Quiz
newborn nclex
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Perguntas do quiz (66)
1The mother of a newborn reports to the nurse that her infant has had a black tarry stool. The nurse would tell the mother that:
- Athis is most likely caused by blood the infant may have swallowed during the birth process
- Bthe health care provider will be promptly notified
- Cthe infant will be given nothing by mouth (remain NPO) until a stool culture is taken
- Dthis is a normal stool in newborn infants
2Which of the following observations of the newborn infant should be promptly reported to the health care provider? (select all that apply)
- Aa respiratory rate of 24/min
- Btemperature of 98.4 F
- Cpulse rate of 88/min
- Dnasal flaring
3infections in the newborn require prompt intervention because:
- Athey spread more quickly
- Binfections that are relatively harmless to an adult can be fatal to the newborn
- Cthe portals of entry and exit are more numerous
- Dthe newborn has no defenses against infection
4The mother states that her newborn has white pinpoint "pimples" on his nose and chin and she plans to squeeze them to make them disappear. The best response of the nurse would be:
- A"Be sure to wipe the area with an alcohol sponge to avoid infection"
- B"Ask your health care provider to prescribe an antibiotic ointment for the pimples"
- C"These pimples are called 'Epstein's pearls' and are a normal occurrence."
- D"These pimples are called 'milia' and will disappear on their own in a week or two"
5Which observation of the newborn should be reported to the health care provider as soon as possible?
- AA swelling beneath the scalp on one side of the head
- BA respiratory rate of 55 breaths/min
- CA unilateral Moro reflex
- DCyanosis of the hands and feet
6A characteristic sign of necrotizing enterocolitis (NEC) in the newborn is :
- Abloody diarrhea
- Bnecrosis of the abdomen
- Cprojectile vomiting
- Dhigh fever
7Which of the following observations of a preterm neonate would indicate presence of respiratory distress? (select all that apply)
- Asubsternal retractions
- Brespiratory rate of 70/min
- Cgrunting
- Dlethargy
8An infant is born at 43 weeks gestation. The nurse should monitor the infant for common problems such as: (select all that apply)
- Arespiratory distress caused by possible meconium aspiration
- Bincreased weight gain resulting from increased glucose availability
- Chypoglycemia resulting from decreased glucose reserves
- Dpresence of increased amounts of languo
9A preterm infant in the NICU is receiving calcium gluconate for hypoglycemia. What assessment would the nurse prioritize?
- AColor
- BLevel of consciousness
- CTemperature
- DHeart rate
10Which characteristic put a preterm infant at risk for sepsis?
- AImmature liver
- BLack of brown fat
- CHypocalcemia
- DDecreased prothrombin
11What terminology will the nurse use when considering how well developed the infant is at birth and the ability of the organs to function outside the uterus?
- ALevel of growth
- BLevel of development
- CGestational level
- DLevel of maturation
12Identify the physical characteristics that would be present in an infant with respiratory distress syndrome.
Select all that apply.- ARespiratory rate above 60
- BGrunting and retractions
- CEdema
- DMeconium stained sputum
13What physical characteristic most likely indicates postmaturity?
- AAbundant lanugo
- BPeeling skin
- CAbundant vernix caseosa
- DThin, transparent skin
14Which signs and symptoms characterize cold stress?
Select all that apply.- AFever
- BTachycardia
- CMottling of the skin
- DPeriods of apnea
- EHyperactivity
15What are the signs of necrotizing enterocolitis (NEC)?
Select all that apply.- AAbdominal distention
- BJaundice
- CDecreased urine output
- DDiarrhea
- EBilious vomitus
- FBloody stools
16[blank_start]Surfactant[blank_end] is a chemical necessary for the absorption of oxygen by the lungs.
- ASurfactant
17The nurse assesses blood-tinged mucus discharge in a newborn baby girl’s diaper. What education can the nurse provide to the mother about why this is occurring?
- ANewborn urinary tract infection
- BUrinary reflux disease
- CHormonal withdrawal from mother at birth
- DExcessive amounts of follicle-stimulating hormone
18Which assessments are included in evaluating a newborn using the Apgar scoring system?
