NR327 - Quiz 4 - Newborn Care NCLEX-Style Questions Answers

NR327 - Quiz 4 - Newborn Care NCLEX-Style Questions| Answers| Rationale

• A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is

in the 60th percentile for weight. Based on the weight and gestational age, the nurse should classify this neonate as which of the following?

• Low birth weight
• Appropriate for gestational age
• Small for gestational age
• Large for gestational age

Rationale:

• A newborn who has a low birth weight would weigh less than 2,500 g.
• CORRECT: This newborn is classified as appropriate for gestational age because

the weight is between the 10th and 90th percentile.

• A newborn who is small for gestational age would weigh less than the 10th percentile.
• A newborn who is large for gestational age would weigh greater than the 90th

percentile."

• A nurse is completing a newborn assessment and observes small white nodules on the roof of

the newborn's mouth. this finding is a characteristic of which of the following conditions?

• mongolian spots
• milia spots
• erythema toxicum
• Epstein's pearls

Rationale:

• mongolian spots are dark areas observed in dark‑skinned newborns.
• milia are small white bumps that occur on the nose due to clogged sebaceous glands.
• erythema toxicum is a transient maculopapular rash seen in newborns.
• CORRECT: Epstein's pearls are small white nodules that appear on the roof of a

newborn's mouth."

• A nurse is assessing the reflexes of a newborn. In checking for the moro reflex, the nurse

should perform which of the following?

• Hold the newborn vertically under arms and allow one foot to touch table.
• Stimulate the pads of the newborn's hands with stroking or massage.
• Stimulate the soles of the newborn's feet on the outer lateral surface of each foot.

• Hold the newborn in a semi‑sitting position, then allow the newborn's head and

trunk to fall backward.

Rationale:

• Holding the newborn vertically under the arms and allowing one foot to touch the

table elicits the stepping reflex.

• Stimulating the pads of the newborn's hands elicits the grasp reflex.
• Stimulating the outer lateral portion of the newborn's soles elicits the babinski reflex.
• CORRECT: The moro reflex is elicited by holding the newborn in a semi‑sitting

position and then allowing the head and trunk to fall backward.

• A nurse is completing an assessment. which of the following data indicate the newborn is

adapting to extrauterine life? (Select all that apply.)

• expiratory grunting
• Inspiratory nasal flaring
• Apnea for 10‑second periods
• Obligatory nose breathing
• Crackles and wheezing

Rationale:

• Expiratory grunting is a manifestation of respiratory distress.
• Nasal flaring is a manifestation of respiratory distress.

C. CORRECT: Periods of apnea lasting <15 seconds are an expected finding.

D. CORRECT: Newborns are obligatory nose breathers.

• Crackles and wheezing are manifestations of fluid or infection in the lungs."

• A nurse is teaching a newly licensed nurse how to bathe a newborn and observes a bluish

marking across the newborn's lower back. the nurse should include which of the following information in the teaching?

• "This is frequently seen in newborns who have dark skin."
• "This is a finding indicating hyperbilirubinemia."
• "This is a forceps mark from an operative delivery."
• "This is related to prolonged birth or trauma during delivery."

Rationale:

A. CORRECT: Mongolian spots are commonly found over the lumbosacral area of

newborns who have dark skin/are African American, Asian, or Native American origin.

• Hyperbilirubinemia would present as jaundice.
• Forceps marks would most likely present as a cephalohematoma.

• birth trauma would present as ecchymosis.

• A nurse is preparing to administer prophylactic eye ointment to a newborn to prevent

ophthalmia neonatorum. which of the following medications should the nurse anticipate administering?

• Ofloxacin
• Nystatin
• Erythromycin
• Ceftriaxone

Rationale:

• Ofloxacin is an antibiotic, but it is not used for ophthalmia neonatorum.
• Nystatin is used to treat Candida albicans, an oral yeast infection.

C. CORRECT: One medication of choice for ophthalmia neonatorum is

erythromycin ophthalmic ointment 0.5%. This antibiotic provides prophylaxis against Neisseria gonorrhoeae and Chlamydia trachomatis.

• Ceftriaxone is an antibiotic, but it is not used for ophthalmia neonatorum."

• A newborn was not dried completely after birth. which of the following mechanisms should

the nurse understand causes heat loss?

• Conduction
• Convection
• Evaporation
• Radiation

Rationale:

• Conduction is the loss of heat from the body surface area to cooler surfaces that the

newborn can be in contact with.

• Convection is the flow of heat from the body surface area to cooler air.

C. CORRECT: Evaporation is the loss of heat that occurs when a liquid is

converted to a vapor. in a newborn, heat loss by evaporation occurs as a result of vaporization of the moisture from the skin.

• Radiation is the loss of heat to a cooler surface that is not in direct contact with the

newborn."

• A nurse is caring for a newborn immediately following birth. which of the following nursing

interventions is the highest priority?

• Initiating breastfeeding.
• Performing the initial bath.

• Giving a vitamin K injection.
• Covering the newborn's head with a cap.

Rationale:

• Initiating breastfeeding is important following birth, but it is not the priority action.
• Initial baths aren’t given until the newborn's temp is stable. It isn’t the priority action.
• Vitamin K can be given immediately after birth, but it is not the priority action.
• CORRECT: The greatest risk to the newborn is cold stress. Therefore the highest

priority intervention is to prevent heat loss. Covering the newborn's head with a cap prevents cold stress due to excessive evaporative heat loss.

• A nurse is preparing to administer vitamin K (phytonadione)injection to a newborn. which of

the following responses should the nurse make to the newborn's mother regarding why this medication is given?

• "It assists with blood clotting."
• "It promotes maturation of the bowel."
• "It is a preventative vaccine."
• "It provides immunity."

Rationale:

• CORRECT: 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.

• Vitamin K does not assist the bowel to mature.
• Vitamin K is not part of the vaccines that are administered.
• Vitamin K does not provide immunity"

• A nurse is taking a newborn to a mother following a circumcision. which of the following

actions should the nurse take for security purposes?

• Ask the mother to state her full name.
• Look at the name on the newborn's bassinet.
• Match the mother's identification band with the newborn's band.
• Compare name on the bassinet and room number.

Rationale:

• Asking the mother to state her full name is not appropriate verification because two

identifiers should be used.

• Looking at the name on the bassinet is not appropriate verification because two

identifiers should be used.