NUR 421 Exam 3 Study Questions and
Correct Answers
At birth, which should the nurse do to prevent heat loss in the newborn?
A. Dry the infant.
B. Place the infant on a flat surface.
C. Monitor the temperature.
D. Rub the infant's back. ✅A. Dry the infant.
One reason that preterm infants are at higher risk for cold stress is the fact that they
A. have a smaller surface area.
B. have a decreased amount of brown fat.
C. cannot nurse as effectively.
D. cannot buffer the acids in the body as well. ✅B. have a decreased amount of brown
fat.
When caring for a newborn the nurse must be alert for signs of cold stress, which would
include which one of the following?
A. Decreased activity level
B. Increased respiratory rate
C. Hyperglycemia
D. Shivering ✅B. Increased respiratory rate
The hematocrit for a newborn is 72%. The nurse is aware that this newborn is at risk for
A. blood clots.
B. jaundice.
C. anemia.
D. leukocytosis. ✅B. jaundice.
Vitamin K is given to the newborn for which one of the following reasons?
A. Reduce bilirubin levels.
B. Increase the production or red blood cells.
C. Enhance ability of blood to clot.
D. Stimulate the formation of surfactant. ✅C. Enhance ability of blood to clot.
A new mother is bottle-feeding her newborn for the first time. The mother expresses
concern to the nurse that the newborn is only drinking ½ ounce. The nurse can best
answer the mother's concerns by stating:
A. "Don't worry; the baby will drink more when he gets hungry."
B. "Yes, he should be drinking more; let me try to feed him."
C. "His stomach just holds about ½ ounce right now. By the end of the week it will have
expanded and he will be drinking more."
D. "Babies don't drink much at the first feeding, they are tired." ✅C. "His stomach just
holds about ½ ounce right now. By the end of the week it will have expanded and he will
be drinking more."
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn
after the first bowel movement. The mother expresses concern because the large
,amount of thick, sticky stool is dark green, almost black. She asks the nurse if
something is wrong. The nurse should respond to this mother's concern by
A. telling her not to worry because all breast-fed babies have this type of stool.
B. explaining that the stool is called meconium and is expected for the first few bowel
movements of all newborns.
C. asking the mother what she ate at her last meal.
D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to
her. ✅B. explaining that the stool is called meconium and is expected for the first few
bowel movements of all newborns.
When doing a newborn assessment on a 2-day-old infant, the nurse notices facial
jaundice. The bilirubin level was assessed and found to be 6 mg/dL. The nurse
understands that this jaundice will be classified as
A. physiologic jaundice.
B. pathologic jaundice.
C. breastfeeding jaundice.
D. true breast mild jaundice. ✅A. physiologic jaundice.
A new mother expresses concern that her 18-hour-old son has only voided once since
birth. The nurse's best response is:
A. "We are aware of that and have notified the pediatrician."
B. "How is he eating?"
C. "Newborns don't void frequently for the first 2 days, but by the fourth day it will be
about six times a day."
D. "This may be a concern, so we will continue to monitor his voidings for the next 12
hours." ✅C. "Newborns don't void frequently for the first 2 days, but by the fourth day it
will be about six times a day."
The unit manager of the newborn nursery is orienting a group of nursing students.
Infection control is one of the manager's major topics. When comparing infection control
in a nursery with that in an adult medical unit, one major difference is that
A. all the patients in the nursery are usually in one room.
B. the medical unit has many different organisms brought onto the unit.
C. newborns have a decreased ability to localize infections.
D. adults have a weaker immune system, which makes them more prone to developing
infections. ✅C. newborns have a decreased ability to localize infections.
If a nurse desires to promote infant-parent attachment, the best time to have the parents
spend time with the infant is when the infant is going through which stage?
A. Period of sleep
B. Second period of reactivity
C. Quiet sleep state
D. Active sleep state ✅B. Second period of reactivity
While observing a 3-hour-old newborn, the nurse counted respirations of 45 breaths per
minute, irregular, with one episode of periodic breathing lasting 10 seconds. The
newborn had no cyanosis during this time, no retractions, and no grunting. The nurse's
next action is to
A. notify the pediatrician.
B. document the normal findings.
C. administer oxygen.
, D. stimulate the newborn to cry. ✅B. document the normal findings.