Select all that apply.- AHeart rate
- BReflexes
- CCry
- DColor
19Parents of a newborn express concern over the apparent swelling of their newborn’s scalp. What is the nurse’s best response?
- A“I will notify the physician immediately.”
- B“I will get an ice pack to apply.”
- C“Don’t worry about it, and just enjoy your baby.”
- D“This will gradually subside without treatment.”
20Which nursing diagnosis would be the priority in the newborn?
- AIneffective thermoregulation
- BImpaired skin integrity
- CDisturbed thought processes
- DRisk for Neonatal Jaundice
21What is usually included in parent teaching for newborn care prior to discharge?
Select all that apply.- ACPR training
- BReturn appointments for well-baby care
- CProper use of car safety seats
- DPotential birth control methods
- EBasic infant care
22The nurse administers erythromycin ointment (0.5%) to the newborn's eyes, and the mother asks the nurse why this is done. The nurse should give which response to the client?
- APrevents cataracts in the neonate born to a woman who is susceptible to rubella
- BProtects the neonate's eyes from possible infections acquired while hospitalized
- CMinimizes the spread of microorganisms to the neonate from invasive procedures during labor
- DPrevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection
23A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse should make which statement to the client?
- A"Your newborn needs vitamin K to develop immunity."
- B"The vitamin K will protect your newborn from becoming jaundiced."
- C"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."
- D"Newborns have sterile bowels. The vitamin K will colonize the bowel with the necessary bacteria."
24The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV) positive. The nurse understands that which should be included in the plan of care?
- AMonitoring the neonate's vital signs routinely
- BMaintaining standard precautions at all times while caring for the neonate
- CInstructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream
- DInitiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate
25The nurse is assisting in caring for a postterm neonate immediately after admission to the nursery. The priority nursing action should be to monitor which?
- AUrinary output
- BBlood glucose levels
- CTotal bilirubin levels
- DHemoglobin and hematocrit level
26The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse should tell the mother that which is a sign of infection?
- AA darkened drying stump
- BA moist cord with discharge
- CA purple stump that shows pinkness around the base
- DA purple stump that shows some moistness at the base
27The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?
- ABegin with the eyes and face.
- BStart with the dirtiest area first.
- CBegin with the feet and work upward.
- DOnly wash the diaper area, because this is the only part of the baby that gets soiled.
28After birth the nurse prevents hypothermia as a result of evaporation by performing which action?
- AWarming the crib pad
- BClosing the doors of the room
- CDrying the baby with a warm blanket
- DTurning on the overhead radiant warmer
29The nurse in the newborn nursery receives a telephone call to prepare for the admission of an infant born at 43 weeks gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, the nurses highest priority should be to:
- Aturn on the apnea and cardiorespiratory monitor
- Bconnect the resuscitation bag to the oxygen outlet
- Cset up the intravenous line with 5 % dextrose in water
- Dset the radiant warmer control temperature at 36.5C (97.6F)
30The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.
- AAvoid stimulation.
- BDecrease fluid intake.
- CExpose all of the newborn's skin.
- DMonitor the skin temperature closely.
- EReposition the newborn every 2 hours.
- FCover the newborn's eyes with shields or patches.
31The nurse is planning to teach cord care to a new mother. The nurse plans to tell the mother that:
- Aalcohol is the only agent used to clean the cord
- Bit takes 21 days for the cord to dry up and fall off
- Ccord care is done only at birth to control bleeding
- Dthe process of keeping the cord clean and dry will decrease bacterial growth
32A newborn has just been circumcised. Which describes how the nurse should expect the surgical site to appear?
- APink, without drainage
- BReddened, with a small amount of bloody drainage
- CReddened, with a small amount of yellow exudate on the glans
- DReddened, with a large amount of bloody drainage that requires a dressing change every 30 minutes
33The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?
- ATachypnea and retractions
- BAcrocyanosis and grunting
- CHypotension and bradycardia
- DThe presence of a barrel chest with acrocyanosis
34The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS?
- AA length of 19 inches
- BAbnormal palmar creases
- CA birth weight of 6 pounds and 14 ounces
- DA head circumference that is appropriate for gestational age
35A pregnant human immunodeficiency virus (HIV)–positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed?
