1. 1.

Question
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:

o A. Warming the crib pad

o B. Turning on the overhead radiant warmer

o C. Closing the doors to the room

o D. Drying the infant in a warm blanket

Correct
Correct Answer: D. Drying the infant in a warm blanket.
Newborn temperature at birth is around 37.2ºC (99ºF) because they
have been confined in their mother’s warm uterine environment. The
newborn’s temperature will immediately drop upon delivery due to
various factors like the newborn’s immature temperature-regulating
mechanism, inability to properly conserve heat, temperature of the
birthing environment, and if the newborn is not protected from heat
loss following delivery.
• Option D: 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.
• Option A: Warming the crib pad prevents heat loss
through conduction, which is the transfer of body heat to a
cooler solid object in contact with the newborn.
• Option B: Using the overhead radiant warmer is heat loss
through radiation, which is the transfer of body heat to a
cooler solid object not in contact with the baby
• Option C: Closing the doors to the room eliminates drafts
is heat loss through convection (flow of heat from the
newborn’s body to cooler surrounding air).
2. 2. Question
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

Correct
Correct Answer: A. Document the findings. The penis is normally
red during the healing process.
• Option A: 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.
• Option B: Hemorrhage, infection, and urethral fistula
formation are rare complications that can occur from
circumcision. If bleeding is not controlled, then the blood
vessel may need to be ligated, and the nurse would contact
the physician.
• Option C: A circumcision site that appears red is normal as
long as it does not have a strong odor or strong discharge.
• Option D: If the bleeding is excessive, the nurse would
apply gentle pressure with sterile gauze.
3. 3. Question
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

Correct
Correct Answer: B. Tachypnea and retractions
Respiratory distress syndrome (RDS) usually affects premature babies. It
is caused by the absence or lack of surfactant, a phospholipid that lines
the alveoli and reduces the surface tension to keep the alveoli from
collapsing on expiration. Surfactant is not formed until the 34th week of
gestation that is why premature infants are vulnerable.
• Option B: 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.
• Options A, C, & D: These are late signs (after a few hours)
of respiratory distress as its intensity
increases. Acrocyanosis is the blue or cyanotic
discoloration of the extremities. Expiratory grunting is
when the infant closes the glottis in an attempt to increase
pressure in the alveoli on expiration in order to keep them
from collapsing. Additionally, auscultation may reveal fine
rales and diminished breath sounds due to poor air entry.

4. 4. Question
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:
 • A. Wrap the tape measure around the infant’s head and
measure just above the eyebrows.

• B. Place the tape measure under the infant's head at the base
of the skull and wrap around to the front just above the eyes

• C. Place the tape measure under the infant's head, wrap

around the occiput, and measure just above the eyes

• D. Place the tape measure at the back of the infant’s head,

wrap around across the ears, and measure across the infant’s
mouth.
Correct
Correct Answer: C. Place the tape measure under the infant’s head,
wrap around the occiput, and measure just above the eyes.
Option C: 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.

5. 5. Question
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 the breastfeedings and switch to bottle-feeding

permanently

• C. Feed the newborn infant less frequently

• D. Continue to breast-feed every 2-4 hours

Correct
Correct Answer: D. Continue to breastfeed every 2-4 hours.
Hyperbilirubinemia is caused by the accumulation of excess bilirubin in
the blood serum. The skin and sclera of the eyes of the newborn may
appear noticeably yellow as a result of breakdown of fetal red blood
cells.
• Option D: 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.

6. 6. Question
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

• D. Intramuscular injection
Correct
Correct Answer: C. Instillation of the preparation into the lungs
through an endotracheal tube.
Option C: 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.

7. 7. Question
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?

• A. Sleepiness

• B. Cuddles when being held

• C. Lethargy

• D. Incessant crying
 Correct
Correct Answer: D. Incessant crying.
• Option D: 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.

8. 8. Question
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:

• A. “Your infant needs vitamin K to develop immunity.”

• B. “Vitamin K will protect your infant from having jaundice.”

• C. “Newborn infants are deficient in vitamin K, and this

injection prevents your infant from abnormal bleeding.”

• D. “Newborn infants have sterile bowels, and vitamin K

promotes the growth of bacteria in the bowel.”
Correct
Correct Answer: C. “Newborn infants are deficient in vitamin K, and
this injection prevents your infant from abnormal bleeding.”
• Option C: Vitamin K is necessary for the body to synthesize
coagulation factors. Vitamin K is administered to the
newborn infant to prevent abnormal bleeding.
• Option D: 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 support the production of vitamin K until bacteria
adequately colonize it by food ingestion.