During a newborn's first assessment a few minutes after birth, the nurse notes moisture
in the left lower lung field. The newborn is having no respiratory difficulty. The nurse's
next action should be to
A. suction the infant.
B. administer oxygen.
C. notify the pediatrician.
D. document the findings and continue to monitor. ✅D. document the findings and
continue to monitor.
When assessing the heart rate of a sleeping 1-day-old newborn, the nurse counts a rate
of 105 beats/min (bpm). The nurse's next action should be to
A. notify the pediatrician.
B. stimulate the newborn to cry.
C. document this normal finding.
D. reassess in 10 minutes. ✅C. document this normal finding.
A newborn is 2 days old and scheduled for discharge. The hospital stay has been
uneventful. The nurse is preparing to assess the newborn's temperature. Which method
would be the best choice?
A. Tympanic
B. Rectal
C. Axillary
D. oral ✅C. Axillary
Which method is correct for assessing the fontanels of a newborn?
A. Newborn lying supine and at rest
B. Newborn crying with head slightly elevated
C. Newborn quiet and head slightly elevated
D. Newborn lying supine and crying ✅C. Newborn quiet and head slightly elevated
The nurse notices a soft swollen area over the 1-day-old newborn's skull. It is
approximately 3 × 2 cm and has clear edges that stop at the suture line. The nurse may
document this finding as being
A. caput succedaneum.
B. cephalohematoma. ✅B. cephalohematoma.
During an initial assessment of a newborn, the nurse notices that the left arm does not
move as freely as the right arm. When assessing the clavicle, crepitus is noted. The
nurse's next action should be to
A. notify the newborn's health care provider.
B. swaddle the newborn loosely.
C. document this normal finding.
D. check range of motion on the left arm. ✅A. notify the newborn's health care
provider.
If the nurse notices one artery and one vein in the cord during the initial assessment of
a newborn, which one of the following actions should be carried out?
A. Assess for other anomalies.
B. Document this as a normal finding.
Correct Answers
At birth, which should the nurse do to prevent heat loss in the newborn?
A. Dry the infant.
B. Place the infant on a flat surface.
C. Monitor the temperature.
D. Rub the infant's back. ✅A. Dry the infant.
One reason that preterm infants are at higher risk for cold stress is the fact that they
A. have a smaller surface area.
B. have a decreased amount of brown fat.
C. cannot nurse as effectively.
D. cannot buffer the acids in the body as well. ✅B. have a decreased amount of brown
fat.
When caring for a newborn the nurse must be alert for signs of cold stress, which would
include which one of the following?
A. Decreased activity level
B. Increased respiratory rate
C. Hyperglycemia
D. Shivering ✅B. Increased respiratory rate
The hematocrit for a newborn is 72%. The nurse is aware that this newborn is at risk for
A. blood clots.
B. jaundice.
C. anemia.
D. leukocytosis. ✅B. jaundice.
Vitamin K is given to the newborn for which one of the following reasons?
A. Reduce bilirubin levels.
B. Increase the production or red blood cells.
C. Enhance ability of blood to clot.
D. Stimulate the formation of surfactant. ✅C. Enhance ability of blood to clot.
A new mother is bottle-feeding her newborn for the first time. The mother expresses
concern to the nurse that the newborn is only drinking ½ ounce. The nurse can best
answer the mother's concerns by stating:
A. "Don't worry; the baby will drink more when he gets hungry."
B. "Yes, he should be drinking more; let me try to feed him."
C. "His stomach just holds about ½ ounce right now. By the end of the week it will have
expanded and he will be drinking more."
D. "Babies don't drink much at the first feeding, they are tired." ✅C. "His stomach just
holds about ½ ounce right now. By the end of the week it will have expanded and he will
be drinking more."
The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn
after the first bowel movement. The mother expresses concern because the large
,amount of thick, sticky stool is dark green, almost black. She asks the nurse if
something is wrong. The nurse should respond to this mother's concern by
A. telling her not to worry because all breast-fed babies have this type of stool.
B. explaining that the stool is called meconium and is expected for the first few bowel
movements of all newborns.
