Exam (elaborations)
Newborn Nursing Care and Assessment NCLEX Questions & Detailed Answers
- Course
- Newborn assessment
- Institution
- University Of Pennsylvania
Newborn Nursing Care and Assessment NCLEX Questions & Detailed Answers
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Newborn Nursing Care and Assessment NCLEXQuestions & Detailed Answers
A nurse in a delivery room is assisting with the delivery of a newborn infant. After
the delivery, the nurse prepares to prevent heat loss in the newborn resulting
from evaporation by:
A. Warming the crib pad
B. Turning on the overhead radiant warmer
C. Closing the doors to the room
D. Drying the infant in a warm blanket - ANS D. Drying the infant in a warm blanket
(Evaporation is the loss of heat through the conversion of liquid to vapor.
Newborns are wet from the amniotic fluid when they are born, as the fluid
evaporates from their skin, they can lose heat. Drying the infant using a warm
blanket is an excellent measure to help conserve heat or prevent heat loss.
Additionally, drying the face and hair, covering the hair with a cap, and laying the
newborn on the mother's abdomen, effectively reduces heat loss through
evaporation. Keeping the newborn dry by drying the wet newborn infant will
prevent hypothermia via evaporation.)
A nurse is assessing a newborn infant following circumcision and notes that the
circumcised area is red with a small amount of bloody drainage. Which of the
following nursing actions would be most appropriate?
A. Document the findings
,B. Contact the physician
C. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
D. Reinforce the dressing - ANS A. Document the findings
(Close observation of the circumcision site during the first few hours is necessary
to determine if there is a complication. A yellow exudate may be noted after 24
hours, and this is a part of normal healing. This should not be washed away
because it serves a protective function. The nurse would expect that the area
would be red with a small amount of bloody drainage. Because the findings
identified in the question are normal, the nurse would document the assessment.
Additionally, document if the infant is voiding after the procedure to ascertain that
the urethra is not occluded. Instruct the parents to keep the site free from feces
and covered in petrolatum until healing is complete. If the infant cries constantly
and if there is redness or tenderness due to pain, it should be reported to the
physician.)
A nurse in the newborn nursery is monitoring a preterm newborn infant for
respiratory distress syndrome. Which assessment signs if noted in the newborn
infant would alert the nurse to the possibility of this syndrome?
A. Hypotension and Bradycardia
B. Tachypnea and retractions
C. Acrocyanosis and grunting
D. The presence of a barrel chest with grunting - ANS B. Tachypnea and retractions
(Infants who develop RDS have periods during the day when they are free of
symptoms because of an initial release of surfactant. The initial signs of respiratory
distress includes tachypnea (60 breaths per minute), sternal and subcostal
retractions, nasal flaring, cyanotic mucous membranes.)
, A postpartum nurse is providing instructions to the mother of a newborn infant
with hyperbilirubinemia who is being breastfed. The nurse provides which most
appropriate instructions to the mother?
A. Switch to bottle-feeding the baby for 2 weeks
B. Stop breastfeeding and switch to bottle-feeding permanently
C. Feed the newborn infant less frequently
D. Continue to breastfeed every 2-4 hours - ANS D. Continue to breastfeed every 2-
4 hours
(Breastfeeding should be initiated within 2 hours after birth and every 2-4 hours
thereafter. Early feeding of newborns with hyperbilirubinemia promotes intestinal
movement and excretion of meconium which ultimately helps prevent indirect
bilirubin buildup. The other options are not necessary.)
A nurse on the newborn nursery floor is caring for a neonate. On assessment the
infant is exhibiting signs of cyanosis, tachypnea, nasal flaring, and grunting.
Respiratory distress syndrome is diagnosed, and the physician prescribes
surfactant replacement therapy. The nurse would prepare to administer this
therapy by:
A. Subcutaneous injection
B. Intravenous injection
C. Instillation of the preparation into the lungs through an endotracheal tube
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