9. 9. Question
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:

• A. Connect the resuscitation bag to the oxygen outlet

 • B. Turn on the apnea and cardiorespiratory monitors

• C. Set up the intravenous line with 5% dextrose in water

• D. Set the radiant warmer control temperature at 36.5* C

(97.6*F)
Correct
Correct Answer: A. Connect the resuscitation bag to the oxygen
outlet.
• Option A: The highest priority on admission to the nursery
for a newborn with low Apgar scores is airway, which would
involve preparing respiratory resuscitation equipment.
• Options B, C, & D: The other options are also important,
although they are of lower priority.

10. 10. Question

Vitamin K is prescribed for a neonate. A nurse prepares to administer
the medication in which muscle site?

• A. Deltoid

• B. Triceps

• C. Vastus lateralis

• D. Biceps
Correct
Correct Answer: C. Vastus lateralis.
• Option C: Vitamin K is given as a prophylaxis for
hemorrhagic disease. It is administered intramuscular (IM)
in the vastus lateralis muscle. The vastus lateralis muscle lies
lateral to the midline of the thigh and wraps about 1/4 the
distance around the thigh.

11. 11. Question

A nursing instructor asks a nursing student to describe the procedure
for administering erythromycin ointment into the eyes of a neonate. The
instructor determines that the student needs to research this procedure
further if the student states:
 • A. “I will cleanse the neonate’s eyes before instilling
ointment.”

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

• C. “I will instill the eye ointment into each of the neonate’s

conjunctival sacs within one hour after birth.”

• D. “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.”
Correct
Correct Answer: B. “I will flush the eyes after instilling the
ointment.”
• Option B: Eye prophylaxis protects the neonate against
Neisseria gonorrhoeae and Chlamydia trachomatis. The
eyes are not flushed after instillation of the medication
because the flush will wash away the administered
medication.

12. 12. Question

A baby is born precipitously in the ER. The nurse’s initial action should
be to:

• A. Establish an airway for the baby

• B. Ascertain the condition of the fundus

• C. Quickly tie and cut the umbilical cord

• D. Move mother and baby to the birthing unit

Correct
Correct Answer: A. Establish an airway for the baby.
• Option A: The nurse should position the baby with head
lower than chest and rub the infant’s back to stimulate
crying to promote oxygenation.
• Option C: There is no haste in cutting the cord.

13. 13. Question

The primary critical observation for Apgar scoring is the:
 • A. Heart rate

• B. Respiratory rate

• C. Presence of meconium

• D. Evaluation of the Moro reflex

Correct
Correct Answer: A. Heart rate.
• Option A: The heart rate is vital for life and is the most
critical observation in Apgar scoring. Respiratory effect
rather than rate is included in the Apgar score; the rate is
very erratic.

14. 14. Question

When performing a newborn assessment, the nurse should measure the
vital signs in the following sequence:

• A. Pulse, respirations, temperature

• B. Temperature, pulse, respirations

• C. Respirations, temperature, pulse

• D. Respirations, pulse, temperature

Correct
Answer: D. Respirations, pulse, temperature.
• Option D: This sequence is least disturbing. Touching with
the stethoscope and inserting the thermometer increase
anxiety and elevate vital signs.

15. 15. Question

Within three (3) minutes after birth the normal heart rate of the infant
may range between:

• A. 100 and 180

• B. 130 and 170

• C. 120 and 160

• D. 100 and 130

 Correct
Correct Answer: C. 120 and 160.
• Option C: The heart rate varies with activity; crying will
increase the rate, whereas deep sleep will lower it; a rate
between 120 and 160 is expected.

16. 16. Question

The expected respiratory rate of a neonate within three (3) minutes of
birth may be as high as:

• 50

• 60

• 80

• 100
Correct
Correct Answer: B. 60.
• Option B: The respiratory rate is associated with activity
and can be as rapid as 60 breaths per minute; over 60
breaths per minute are considered tachypneic in the infant.

17. 17. Question

The nurse is aware that a healthy newborn’s respirations are:

• A. Regular, abdominal, 40-50 per minute, deep

• B. Irregular, abdominal, 30-60 per minute, shallow

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

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

shallow
Correct
Correct Answer: B. Irregular, abdominal, 30-60 per minute, shallow.
• Option B: Normally the newborn’s breathing is abdominal
and irregular in-depth and rhythm; the rate ranges from 30-
60 breaths per minute.

