new mot"er and "er in#ant. ,"e %lan s"ould in'lude:

1. Discussing the matter with her in a non+threatening manner 2. *howing by e5ample and e5planation how to care for the infant

3. *etting up a schedule for teaching the mother how to care for her baby

4. *upplying the emotional support to the mother and encouraging her independence

&&. "i'" a'tion best ex%lains t"e main role o# sur#a'tant in t"e neonate

1. %ssists with ciliary body maturation in the upper airways

2. #elps maintain a rhythmic breathing pattern

3. (romotes clearing mucus from the respiratory tract

4. #elps the lungs remain e5panded after the initiation of breathing

&*. "ile assessing a &6"our old neonate$ t"e nurse obseres t"e neonate to "ae a'ro'!anosis. "i'" o# t"e #ollowing nursing

a'tions s"ould be %er#ormed initiall!

1. %ctivate the code blue or emergency system

2. Do nothing because acrocyanosis is normal in the neonate3. mmediately tae the newborn&s temperature according to hospital policy

4. otify the physician of the need for a cardiac consult

&+. ,"e nurse is aware t"at a neonate o# a mot"er wit" diabetes is at ris4 #or w"at 'om%li'ation

1. %nemia2. #ypoglycemia

3. itrogen loss4. Thrombosis

&5. A 'lient wit" grou% A blood w"ose "usband "as grou% "as 3ust gien birt". ,"e ma3or sign o# A blood

in'om%atibilit! in t"e neonate is w"i'" 'om%li'ation or test result

1. egative Coombs test

2. $leeding from the nose and ear

3. Eaundice after the first 24 hours of life

4. Eaundice within the first 24 hours of life



&-. A 'lient "as 3ust gien birt" at +& wee4s7 gestation. "en assessing t"e neonate$ w"i'" %"!si'al #inding is ex%e'ted

1. % sleepy) lethargic baby

2. /anugo covering the body3. Des-uamation of the epidermis

4. >erni5 caseosa covering the body

&. A#ter reiewing t"e 'lient7s maternal "istor! o# magnesium sul#ate during labor$ w"i'" 'ondition would t"e nurseanti'i%ate as a %otential %roblem in t"e neonate

1. #ypoglycemia

2. Eitteriness

3. "espiratory depression

4. Tachycardia

&. Neonates o# mot"ers wit" diabetes are at ris4 #or w"i'" 'om%li'ation #ollowing birt"

1. %telectasis2. Aicrocephaly

3. (neumothora54. Aacrosomia

&. ! 4ee%ing t"e nurser! tem%erature warm and wra%%ing t"e neonate in blan4ets$ t"e nurse is %reenting w"i'" t!%e o#

"eat loss

1. Conduction2. Convection

3. ?vaporation

4. "adiation

*0. A neonate "as been diagnosed wit" 'a%ut su''edaneum. "i'" statement is 'orre't about t"is 'ondition

1. t usually resolves in 3+8 wees

2. t doesn&t cross the cranial suture line

3. t&s a collection of blood between the sull and the periosteum

4. t involves swelling of tissue over the presenting part of the presenting head

*1. ,"e most 'ommon neonatal se%sis and meningitis in#e'tions seen wit"in &+ "ours a#ter birt" are 'aused b! w"i'"

organism

1. Candida albicans

2. Chlamydia trachomatis

3. Escherichia coli4. Froup $ beta+hemolytic streptococci

*&. "en attem%ting to intera't wit" a neonate ex%erien'ing drug wit"drawal$ w"i'" be"aior would indi'ate t"at t"e neonate

is willing to intera't



1. Fae aversion

2. #iccups

3. @uiet alert state4. awning

**. "en tea'"ing umbili'al 'ord 'are to a new mot"er$ t"e nurse would in'lude w"i'" in#ormation

1. %pply pero5ide to the cord with each diaper change2. Cover the cord with petroleum 'elly after bathing3. eep the cord dry and open to air

4. Wash the cord with soap and water each day during a tub bath

*+. A mot"er o# a term neonate as4s w"at t"e t"i'4$ w"ite$ '"ees! 'oating is on "is s4in. "i'" 'orre'tl! des'ribes t"is

#inding

1. /anugo

2. Ailia

3. evus flammeus

4. >erni5

*5. "i'" 'ondition or treatment best ensures lung maturit! in an in#ant

1. Aeconium in the amniotic fluid

2. Flucocorticoid treatment 'ust before delivery

3. /ecithin to sphingomyelin ratio more than 2G14. %bsence of phosphatidylglycerol in amniotic fluid

*-. "en %er#orming nursing 'are #or a neonate a#ter a birt"$ w"i'" interention "as t"e "ig"est nursing %riorit!