- A"I will be sure to wash my hands before feeding the newborn."
- B"I will breastfeed, especially for the first 6 weeks postpartum."
- C"I will be sure to wash my hands before and after bathroom use."
- D"I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."
36The nurse is monitoring a newborn infant who was circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?
- ADocument the findings.
- BReinforce the dressing.
- CNotify the registered nurse.
- DSwab the drainage and send the sample to the laboratory for culture.
37The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?
- AEncourage the parents to touch their newborn.
- BIdentify specific caregiving tasks that may be assumed by the parents.
- CExplain the equipment used and how it functions to assist their newborn.
- DGive the parents pamphlets that will help them understand their newborn's condition.
38The nurse is reviewing the treatment plan with the parents of a newborn infant with hypospadias. Which statement by the parents indicates their understanding of the plan?
- A"Caution should be used when straddling my infant on a hip."
- B"Catheterization will be necessary if my infant does not void."
- C"Vital signs should be taken daily to check for bladder infection."
- D"Circumcision has been delayed to save tissue for surgical repair."
39The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse should make which statement to address the client's concern?
- A"Don't worry about your baby, complications are rare."
- B"You will not have any problems if you follow the advice the health care provider has given you."
- C"Your baby will need to spend a few days in the neonatal intensive care unit following delivery."
- D"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential."
40The nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to make which observation while caring for the neonate?
- AThe neonate is lethargic.
- BThe neonate sleeps quietly.
- CThe neonate cries incessantly.
- DThe neonate is easy to console when crying.
41The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?
- AMonitoring for signs of dehydration
- BMonitoring urine for specific gravity
- CMonitoring the anterior fontanel for bulging
- DMonitoring blood pressure for signs of hypotension
42The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?
- AMaintain the neonate in a brightly lit area of the nursery.
- BAllow the neonate to establish his or her own sleep/rest pattern.
- CEncourage frequent handling of the neonate by staff and parents.
- DMonitor neonate response to feedings and the weight gain pattern.
43A client delivers a viable neonate who is given APGAR scores of 8 and 9 at 1 and 5 minutes. How does the nurse characterize the neonate's physical condition?
- APoor
- BFair
- CGood
- DCritical
44In providing initial care to the newborn following delivery, what is the nurse's priority action?
- AIdentify gestational age.
- BIdentify the infant and mother.
- CTurn the infant's head to the side.
- DRecord the number of umbilical vessels.
45While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?
- AThe client is likely to demonstrate malattachment.
- BThe client is disappointed with the baby's gender.
- CThe client is experiencing a normal response to birth.
- DThe client is grieving over the loss of the pregnancy.
46The nurse is caring for a newborn diagnosed with hyperbilirubinemia. Which action is recommended for a newborn who is being breast-fed when diagnosed with hyperbilirubinemia?
- AIncrease the frequency of breast-feeding.
- BAlternate feeding with supplemental formula.
- CAdd additional feedings with bottled glucose.
- DStop breast-feeding for 48 hours, and have the mother pump the breasts.
47The nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which guideline?
- AFacial jaundice is common from birth to 5 days of age.
- BBilirubin is produced at minimal rates in the neonate immediately following delivery.
- CThe neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery.
- DJaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dL, which are not abnormal in a 2-day-old neonate.
48The nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmia neonatorum and gonococcal infection. The student correctly identifies which medication?
- ANeomycin
- BPenicillin
- CSilver nitrate
- DErythromycin
49The nurse is assisting in collecting data on a large-for-gestational age (LGA) newborn. Which technique should the nurse anticipate being used to check for evidence of birth trauma?
- APalpating the clavicles for a fracture
- BListening to the heart for a cardiac defect
- CBlanching the skin for the evidence of jaundice
- DPerforming Ortolani's maneuver for hip dislocation
50The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?
- AWithin acceptable ranges
- BIndicative of Rh incompatibility
- CIndicative of a need for phototherapy
- DLower than normal for the newborn's age
51The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. What does the result indicate to the nurse?
- AHypotonia
- BHypoglycemia
- CA normal level
- DHyperglycemia
52An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?
- ASepsis
- BHypercalcemia
- CDrug withdrawal
- DIntraventricular hemorrhage
53The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?
