Question You are a nurse in a neonatal intensive care unit (NICU) caring for a preterm newborn. The infant is receiving oxygen therapy due to respiratory distress syndrome. It is crucial to monitor the infant for signs of oxygen toxicity. Which of the following signs would indicate oxygen toxicity in this newborn? A. Increased heart rate
B. Decreased respiratory effort
C. Flaring nostrils
D. Retractions
E. Sudden bradycardia
Rationale: Oxygen toxicity in newborns can lead to free radical damage, affecting various organs and systems. Sudden bradycardia may indicate an adverse reaction to high oxygen levels, signaling potential cardiac or central nervous system distress. Increased heart rate, decreased respiratory effort, flaring nostrils, and retractions are more indicative of respiratory distress or insufficiency rather than oxygen toxicity.
NCLEX Practice Quizzes: Test Your Knowledge (200+ Quizzes)
Question You are assessing a newborn immediately after birth. The baby appears pink with active movement but does not cry immediately and grimaces when stimulated. Based on the initial assessment, what Apgar score should the newborn receive at 1 minute?
A. 7
B. 8
C. 9
D. 10
E. 11
Rationale: The Apgar score assesses newborn vitality at 1 and 5 minutes after birth based on five criteria: appearance (color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration. A baby that is pink (2 points), has active movement (2 points), does not cry immediately but breathes (1 point), and grimaces when stimulated (1 point), receives an 8. The absence of immediate crying indicates a slight deduction for respiratory effort.
Question You are a nurse in a neonatal intensive care unit (NICU) caring for a preterm newborn. The infant is receiving oxygen therapy due to respiratory distress syndrome. It is crucial to monitor the infant for signs of oxygen toxicity.Which of the following signs would indicate oxygen toxicity in this newborn
A. Increased heart rate
B. Decreased respiratory effort
C. Flaring nostrils
D. Retractions
E. Sudden bradycardia
Rationale: Oxygen toxicity in newborns can lead to free radical damage, affecting various organs and systems. Sudden bradycardia may indicate an adverse reaction to high oxygen levels, signaling potential cardiac or central nervous system distress. Increased heart rate, decreased respiratory effort, flaring nostrils, and retractions are more indicative of respiratory distress or insufficiency rather than oxygen toxicity.
Question You are assessing a newborn immediately after birth. The baby appears pink with active movement but does not cry immediately and grimaces when stimulated.Based on the initial assessment, what Apgar score should the newborn receive at 1 minute?
A. 7
B. 8
C. 9
D. 10
E. 11
Rationale: The Apgar score assesses newborn vitality at 1 and 5 minutes after birth based on five criteria: appearance (color), pulse (heart rate), grimace (reflex irritability), activity (muscle tone), and respiration. A baby that is pink (2 points), has active movement (2 points), does not cry immediately but breathes (1 point), and grimaces when stimulated (1 point), receives an 8. The absence of immediate crying indicates a slight deduction for respiratory effort.
Question A full-term newborn is being monitored in the nursery. The nurse observes mild jaundice 24 hours after birth.Which action is most appropriate for the nurse to take first?
A. Start phototherapy.
B. Increase fluid intake.
C. Notify the healthcare provider.
D. Prepare the infant for exchange transfusion.
E. Encourage more frequent breastfeeding.
Rationale: Early jaundice can indicate neonatal hyperbilirubinemia, which requires prompt evaluation by a healthcare provider to determine the cause and appropriate treatment. While phototherapy and increased feeding can be part of the management, the initial step should always be to notify the healthcare provider for assessment and orders. This ensures a timely and appropriate response to the jaundice.
Question During a routine newborn screening, a nurse notices a newborn has not passed meconium within the first 48 hours of life.What is the most likely complication associated with this finding?
A. Gastroesophageal reflux disease (GERD)
B. Hirschsprung disease
C. Celiac disease
D. Lactose intolerance
E. Intestinal atresia
Rationale: Delayed passage of meconium, especially beyond 48 hours in a newborn, is a classic sign of Hirschsprung disease, which is a congenital disorder characterized by the absence of ganglion cells in the distal colon, leading to bowel obstruction. GERD, celiac disease, and lactose intolerance typically present later in infancy or early childhood and are not associated with delayed meconium passage. Intestinal atresia could cause similar symptoms but is less common and usually diagnosed with other clinical signs and imaging.
