Newborn Nursing care NCLEX Quiz 2

1. A baby is born precipitously in the ER. What should be the initial action of the nurses?

Establish an airway for the baby

Check the condition of the fundus.

Quickly cut the umbilical cord.

Move baby to the birthing unit

When a baby is born precipitously in the ER, the initial action of the nurses should be to establish an airway for the baby. This is because ensuring that the baby has a clear and open airway is crucial for their survival and proper breathing. It is important to prioritize this action to prevent any potential respiratory distress or complications that may arise from a blocked airway. Checking the condition of the fundus, cutting the umbilical cord, or moving the baby to the birthing unit can be done after the airway has been established.

Explanation

When a baby is born precipitously in the ER, the initial action of the nurses should be to establish an airway for the baby. This is because ensuring that the baby has a clear and open airway is crucial for their survival and proper breathing. It is important to prioritize this action to prevent any potential respiratory distress or complications that may arise from a blocked airway. Checking the condition of the fundus, cutting the umbilical cord, or moving the baby to the birthing unit can be done after the airway has been established.

2. What's the normal heart rate range of an infant within 3 minutes after birth?

100 and 180

130 and 170

120 and 160

100 and 130

The normal heart rate range of an infant within 3 minutes after birth is between 120 and 160 beats per minute.

Explanation

The normal heart rate range of an infant within 3 minutes after birth is between 120 and 160 beats per minute.

3. If a newborn has small, whitish pinpoint spots over the nose. which the nurse is aware are caused by retained sebaceous secretions, the nurse should identify it as:

Milia

Lanugo

Whiteheads

Mongolian spots

Milia are small, whitish pinpoint spots that appear on the nose of a newborn. These spots are caused by retained sebaceous secretions. Lanugo refers to fine, downy hair that covers a newborn's body. Whiteheads are small, acne-like bumps that occur when the pores become clogged with oil and dead skin cells. Mongolian spots are bluish-gray birthmarks that are commonly found on the buttocks or lower back of newborns. Therefore, the correct identification for the given description is Milia.

Explanation

Milia are small, whitish pinpoint spots that appear on the nose of a newborn. These spots are caused by retained sebaceous secretions. Lanugo refers to fine, downy hair that covers a newborn's body. Whiteheads are small, acne-like bumps that occur when the pores become clogged with oil and dead skin cells. Mongolian spots are bluish-gray birthmarks that are commonly found on the buttocks or lower back of newborns. Therefore, the correct identification for the given description is Milia.

4. How high can the expected respiratory rate of a neonate be within three minutes of birth?

50

60

80

100

The expected respiratory rate of a neonate within three minutes of birth can be as high as 60. This means that the newborn can have up to 60 breaths per minute during this time period. It is important to monitor the respiratory rate of neonates as any abnormalities can indicate potential health issues.

Explanation

The expected respiratory rate of a neonate within three minutes of birth can be as high as 60. This means that the newborn can have up to 60 breaths per minute during this time period. It is important to monitor the respiratory rate of neonates as any abnormalities can indicate potential health issues.

5. What is the primary critical observation for Apgar scoring?

Heart rate

Respiratory rate

Presence of meconium

Evaluation of the Moro reflex

The primary critical observation for Apgar scoring is the heart rate. Apgar scoring is a method used to quickly assess the health of a newborn baby. It evaluates five vital signs: heart rate, respiratory rate, muscle tone, reflex irritability, and skin color. However, the heart rate is considered the most important observation as it provides crucial information about the baby's circulatory system and overall well-being.

Explanation

The primary critical observation for Apgar scoring is the heart rate. Apgar scoring is a method used to quickly assess the health of a newborn baby. It evaluates five vital signs: heart rate, respiratory rate, muscle tone, reflex irritability, and skin color. However, the heart rate is considered the most important observation as it provides crucial information about the baby's circulatory system and overall well-being.

6. A nursing instructor asked a nursing student about the procedure for administering erythromycin ointment into the eyes of a neonate. The instructor finds that the student has to research this procedure further if the student states:

“I will cleanse the neonate’s eyes before instilling ointment.”

“I will flush the eyes after instilling the ointment.”

“I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”

“Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and parent-infant attachment and bonding can occur.”

The correct answer is "I will flush the eyes after instilling the ointment." This statement is incorrect because flushing the eyes after instilling the ointment can wash away the medication and reduce its effectiveness. The correct procedure is to cleanse the neonate's eyes before instilling the ointment and then wait for a specific period of time before flushing the eyes, if necessary.