- ADehydration
- BA normal finding
- CIncreased intracranial pressure
- DDecreased intracranial pressure
54The nurse is collecting initial data on a newborn in the delivery room. Which observation should the nurse expect to note when examining the umbilical cord of the newborn?
- AOne artery and one vein
- BTwo arteries and one vein
- CTwo veins and one artery
- DTwo arteries and two veins
55The nurse educates a mother about her newborn's diagnosis of fetal alcohol syndrome (FAS). Which statement by the mother provides the nurse with assurance that the mother understands this syndrome?
- A"Mental retardation is unlikely to happen."
- B"Withdrawal symptoms will occur in about 3 days."
- C"The reason my baby is so large is because of this metabolic problem."
- D"Withdrawal symptoms include tremors, abnormal reflexes, and uncontrollable crying."
56The nurse is reviewing the record of a newborn infant and notes that the health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indication on data collection of the infant?
- AA hard, rigid immobile suture line
- BA suture split greater than 1 cm wide
- CSwelling of the soft tissues of both the head and the scalp
- DEdema caused from bleeding below the brain's periosteum
57The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first?
- AFeed the infant.
- BLet the infant sleep.
- CCheck the blood glucose level.
- DCall the health care provider immediately.
58The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?
- ASerum insulin level
- BHeel stick blood glucose
- CRh and ABO blood typing
- DIndirect and direct bilirubin levels
59The nurse is assisting in checking the reflexes on a neonate. In eliciting the Moro reflex, the nurse should perform which action?
- ATouch the cheek with a finger.
- BClap the hand or slap on the mattress.
- CStimulate the ball of the foot by firm pressure.
- DStimulate the pads of the hands by firm pressure.
60A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?
- AAnemia
- BMacrosomia
- CHyperglycemia
- DPostmaturity syndrome
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Study Mode
Question 66 of 85
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The nurse prepares to administer erythromycin ophthalmic ointment to a newborn infant immediately after delivery. The nurse understands that this ointment is characterized by which description?- AAdministered at room temperature to prevent side effects
- BMore irritating to the newborn's eyes than silver nitrate drops
- CStaining to the infant's skin and must be wiped off immediately
- DEffective in protecting the newborn from Neisseria gonorrhoeae and Chlamydia
62The nurse is caring for an infant with a diagnosis of hyperbilirubinemia. When explaining to the infant's mother the use of phototherapy, the nurse should make which statement?
- A"Lotion is used on your infant during phototherapy to prevent excoriation and skin breakdown."
- B"While undergoing phototherapy, your infant will be required to wear an eye and nose shield at all times."
- C"During phototherapy it is important for your infant to receive plain water in order to ensure hydration."
- D"While undergoing phototherapy, your infant should wear an eye shield that is removed during feedings."
63The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?
- AThe nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action?
- BClosing the doors to the delivery room
- CDrying the newborn with a warm blanket
- DWarming the crib pad before placing the newborn in the crib
64The mother of a newborn calls the clinic and reports to the nurse that when she was cleansing the newborn's umbilical cord, the cord was moist and discharge was noted. Which nursing instruction to the mother is appropriate?
- ATo bring the infant to the clinic
- BTo characterize this as a normal occurrence
- CTo increase the number of times that the cord is cleansed per day
- DTo monitor the cord for another 24 to 48 hours and to call the clinic if the discharge continues
65The nurse is monitoring a newborn who was born to a drug-addicted mother. Which findings should the nurse expect to note during data collection for this newborn? Select all that apply.
- AThe newborn is irritable.
- BThe newborn is lethargic.
- CThe newborn cuddles easily.
- DThe newborn cries incessantly.
- EThe newborn is difficult to console.
- FThe newborn hyperextends and postures.
66The nurse is caring for a neonate that is 3 hours old and should assess for which signs/symptoms of cold stress? Select all that apply.
- ATachycardia
- BHyperactivity
- CMottling of skin
- DIncreased skin temperature
- EIncreased respirations with apnea
Informações
- Descrição
- Quiz sobre newborn nclex, criado por Dina Romero em 29-03-2019.
- Autor
- Dina Romero
- Idioma
- English
- Visualizações
- 6
- Etiquetas
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