1. Hbtain a de5trosti5

2. Five the initial bath3. Five the vitamin in'ection

4. Cover the neonates head with a cap

*. "en %er#orming an assessment on a neonate$ w"i'" assessment #inding is most suggestie o# "!%ot"ermia

1. $radycardia2. #yperglycemia

3. Aetabolic alalosis4. *hivering

*. A woman deliers a *.&50 g neonate at +& wee4s7 gestation. "i'" %"!si'al #inding is ex%e'ted during an examination i#

t"is neonate

1. %bundant lanugo

2. %bsence of sole creases

3. $reast bud of 1+2 mm in diameter

4. /eathery) craced) and wrinled sin



*. A "ealt"! term neonate born b! C6se'tion was admitted to t"e transitional nurser! *0 minutes ago and %la'ed under a

radiant warmer. ,"e neonate "as an axillar! tem%erature o# .5o;$ a res%irator! rate o# 0 breat"s<minute$ and a "eel sti'4

glu'ose alue o# -0 mg<dl. "i'" a'tion s"ould t"e nurse ta4e

1. Wrap the neonate warmly and place her in an open crib

2. %dminister an oral glucose feeding of 1!7 de5trose in water

3. ncrease the temperature setting on the radiant warmer

4. Hbtain an order for > fluid administration

+0. "i'" neonatal be"aior is most 'ommonl! asso'iated wit" #etal al'o"ol s!ndrome (;A=)

1. #ypoactivity

2. #igh birth weight

3. (oor wae and sleep patterns4. #igh threshold of stimulation

+1. "i'" o# t"e #ollowing be"aiors would indi'ate t"at a 'lient was bonding wit" "er bab!

1. The client ass her husband to give the baby a bottle of water.

2. The client tals to the baby and pics him up when he cries.3. The client feeds the baby every three hours.

4. The client ass the nurse to recommend a good child care manual.

+&. A newborn7s mot"er is alarmed to #ind small amounts o# blood on "er in#ant girl7s dia%er. "en t"e nurse '"e'4s t"e

in#ant7s urine it is straw 'olored and "as no o##ensie odor. "i'" ex%lanation to t"e newborn7s mot"er is most a%%ro%riate

1. 0t appears your baby has a idney infection

2. 0$reast+fed babies often e5perience this type of bleeding problem due to lac of vitamin C in the breast mil

3. 0The baby probably passed a small idney stone4. 0*ome infants e5perience menstruation lie bleeding when hormones from the mother are not available

+*. An insulin6de%endent diabeti' deliered a 106%ound male. "en t"e bab! is broug"t to t"e nurser!$ t"e %riorit! o# 'are is

to

1. clean the umbilical cord with $etadine to prevent infection

2. give the baby a bath3. call the laboratory to collect a ( screening test

4. chec the baby&s serum glucose level and administer glucose if I 4! mgJd/

++. =oon a#ter delier! a neonate is admitted to t"e 'entral nurser!. ,"e nurser! nurse begins t"e initial assessment b!

1. auscultate bowel sounds.

2. determining chest circumference.3. inspecting the posture) color) and respiratory effort.

4. checing for identifying birthmars.

+5. ,"e "ome "ealt" nurse isits t"e Cox #amil! & wee4s a#ter "os%ital dis'"arge. ="e obseres t"at t"e umbili'al 'ord "as

dried and #allen o##. ,"e area a%%ears "ealed wit" no drainage or er!t"ema %resent. ,"e mot"er 'an be instru'ted to



1. cover the umbilicus with a band+aid.

2. continue to clean the stump with alcohol for one wee.

3. apply an antibiotic ointment to the stump.4. give him a bath in an infant tub now.

+-. A neonate is admitted to a "os%ital7s 'entral nurser!. ,"e neonate7s ital signs are: tem%erature > -.5 degrees ;.$ "eart

rate > 1&0 b%m$ and res%irations > +0<minute. ,"e in#ant is %in4 wit" slig"t a'ro'!anosis. ,"e %riorit! nursing diagnosis #or

t"e neonate is

1. neffective thermoregulation related to fluctuating environmental temperatures.

