OB-Newborn-NCLEX Practice Questions

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?
1. Document the findings
2. Contact the physician
3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing
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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?
1. Document the findings
2. Contact the physician
3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing
1. Document the findings - The penis is normally red during the healing process. A yellow exudate may be noted in 24 hours, and this is a part of normal healing. The nurse would expect that the area would be red with a small amount of bloody drainage. If the bleeding is excessive, the nurse would apply gentle pressure with sterile gauze. If bleeding is not controlled, then the blood vessel may need to be ligated, and the nurse would contact the physician. Because the findings identified in the question are normal, the nurse would document the assessment.
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:
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 blanket
4. Drying the infant in a warm blanket - Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation.
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?
1. Hypotension and Bradycardia
2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest with grunting
2. Tachypnea and retractions - The infant with respiratory distress syndrome may present with signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.
A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure the head circumference of the infant. The nurse would most appropriately:
1. Wrap the tape measure around the infant's head and measure just above the eyebrows.
2. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above the eyes
3. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
4. Place the tape measure at the back of the infant's head, wrap around across the ears, and measure across the infant's mouth.
3. 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 just above the eyebrows so that the largest area of the occiput is included.
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?
1. Switch to bottle feeding the baby for 2 weeks
2. Stop the breast feedings and switch to bottle-feeding permanently
3. Feed the newborn infant less frequently
4. Continue to breast-feed every 2-4 hours
4. Continue to breast-feed every 2-4 hours - Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter. 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:
1. Subcutaneous injection
2. Intravenous injection
3. Instillation of the preparation into the lungs through an endotracheal tube
4. Intramuscular injection
3. The aim of therapy in RDS is to support the disease until the disease runs its course with the subsequent development of surfactant. The infant may benefit from surfactant replacement therapy. In surfactant replacement, an exogenous surfactant preparation is instilled into the lungs through an endotracheal tube.
A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following assessment findings would the nurse expect to note during the assessment of this newborn?
1. Sleepiness
2. Cuddles when being held
3. Lethargy
4. Incessant crying
4. Incessant crying - A 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.
A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her newborn infant needs the injection. The best response by the nurse would be:
1. "You infant needs vitamin K to develop immunity."
2. "The vitamin K will protect your infant from being jaundiced."
3. "Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding."
4. "Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
3. Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The infant's bowel does not have support the production of vitamin K until bacteria adequately colonizes it by food ingestion.
A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to:
1. Connect the resuscitation bag to the oxygen outlet
2. Turn on the apnea and cardiorespiratory monitors
3. Set up the intravenous line with 5% dextrose in water
4. Set the radiant warmer control temperature at 36.5 C (97.6F)
1. Connect the resuscitation bag to the oxygen outlet. The highest priority on admission to the nursery for a newborn with low Apgar scores is AIRWAY, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.
Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?
1. Deltoid
2. Triceps.
3. Vastus lateralis
4. Biceps
3. Vastus lateralis (thigh) - Use a 5/8" needle at a 90 degree angle: Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, 5/8-inch needle. It is injected into skin that has been cleansed with alcohol and allowed to dry for 1 minute. It is administered at a 90-degree angle. The site is massaged after removing needle to increase absorption of the medication.