Explanation

The correct answer is "I will flush the eyes after instilling the ointment." This statement is incorrect because flushing the eyes after instilling the ointment can wash away the medication and reduce its effectiveness. The correct procedure is to cleanse the neonate's eyes before instilling the ointment and then wait for a specific period of time before flushing the eyes, if necessary.

7. In what sequence should the nurse measure the vital signs when performing a newborn assessment?

Pulse, respirations, temperature

Temperature, pulse, respirations

Respirations, temperature, pulse

Respirations, pulse, temperature

The correct sequence for measuring vital signs during a newborn assessment is to first measure respirations, followed by pulse, and then temperature. This order is important because measuring respirations requires the least amount of contact with the baby, minimizing any potential disturbance. Measuring pulse comes next as it still requires minimal contact but may cause slight disruption. Finally, measuring temperature requires the most contact and can be the most uncomfortable for the baby, so it is done last.

Explanation

The correct sequence for measuring vital signs during a newborn assessment is to first measure respirations, followed by pulse, and then temperature. This order is important because measuring respirations requires the least amount of contact with the baby, minimizing any potential disturbance. Measuring pulse comes next as it still requires minimal contact but may cause slight disruption. Finally, measuring temperature requires the most contact and can be the most uncomfortable for the baby, so it is done last.

8. The nurse knows that a healthy newborn’s respirations are:

Regular, abdominal, 40-50 per minute. deep

Irregular, abdominal, 30-60 per minute. shallow

Irregular, initiated by chest wall, 30-60 per minute. deep

Regular, initiated by the chest wall, 40-60 per minute. shallow

The correct answer is "Irregular, abdominal, 30-60 per minute. shallow." This is because healthy newborns have immature respiratory systems, which result in irregular breathing patterns. Their respirations are primarily abdominal, as the diaphragm is the main muscle used for breathing at this stage. The respiratory rate can vary between 30-60 breaths per minute, and the breaths are typically shallow.

Explanation

The correct answer is "Irregular, abdominal, 30-60 per minute. shallow." This is because healthy newborns have immature respiratory systems, which result in irregular breathing patterns. Their respirations are primarily abdominal, as the diaphragm is the main muscle used for breathing at this stage. The respiratory rate can vary between 30-60 breaths per minute, and the breaths are typically shallow.

9. What should the plan of care include to help limit the development of hyperbilirubinemia in the neonate?

Monitoring for the passage of meconium each shift

Instituting phototherapy for 50 minutes within 6 hours

Substituting breastfeeding

Supplementing breastfeeding with glucose water

To limit the development of hyperbilirubinemia in the neonate, monitoring for the passage of meconium each shift should be included in the plan of care. Meconium is the first stool of a newborn, and the presence of meconium indicates that the baby's digestive system is functioning properly. If meconium is not passed within the expected timeframe, it may indicate an obstruction or other issues that can lead to hyperbilirubinemia. Therefore, monitoring for the passage of meconium helps to identify any potential problems early on and take appropriate measures to prevent hyperbilirubinemia.

Explanation

To limit the development of hyperbilirubinemia in the neonate, monitoring for the passage of meconium each shift should be included in the plan of care. Meconium is the first stool of a newborn, and the presence of meconium indicates that the baby's digestive system is functioning properly. If meconium is not passed within the expected timeframe, it may indicate an obstruction or other issues that can lead to hyperbilirubinemia. Therefore, monitoring for the passage of meconium helps to identify any potential problems early on and take appropriate measures to prevent hyperbilirubinemia.

10. What should the newborns have when they have been on formula for 36-48 hours?

Screening for PKU

Vitamin K injection

Test for necrotizing enterocolitis

Heel stick for blood glucose level

Newborns who have been on formula for 36-48 hours should have screening for PKU. PKU stands for Phenylketonuria, which is a genetic disorder that affects the body's ability to break down an amino acid called phenylalanine. Early detection and treatment of PKU is crucial to prevent intellectual disabilities and other health issues. Therefore, it is important to screen newborns for PKU within the first few days of life.

Explanation

Newborns who have been on formula for 36-48 hours should have screening for PKU. PKU stands for Phenylketonuria, which is a genetic disorder that affects the body's ability to break down an amino acid called phenylalanine. Early detection and treatment of PKU is crucial to prevent intellectual disabilities and other health issues. Therefore, it is important to screen newborns for PKU within the first few days of life.