2. (otential for infection related to lac of immunity.

3. %ltered nutrition) less than body re-uirements related to diminished sucing refle5.

4. %ltered elimination pattern related to lac of nourishment.

+. ,"e nurse "ears t"e mot"er o# a 56%ound neonate telling a #riend on t"e tele%"one$ ?As soon as I get "ome$ I7ll gie "im

some 'ereal to get "im to gain weig"t@ ,"e nurse re'ognies t"e need #or #urt"er instru'tion about in#ant #eeding and tells

"er

1. 0f you give the baby cereal) be sure to use "ice to prevent allergy.2. 0The baby is not able to swallow cereal) because he is too small.

3. 0The infant&s digestive tract cannot handle comple5 carbohydrates lie cereal.

4. 0f you want him to gain weight) 'ust double his daily intae of formula.

+. ,"e nurse instru'ts a %rimi%ara about sa#et! 'onsiderations #or t"e neonate. ,"e nurse determines t"at t"e 'lient does not

understand t"e instru'tions w"en s"e sa!s

1. 0%ll neonates should be in an approved car seat when in an automobile.

2. 0t&s acceptable to prop the infant&s bottle once in a while.

3. 0(illows should not be used in the infant&s crib.

4. 0nfants should never be left unattended on an unguarded surface.

+. ,"e nurse manager is %resenting edu'ation to "er sta## to %romote 'onsisten'! in t"e interentions used wit" la'tating

mot"ers. ="e em%"asies t"at t"e o%timum time to initiate la'tation is

1. as soon as possible after the infant&s birth.2. after the mother has rested for 4+8 hours.

3. during the infant&s second period of reactivity.

4. after the infant has taen sterile water without complications.

50. ,"e nurse is %re%aring to dis'"arge a multi%ara &+ "ours a#ter a aginal delier!. ,"e 'lient is breast6#eeding "ernewborn. ,"e nurse instru'ts t"e 'lient t"at i# engorgement o''urs t"e 'lient s"ould

1. wear a tight fitting bra or breast binder.

2. apply warm) moist heat to the breasts.

3. contact the nurse midwife for a lactation suppressant.4. restrict fluid intae to 1!!! ml. daily .

%nswers and "ationale



Fauge your performance by counter checing your answers to the answers below. /earn more about the -uestion by reading the

rationale. f you have any disputes or -uestions) please direct them to the comments section.

1. Answer: +. Br!ing t"e in#ant in a warm blan4et. ?vaporation of moisture from a wet body dissipates heat along with themoisture. eeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.

&. Answer: 1. Bo'ument t"e #indings. ,"e %enis is normall! red during t"e "ealing %ro'ess. % yellow e5udate may be noted in

24 hours) and this is a part of normal healing. The nurse would e5pect that the area would be red with a small amount of bloodydrainage. f the bleeding is e5cessive) the nurse would apply gentle pressure with sterile gaue. f bleeding is not controlled) then the blood vessel may need to be ligated) and the nurse would contact the physician. $ecause the findings identified in the -uestion are

normal) the nurse would document the assessment.

*. Answer: &. A'ro'!anosis and grunting. The infant with respiratory distress syndrome may present with signs of cyanosis)

tachypnea or apnea) nasal flaring) chest wall retractions) or audible grunts.

+. Answer: *. la'e t"e ta%e measure under t"e in#ants "ead$ wra% around t"e o''i%ut$ and measure 3ust aboe t"e e!es. To

measure the head circumference) the nurse should place the tape measure under the infant&s head) wrap the tape around the occiput)

and measure 'ust above the eyebrows so that the largest area of the occiput is included.

5. Answer: +. Continue to breast#eed eer! &6+ "ours. $reast feeding should be initiated within 2 hours after birth and every 2+4hours thereafter. The other options are not necessary.

-. Answer: *. Instillation o# t"e %re%aration into t"e lungs t"roug" an endotra'"eal tube. The aim of therapy in "D* is to suppor

the disease until the disease runs its course with the subse-uent development of surfactant. The infant may benefit from surfactant

replacement therapy. n surfactant replacement) an e5ogenous surfactant preparation is instilled into the lungs through an endotrachealtube.