18. 18. Question

 To help limit the development of hyperbilirubinemia in the neonate, the
plan of care should include:

• A. Monitoring for the passage of meconium each shift

• B. Instituting phototherapy for 30 minutes every 6 hours

• C. Substituting breastfeeding for formula during the 2nd day

after birth

• D. Supplementing breastfeeding with glucose water during

the first 24 hours
Incorrect
Correct Answer: A. Monitoring for the passage of meconium each
shift.
• Option A: Bilirubin is excreted via the GI tract; if meconium
is retained, the bilirubin is reabsorbed.

19. 19. Question

A newborn has small, whitish, pinpoint spots over the nose, which the
nurse knows are caused by retained sebaceous secretions. When
charting this observation, the nurse identifies it as:

• A. Milia

• B. Lanugo

• C. Whiteheads

• D. Mongolian spots
Correct
Correct Answer: A. Milia.
• Option A: Milia occurs commonly, are not indicative of any
illness, and eventually disappear.

20. 20. Question

When newborns have been on formula for 36-48 hours, they should
have a:

• A. Screening for PKU

 • B. Vitamin K injection

• C. Test for necrotizing enterocolitis

• D. Heel stick for blood glucose level

Incorrect
Correct Answer: A. Screening for PKU.
• Option A: By now the newborn will have ingested an ample
amount of the amino acid phenylalanine, which, if not
metabolized because of a lack of the liver enzyme, can
deposit injurious metabolites into the bloodstream and
brain; early detection can determine if the liver enzyme is
absent.

21. 21. Question

The nurse decides on a teaching plan for a new mother and her infant.
The plan should include:

• A. Discussing the matter with her in a non-threatening

manner

• B. Showing by example and explanation how to care for

the infant

• C. Setting up a schedule for teaching the mother how to

care for her baby

• D. Supplying the emotional support to the mother and

encouraging her independence
Incorrect
Correct Answer: B. Showing by example and explanation how to
care for the infant.
• Option B: Teaching the mother by example is a non-
threatening approach that allows her to proceed at her own
pace.

22. 22. Question

Which action best explains the main role of surfactant in the neonate?

• A. Assists with ciliary body maturation in the upper airways

 • B. Helps maintain a rhythmic breathing pattern

• C. Promotes clearing mucus from the respiratory tract

• D. Helps the lungs remain expanded after the initiation of

breathing
Correct
Correct Answer: D. Helps the lungs remain expanded after the
initiation of breathing.
• Option D: Surfactant works by reducing surface tension in
the lung. Surfactant allows the lung to remain slightly
expanded, decreasing the amount of work required for
inspiration.

23. 23. Question

While assessing a 2-hour old neonate, the nurse observes the neonate
to have acrocyanosis. Which of the following nursing actions should be
performed initially?

• A. Activate the code blue or emergency system

• B. Do nothing because acrocyanosis is normal in the

neonate

• C. Immediately take the newborn’s temperature according to

hospital policy

• D. Notify the physician of the need for a cardiac consult

Incorrect
Correct Answer: B. Do nothing because acrocyanosis is normal in
the neonate.
• Option B: Acrocyanosis, or bluish discoloration of the
hands and feet in the neonate (also called peripheral
cyanosis), is a normal finding and shouldn’t last more than
24 hours after birth.

24. 24. Question

The nurse is aware that a neonate of a mother with diabetes is at risk for
what complication?

• A. Anemia
 • B. Hypoglycemia

• C. Nitrogen loss

• D. Thrombosis
Correct
Correct Answer: B. Hypoglycemia.
• Option B: Neonates of mothers with diabetes are at risk for
hypoglycemia due to increased insulin levels. During
gestation, an increased amount of glucose is transferred to
the fetus across the placenta. The neonate’s liver cannot
initially adjust to the changing glucose levels after birth.
This may result in an overabundance of insulin in the
neonate, resulting in hypoglycemia.

25. 25. Question

A client with group AB blood whose husband has group O has just
given birth. The major sign of ABO blood incompatibility in the neonate
is which complication or test result?

• A. Negative Coombs test

• B. Bleeding from the nose and ear

• C. Jaundice after the first 24 hours of life

• D. Jaundice within the first 24 hours of life

Correct
Correct Answer: D. Jaundice within the first 24 hours of life.
• Option D: The neonate with ABO blood incompatibility
with its mother will have jaundice (pathologic) within the
first 24 hours of life. The neonate would have a positive
Coombs test result.