C. asking the mother what she ate at her last meal.
D. suggesting that the mother ask her pediatrician to explain newborn stool patterns to
her. ✅B. explaining that the stool is called meconium and is expected for the first few
bowel movements of all newborns.
When doing a newborn assessment on a 2-day-old infant, the nurse notices facial
jaundice. The bilirubin level was assessed and found to be 6 mg/dL. The nurse
understands that this jaundice will be classified as
A. physiologic jaundice.
B. pathologic jaundice.
C. breastfeeding jaundice.
D. true breast mild jaundice. ✅A. physiologic jaundice.
A new mother expresses concern that her 18-hour-old son has only voided once since
birth. The nurse's best response is:
A. "We are aware of that and have notified the pediatrician."
B. "How is he eating?"
C. "Newborns don't void frequently for the first 2 days, but by the fourth day it will be
about six times a day."
D. "This may be a concern, so we will continue to monitor his voidings for the next 12
hours." ✅C. "Newborns don't void frequently for the first 2 days, but by the fourth day it
will be about six times a day."
The unit manager of the newborn nursery is orienting a group of nursing students.
Infection control is one of the manager's major topics. When comparing infection control
in a nursery with that in an adult medical unit, one major difference is that
A. all the patients in the nursery are usually in one room.
B. the medical unit has many different organisms brought onto the unit.
C. newborns have a decreased ability to localize infections.
D. adults have a weaker immune system, which makes them more prone to developing
infections. ✅C. newborns have a decreased ability to localize infections.
If a nurse desires to promote infant-parent attachment, the best time to have the parents
spend time with the infant is when the infant is going through which stage?
A. Period of sleep
B. Second period of reactivity
C. Quiet sleep state
D. Active sleep state ✅B. Second period of reactivity
While observing a 3-hour-old newborn, the nurse counted respirations of 45 breaths per
minute, irregular, with one episode of periodic breathing lasting 10 seconds. The
newborn had no cyanosis during this time, no retractions, and no grunting. The nurse's
next action is to
A. notify the pediatrician.
B. document the normal findings.
C. administer oxygen.
, D. stimulate the newborn to cry. ✅B. document the normal findings.
During a newborn's first assessment a few minutes after birth, the nurse notes moisture
in the left lower lung field. The newborn is having no respiratory difficulty. The nurse's
next action should be to
A. suction the infant.
B. administer oxygen.
C. notify the pediatrician.
D. document the findings and continue to monitor. ✅D. document the findings and
continue to monitor.
When assessing the heart rate of a sleeping 1-day-old newborn, the nurse counts a rate
of 105 beats/min (bpm). The nurse's next action should be to
A. notify the pediatrician.
B. stimulate the newborn to cry.
C. document this normal finding.
D. reassess in 10 minutes. ✅C. document this normal finding.
A newborn is 2 days old and scheduled for discharge. The hospital stay has been
uneventful. The nurse is preparing to assess the newborn's temperature. Which method
would be the best choice?
A. Tympanic
B. Rectal
C. Axillary
D. oral ✅C. Axillary
Which method is correct for assessing the fontanels of a newborn?
A. Newborn lying supine and at rest
B. Newborn crying with head slightly elevated
C. Newborn quiet and head slightly elevated
D. Newborn lying supine and crying ✅C. Newborn quiet and head slightly elevated
The nurse notices a soft swollen area over the 1-day-old newborn's skull. It is
approximately 3 × 2 cm and has clear edges that stop at the suture line. The nurse may
document this finding as being
A. caput succedaneum.
B. cephalohematoma. ✅B. cephalohematoma.
During an initial assessment of a newborn, the nurse notices that the left arm does not
move as freely as the right arm. When assessing the clavicle, crepitus is noted. The
nurse's next action should be to
A. notify the newborn's health care provider.
B. swaddle the newborn loosely.
C. document this normal finding.
D. check range of motion on the left arm. ✅A. notify the newborn's health care
provider.
If the nurse notices one artery and one vein in the cord during the initial assessment of
a newborn, which one of the following actions should be carried out?
A. Assess for other anomalies.
B. Document this as a normal finding.