. Answer: +. In'essant 'r!ing. % newborn infant born to a woman using drugs is irritable. The infant is overloaded easily by sensory

stimulation. The infant may cry incessantly and posture rather than cuddle when being held.

. Answer: *. ?Newborn in#ants are de#i'ient in itamin 2$ and t"is in3e'tion %reents !our in#ant #rom abnormal

bleeding.@ >itamin is necessary for the body to synthesie coagulation factors. >itamin is administered to the newborn infant to

prevent abnormal bleeding. ewborn infants are vitamin deficient because the bowel does not have the bacteria necessary for

synthesiing fat+soluble vitamin . The infant&s bowel does not have support the production of vitamin until bacteria ade-uately

colonies it by food ingestion.

. Answer: 1. Conne't t"e resus'itation bag to t"e ox!gen outlet. The highest priority on admission to the nursery for a newborn

with low %pgar scores is airway) which would involve preparing respiratory resuscitation e-uipment. The other options are also

important) although they are of lower priority.

10. Answer: *. 8astus lateralis.

11. Answer: &. ?I will #lus" t"e e!es a#ter instilling t"e ointment.@ ?ye prophyla5is protects the neonate against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash

away the administered medication.

1&. Answer: 1. Establis" an airwa! #or t"e bab!. The nurse should position the baby with head lower than chest and rub the infant&s

bac to stimulate crying to promote o5ygenation. There is no haste in cutting the cord.



1*. Answer: 1. Deart rate. The heart rate is vital for life and is the most critical observation in %pgar scoring. "espiratory effect

rather than rate is included in the %pgar scoreK the rate is very erratic.

1+. Answer: +. /es%irations$ %ulse$ tem%erature. This se-uence is least disturbing. Touching with the stethoscope and inserting thethermometer increase an5iety and elevate vital signs.

15. Answer: *. 1&0 and 1-0. The heart rate varies with activityK crying will increase the rate) whereas deep sleep will lower itK a rate

between 12! and 18! is e5pected.

1-. Answer: &. -0. The respiratory rate is associated with activity and can be as rapid as 8! breaths per minuteK over 8! breaths perminute are considered tachypneic in the infant.

1. Answer: &. Irregular$ abdominal$ *06-0 %er minute$ s"allow. ormally the newborn&s breathing is abdominal and irregular in

depth and rhythmK the rate ranges from 3!+8! breaths per minute.

1. Answer: 1. onitoring #or t"e %assage o# me'onium ea'" s"i#t. $ilirubin is e5creted via the F tractK if meconium is retained)the bilirubin is reabsorbed.

1. Answer: 1. ilia. Ailia occur commonly) are not indicative of any illness) and eventually disappear.

&0. Answer: 1. ='reening #or 2F. $y now the newborn will have ingested an ample amount of the amino acid phenylalanine)

which) if not metabolied because of a lac of the liver enyme) can deposit in'urious metabolites into the bloodstream and brainKearly detection can determine if the liver enyme is absent.

&1. Answer: &. ="owing b! exam%le and ex%lanation "ow to 'are #or t"e in#ant. Teaching the mother by e5ample is a non+

threatening approach that allows her to proceed at her own pace.

&&. Answer: +. Del%s t"e lungs remain ex%anded a#ter t"e initiation o# breat"ing. *urfactant wors by reducing surface tension in

the lung. *urfactant allows the lung to remain slightly e5panded) decreasing the amount of wor re-uired for inspiration.

&*. Answer: &. Bo not"ing be'ause a'ro'!anosis is normal in t"e neonate. %crocyanosis) or bluish discoloration of the hands and

feet in the neonate :also called peripheral cyanosis=) is a normal finding and shouldn&t last more than 24 hours after birth.

&+. Answer: &. D!%ogl!'emia. eonates of mothers with diabetes are at ris for hypoglycemia due to increased insulin levels. During

gestation) an increased amount of glucose is transferred to the fetus across the placenta. The neonate&s liver cannot initially ad'ust tothe changing glucose levels after birth. This may result in an overabundance of insulin in the neonate) resulting in hypoglycemia.

&5. Answer: +. Gaundi'e wit"in t"e #irst &+ "ours o# li#e. The neonate with %$H blood incompatibility with its mother will have

'aundice :pathologic= within the first 24 hours of life. The neonate would have a positive Coombs test result.

