Newborn And Infant Care Support - NCLEX Pn
- Which assessment finding is most consistent with dehydration in an infant?
- Sunken fontanelle with decreased urine output. These indicate fluid deficit, as fontanelles reflect intracranial pressure and urine output measures renal perfusion.
- What is the priority nursing action for a newborn who is choking during feeding?
- Stop feeding, position side-lying, and clear airway as needed. This intervention clears the airway and prevents aspiration, prioritizing respiratory safety during the episode.
- Which vitamin is routinely administered to newborns to prevent hemorrhagic disease?
- Vitamin K (phytonadione) IM. Newborns have low vitamin K levels, increasing bleeding risk, so administration supports clotting factor production.
- Which newborn reflex is elicited by a sudden noise, causing arm extension then flexion?
- Moro (startle) reflex. This reflex assesses neurological integrity, mimicking a startle response to protect against falling in primitive survival instincts.
- What is the priority teaching for umbilical cord care in a healthy newborn?
- Keep cord clean and dry; fold diaper below stump. This promotes natural drying and prevents infection by avoiding moisture accumulation around the stump.
- Which jaundice finding requires immediate provider notification in a newborn?
- Jaundice present in the first 24 hours. Early onset suggests pathologic causes like hemolysis or infection, requiring prompt evaluation to prevent complications such as kernicterus.
- What is the expected number of wet diapers per day after day 4 of life?
- At least 6 wet diapers/day. This output indicates sufficient hydration and intake, as newborns concentrate urine less efficiently early on.
- Which newborn reflex is elicited by stroking the cheek near the mouth?
- Rooting reflex. This reflex aids in feeding by prompting the newborn to turn toward a stimulus, facilitating nipple location for breastfeeding.
- Which finding indicates adequate breastfeeding intake in the newborn?
- Audible swallowing with at least 6 wet diapers/day after day 4. These signs confirm effective milk transfer and hydration, essential for preventing weight loss and supporting growth.
- What is the key safety teaching for infant car seat use at discharge?
- Rear-facing seat in the back seat, harness snug at armpit level. This configuration protects against impact forces and supports the infant's weak neck muscles during crashes.
- What is the best method to prevent heat loss by evaporation immediately after birth?
- Dry the newborn thoroughly and remove wet linens. Evaporation causes rapid heat loss in wet newborns, so immediate drying minimizes this risk and stabilizes body temperature.
- What is the priority nursing action for a newborn with grunting and nasal flaring?
- Maintain airway and administer oxygen as ordered. These signs indicate respiratory distress, so ensuring airway patency and oxygenation addresses potential hypoxia immediately.
- Which newborn reflex is elicited by placing a finger in the infant's palm?
- Palmar grasp reflex. This primitive reflex demonstrates intact neurological function, with the infant's fingers curling around the object instinctively.
- What is the expected time frame for umbilical cord stump separation?
- About 1–2 weeks. The stump dries and separates as the umbilical vessels necrose naturally, with this timeline indicating normal healing.
- Which prophylactic medication is applied to newborn eyes to prevent gonococcal infection?
- Erythromycin ophthalmic ointment. This prevents ophthalmia neonatorum from maternal gonorrhea, providing broad-spectrum coverage against bacterial conjunctivitis.
- What positioning best promotes airway patency in a newborn without distress?
- Supine with neck in neutral "sniffing" position. This position aligns the airway optimally, reducing obstruction risk in newborns with relatively large heads and short necks.
- Which finding suggests hip dysplasia on infant assessment and requires follow-up?
- Positive Ortolani or Barlow maneuver (hip "clunk"). These maneuvers detect hip instability from developmental dysplasia, prompting early intervention to prevent long-term issues.
- What axillary temperature range is expected for a stable newborn?
- 36.5–37.5°C (97.7–99.5°F). This range maintains thermoregulation in newborns, who are prone to heat loss due to limited subcutaneous fat and immature sweating mechanisms.
- Which assessment finding indicates physiologic jaundice rather than pathologic jaundice?
- Onset after 24 hours of life. Physiologic jaundice results from normal bilirubin accumulation after birth, typically appearing after the first day as the liver matures.
- Which sleep position is recommended to reduce the risk of SIDS for infants?
- Supine for every sleep. Back sleeping decreases SIDS risk by preventing airway obstruction from prone positioning and reducing rebreathing of exhaled air.
- What is the expected stool transition in a healthy newborn during the first days?
- Meconium to transitional stools by day 3–4. Meconium clears fetal waste, transitioning to milk-based stools as the gastrointestinal tract matures with feeding.
- What is the normal newborn respiratory rate (breaths/min) at rest?
- 30–60 breaths/min. This rate supports adequate oxygenation in newborns due to their immature respiratory system and higher metabolic demands.
- Which umbilical cord finding requires provider notification?
- Foul odor, purulent drainage, or spreading redness. These signs indicate potential infection, necessitating medical intervention to prevent systemic spread in vulnerable newborns.
- What is the normal newborn apical heart rate (beats/min) at rest?
- 110–160 beats/min. Newborns have a higher heart rate to meet circulatory needs during the transition from fetal to neonatal physiology.
- Which sleep environment is recommended to reduce SIDS risk for an infant?
- Firm mattress, no soft bedding or loose items. A bare, firm sleep surface minimizes suffocation hazards from soft materials that could cover the infant's face.