Question A nurse is educating new parents on how to care for their newborn’s umbilical cord stump. Which instruction should the nurse include?
A. Soak the stump in warm water daily.
B. Apply alcohol wipes to the stump at each diaper change.
C. Keep the stump dry and exposed to air as much as possible.
D. Cover the stump with a tight, sterile bandage.
E. Use talcum powder around the stump to absorb moisture.
Rationale: Keeping the umbilical cord stump dry and exposed to air promotes healing and reduces the risk of infection. Wet or moist conditions can encourage bacterial growth. The use of alcohol wipes is outdated and no longer recommended as it can delay healing. Covering the stump with a tight bandage or using talcum powder are not recommended practices as they can also inhibit drying and increase the risk of infection.
Question A nurse is assessing a newborn for signs of hypoglycemia due to the mother having gestational diabetes. The baby is jittery and has a weak cry. Which of the following is the most appropriate initial intervention?
A. Administer 10% dextrose intravenously.
B. Encourage the mother to breastfeed immediately.
C. Perform a heel stick to check blood sugar.
D. Give the baby formula as soon as possible.
E. Wrap the baby in a warm blanket.
Rationale: The initial step in managing suspected neonatal hypoglycemia is to confirm the blood sugar level, which is efficiently done through a heel stick test. Jitteriness and a weak cry are common signs of hypoglycemia in newborns, and prompt identification of blood glucose levels is crucial for determining the appropriate intervention. Breastfeeding, formula feeding, or administering dextrose come after confirming hypoglycemia to ensure targeted treatment.
Question In the newborn nursery, a nurse is caring for a baby born at 35 weeks gestation. The nurse is monitoring the baby for apnea of prematurity.What is the most important nursing action to prevent apnea in this baby?
A. Keeping the baby in a supine position
B. Monitoring temperature regularly
C. Administering caffeine as prescribed
D. Ensuring the baby is fed every 2 hours
E. Providing continuous positive airway pressure (CPAP)
Rationale: Caffeine is commonly used in the management of apnea of prematurity because of its stimulant effects on the respiratory center in the brain, reducing the frequency and severity of apnea episodes. Keeping the baby in a supine position, monitoring temperature, and ensuring regular feeding are all important for general newborn care but do not directly prevent apnea. CPAP may be used in more severe cases but is not the primary action for prevention.
NCLEX Questions: Focus on Newborn Nursing
Question A nurse is preparing to administer the first hepatitis B vaccine to a newborn. The mother asks why the vaccine is necessary so soon after birth.What is the best response by the nurse?
A. “It provides immediate protection against infections.”
B. “It’s a requirement before the baby can leave the hospital.”
C. “The vaccine is most effective if given within the first 12 hours.”
D. “Early vaccination helps prevent transmission from mother to child.”
E. “It’s the first step in the baby’s long-term immunization schedule.”
Rationale: The hepatitis B vaccine is given soon after birth primarily to prevent mother-to-child transmission of hepatitis B virus, which can occur during birth. This early vaccination is crucial, especially in cases where the mother is hepatitis B surface antigen-positive, to protect the newborn from developing chronic hepatitis B infection. While it also marks the beginning of the child’s immunization schedule and offers protection against infections, the primary rationale for immediate vaccination is to block vertical transmission of the virus.
Understanding the Newborn NCLEX Questions
Question A nurse is caring for a newborn who is showing signs of neonatal abstinence syndrome (NAS) due to opioid exposure during pregnancy.Which of the following is the most appropriate nursing intervention?
A. Place the newborn in a brightly lit room.
B. Engage in frequent, vigorous stimulation.
C. Administer oral morphine as prescribed.
D. Limit holding and cuddling the newborn.
E. Offer a pacifier for non-nutritive sucking.
Rationale: Non-nutritive sucking, such as offering a pacifier, is a supportive care strategy for newborns with NAS, as it can help soothe and calm them. Neonates with NAS often exhibit increased irritability and have difficulty being soothed. While oral morphine may be part of the treatment protocol for NAS, it is specifically for managing withdrawal symptoms under medical supervision. Bright lighting and vigorous stimulation can increase stress in these newborns, and they benefit from a quiet, dimly lit environment with gentle handling.