&-. Answer: *. Bes9uamation o# t"e e%idermis. (ostdate fetuses lose the verni5 caseosa) and the epidermis may becomedes-uamated. These neonates are usually very alert. /anugo is missing in the postdate neonate.

&. Answer: *. /es%irator! de%ression. Aagnesium sulfate crosses the placenta and adverse neonatal effects are respiratory

depression) hypotonia) and $radycardia.



&. Answer: +. a'rosomia. eonates of mothers with diabetes are at increased ris for macrosomia :e5cessive fetal growth= as a

result of the combination of the increased supply of maternal glucose and an increase in fetal insulin.

&. Answer: &. Cone'tion. Convection heat loss is the flow of heat from the body surface to the cooler air.

*0. Answer: +. It inoles swelling o# tissue oer t"e %resenting %art o# t"e %resenting "ead. Caput succedaneum is the swelling

of tissue over the presenting part of the fetal scalp due to sustained pressureK it resolves in 3+4 days.

*1. Answer: +. Hrou% beta6"emol!ti' stre%to'o''i. Transmission of Froup $ beta+hemolytic streptococci to the fetus results in

respiratory distress that can rapidly lead to septic shoc.

*&. Answer: *. uiet alert state. When caring for a neonate e5periencing drug withdrawal) the nurse needs to be alert for distress

signals from the neonate. *timuli should be introduced one at a time when the neonate is in a -uiet and alert state. Fae aversion)

yawning) sneeing) hiccups) and body arching are distress signals that the neonate cannot handle stimuli at that time.

**. Answer: *. 2ee% t"e 'ord dr! and o%en to air. eeping the cord dry and open to air helps reduce infection and hastens drying.

*+. Answer: +. 8ernix.

*5. Answer: *. Le'it"in to s%"ingom!elin ratio more t"an &:1. /ecithin and sphingomyelin are phospholipids that help compose

surfactant in the lungsK lecithin peas at 38 wees and sphingomyelin concentrations remain stable.

*-. Answer: +. Coer t"e neonates "ead wit" a 'a%. Covering the neonates head with a cap helps prevent cold stress due toe5cessive evaporative heat loss from the neonate&s wet head. >itamin can be given up to 4 hours after birth.

*. Answer: 1. rad!'ardia. #ypothermic neonates become bradycardic proportional to the degree of core temperature.

#ypoglycemia is seen in hypothermic neonates.

*. Answer: +. Leat"er!$ 'ra'4ed$ and wrin4led s4in. eonatal sin thicens with maturity and is often peeling by post term.

*. Answer: +. btain an order #or I8 #luid administration. %ssessment findings indicate that the neonate is in respiratory distress Lmost liely from transient tachypnea) which is common after cesarean delivery. % neonate with a rate of B! breaths a minute

shouldn&t be fed but should receive > fluids until the respiratory rate returns to normal. To allow for close observation for worsening

respiratory distress) the neonate should be ept unclothed in the radiant warmer.

+0. Answer: *. oor wa4e and slee% %atterns. %ltered sleep patterns are caused by disturbances in the C* from alcohol e5posure in

utero. #yperactivity is a characteristic generally noted. /ow birth weight is a physical defect seen in neonates with ,%*. eonateswith ,%* generally have a low threshold for stimulation.

+1. Answer: &. ,"e 'lient tal4s to t"e bab! and %i'4s "im u% w"en "e 'ries.

+&. Answer: +. ?=ome in#ants ex%erien'e menstruation li4e bleeding w"en "ormones #rom t"e mot"er are not aailable@.

+*. Answer: +. '"e'4 t"e bab!7s serum glu'ose leel and administer glu'ose i# J +0 mg<dL.



++. Answer: *. ins%e'ting t"e %osture$ 'olor$ and res%irator! e##ort.

+5. Answer:+. gie "im a bat" in an in#ant tub now.

+-. Answer: 1. Ine##e'tie t"ermoregulation related to #lu'tuating enironmental tem%eratures.

+. Answer: *. ?,"e in#ant7s digestie tra't 'annot "andle 'om%lex 'arbo"!drates li4e 'ereal.@

+. Answer: &. ?It7s a''e%table to %ro% t"e in#ant7s bottle on'e in a w"ile.@

+. Answer: 1. as soon as %ossible a#ter t"e in#ant7s birt".

50. Answer: &. a%%l! warm$ moist "eat to t"e breasts.

nclex exam newborn nursing care (50 items)

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