Maternal Newborn NCLEX Exam Questions, Exams of Nursing

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Exam 3 maternal newborn NCLEX

Questions

The nurse is proving care to a 1-hour-old newborn who was born at 39 weeks' gestation. Which assessment data is cause for concern? Select all that apply. A) Respiratory rate of 82 breaths per minute B) Negative Babinski reflex C) Mean blood pressure of 52 mmHg D) Acrocyanosis E) Presence of soft heart murmur - Answer-Respiratory rate of 82 breaths per minute Negative Babinski reflex The nurse receives shift change report on infants born within the last 4 hours. Which newborn should the nurse assess first? A) Newborn born at 37 weeks' gestation. Respiratory rate of 45 breaths per minute. B) Term newborn, 2 hours old, who has not passed a meconium stool. C) Term newborn born 3 hours ago. Heart rate is 150 beats per minute.

D) Term newborn born 1 hour ago who is exhibiting grunting respirations. - Answer-Term newborn born 1 hour ago who is exhibiting grunting respirations. A client delivers a newborn son and plans to breastfeed. When the nurse attempts to help the newborn latch on for breastfeeding, the client states, "I would like to bottle feed my baby for the first few days." Which reason might the nurse hear regarding why the client wants to delay breastfeeding? A) Colostrum is bad for the baby. B) The birthing process spoils breast milk. C) It will cause "evil eye." D) Newborns require feeding on demand. - Answer-Colostrum is bad for the baby. The nurse is caring for a newborn boy who was circumcised an hour ago. Which is the priority nursing diagnosis for the newborn? A) Risk for Injury B) Risk for Infection C) Risk for Imbalanced Nutrition D) Risk for Ineffective Breathing Pattern - Answer-Risk for Infection A nurse is caring for the 1-hour-old newborn of a mother with diabetes mellitus. Which actions will the nurse include in the newborn's plan of care? Select all that apply. A) Assess blood glucose frequently. B) Assess for SGA. C) Assess for hyperthyroidism. D) Assess the newborn's temperature hourly. E) Assess for hyperbilirubinemia. - Answer-Assess blood glucose frequently.

B) "Your baby may spit up frequently for the first few weeks." C) "Compress the bulb syringe before placing it in your baby's nose or mouth." D) "You can wipe away any green drainage that might form around the umbilical cord." - Answer-"Compress the bulb syringe before placing it in your baby's nose or mouth." The nurse is providing care to a newborn during the first 24 hours of life. Which is an abnormal finding? A) Respiratory rate of 58 breaths per minute B) Heart rate of 140 beats per minute C) Presence of meconium stool D) Yellowing of the skin - Answer-Yellowing of the skin The nurse conducting a 5-minute Apgar assessment on a newborn assigns the following ratings: Heart rate <100 beats per minute (1 point); slow, irregular respirations (1 point); some flexion of the extremities (1 point); a vigorous cry with flicking of the baby's foot (2 points); and a pink body with blue extremities (1 point). Based on this data, which nursing action is appropriate? A) Having the aide reassess the newborn's heart rate and respiratory rate when admitted to the nursery B) Swaddling the newborn to decrease the risk of increased energy expenditure C) Placing the newborn in the mother's arms and asking her to monitor her baby's breathing D) Repeating the assessment every 5 minutes for up to 20 minutes - Answer-Repeating the assessment every 5 minutes for up to 20 minutes The nurse is providing care to a newborn born at 37 2/7 weeks' gestation. The newborn's weight is 1750 g (3 pounds, 10 ounces). What statement would the nurse use to describe these assessment findings? A) Preterm appropriate for gestational age B) Term appropriate for gestational age

C) Preterm small for gestational age D) Term small for gestational age - Answer-Term small for gestational age The nurse will commonly need to work with all except which member of the healthcare team to provide care to the newborn? A) Audiology specialist B) Cardiac surgeon C) Lactation consultant D) Pediatrician - Answer-Cardiac surgeon After giving birth to a preterm infant who is being cared for in the neonatal intensive care unit (NICU), a client says, "My baby doesn't seem real because she's in the hospital and I'm at home." What can the nurse do to promote parent-infant attachment? A) Limit visits to the intensive care unit so as not to disrupt care the baby needs. B) Explain that once the baby is discharged to home, she will have evidence that the baby is real. C) Have the mother visit when the baby is asleep or resting. D) Provide a picture of the infant including a footprint and current weight and length. - Answer-Provide a picture of the infant including a footprint and current weight and length. The mother of a preterm infant tells the nurse that she was not looking forward to having a baby and now that the baby is sick, she feels worse. Which nursing diagnosis is appropriate based on this data? A) Parental Role Conflict B) Impaired Parenting C) Dysfunctional Family Processes

C) Insert an indwelling urinary catheter. D) Weigh diapers using the estimate that 1 mL = 1 gram of weight. - Answer-Weigh diapers using the estimate that 1 mL = 1 gram of weight. The nurse is preparing to provide an enteral feeding to a preterm infant. Which is the priority nursing action prior to administering the feeding? A) Weigh the current diaper. B) Measure abdominal girth. C) Weigh the baby. D) Measure pulse oximetry. - Answer-Measure abdominal girth. A nurse is caring for a premature infant with a central line. The otherwise healthy, growing infant suddenly develops apnea, bradycardia, and metabolic acidosis. Which is the most likely condition causing this change in health status? A) Hyperbilirubinemia B) Bacterial sepsis C) Hypoglycemia D) Intracranial hemorrhage - Answer-Bacterial sepsis The nurse is assessing a premature newborn who is being cared for in the newborn intensive care unit (NICU). Which assessment finding indicates the newborn is experiencing respiratory distress? A) Acrocyanosis B) Respiratory rate of 58 breaths per minute C) Substernal and intercostal retractions

D) Abdominal breathing - Answer-Substernal and intercostal retractions Which factor contributes to increased respiratory complications in the preterm infant? A) Increased constriction of blood vessels B) Decreased prostaglandin E levels C) Absence of muscular coat on pulmonary blood vessels D) Inadequate surfactant - Answer-Inadequate surfactant Because of the immature development of the kidney, the nurse needs to assess preterm infants for what condition? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis - Answer-Metabolic acidosis A premature newborn's neuronal immaturity may contribute to what complication? A) Apnea of prematurity B) Patent ductus arteriosus C) Respiratory distress syndrome D) Anemia of prematurity - Answer-Apnea of prematurity