NCLEX: Newborn Nursing Questions and Rationale

1. C. Places the newborn under a radiant warmer

Rationale: At birth, the newborn loses its heat due to the dramatic drop in the environmental temperature. The newborn’s heat is mainly lost via radiation, which can be reduced by raising the room temperature or placing the newborn in a radiant warmer. Suctioning helps maintain patent airways, however, coughing and sneezing reflexes are also present at birth and help clear the airway, therefore, suctioning is unnecessary unless indicated by the healthcare provider. Inspecting the condition of the umbilical cord does not prevent the newborn from losing body heat, but it does help in identifying cord anomalies. The umbilical cord is clamped after delivery, and this stimulates the newborn to take in oxygen through the lungs. Apgar scoring is done at one and five minutes after birth wherein the newborn is observed and rated according to the Apgar score. There is a high correlation between a low 5-minute Apgar score and neurologic illness, but it does not prevent body heat loss in newborns.

2. D. “Uric acid crystals are excreted in the urine and stools of a newborn.”

Rationale: The first voiding of a newborn may be pink or dusky because of uric acid crystals that were formed in the bladder in utero; this looks a lot like blood in the urine but is an innocent finding. A newborn placed under phototherapy lights as therapy for jaundice will have bright green stools because of increased bilirubin excretion. Greenish stools are also a sign of iron in the newborn’s formula. The iron in the formula doesn’t absorb as well as the iron in the breastmilk; hence the greenish color. If the mucus is mixed with stool a milk allergy, lactose intolerance, or some other conditions interfering with digestion or absorption is suspected.

3. A. 100 beats per minute

Rationale: Normally, a newborn’s heart rate is 120 to 160 beats per minute; however, it may be much slower when the newborn is asleep. 120 and 140 beats per minute is a normal finding for an awake newborn during the examination. 80 beats per minute, however, may indicate neonatal bradycardia. Neonatal bradycardia is defined as a decrease in heart rate by 30 beats per minute from the baseline. Bradycardia becomes concerning when the heart rate is less than 100 beats per minute. The primary cause of neonatal bradycardia is hypoxia.

4. B. An anterior fontanel larger than the posterior fontanel

Rationale: The anterior fontanel is the large of the six fontanelles, ranging in size from 0.6 cm to 3.6 cm with a mean of 2.1 cm. The posterior fontanel, on the other hand, is 0.5 cm in Caucasian infants and 0.7 cm in infants of African descent. A bulging anterior fontanel may indicate a rise in the intracranial pressure, suggesting multiple pathologies such as hydrocephalus, hypoxemia, or meningitis. A sunken fontanel is primarily due to dehydration. The anterior fontanel resembles a diamond shape, while the posterior fontanel is triangular. The posterior fontanel typically closes within six to eight weeks after birth, while the anterior fontanel closes from 13 to 24 months.

5. C. Cough reflex

Rationale: Coughing is an important defensive reflex present at birth until adulthood that enhances clearance of secretions and particulates from the airways and protects against aspiration of foreign materials occurring as a consequence of aspiration or inhalation of particulates. The rooting reflex is initiated when the corner of the newborn’s mouth is stimulated. It lasts about four to six months. The stepping reflex occurs when a baby appears to take steps or dance when held upright with their feet touching a solid surface. This reflex lasts about two months. The Moro reflex or startle reflex occurs when the infant is startled by a loud sound or movement and throws their head back, extends their arms and legs, and cries. This reflex lasts until the infant is two months old.

6. D. Dorsiflexion of the big toe and fanning of other toes

Rationale: The Babinski reflex is done as part of the routine neurological exam and is utilized to determine the integrity of the corticospinal tract. It is elicited by stroking the infant’s lateral plantar side of the foot from the heel to the toes. The nurse watches for dorsiflexion of the big toe and fanning of the other toes. When this occurs. The Babinski reflex is present. The dorsiflexion of the big toe, the fanning of the other toes along with the dorsiflexion of the foot and knee flexion are altogether known as a triple flexion response, which is present in a comatose client with profound dysfunction of the corticospinal tract. If the toes deviated downward, then the Babinski reflex is absent, which is not a normal finding in newborns.

7. C. Place the crib close to the nursery window during family viewing.

Rationale: Radiation is the transfer of body heat to a cooler solid object not in contact with the newborn, such as a cold window or air conditioner. Moving the newborn closer to the window will be the least effective method for maintaining a neutral environment for the newborn. Covering a cold surface, such as a weighing scale, with a warmed blanket or towel is necessary to help minimize conduction heat loss. Covering the newborn’s head with a cap after drying further reduces the possibility of evaporation cooling, as the head is a large surface area for the newborn and is responsible for a great amount of heat loss. Placing the newborn in a radiant warmer or in an incubator is another effective way to maintain a warm environment and minimize heat loss

8. D. Examine for a fractured clavicle.

Rationale: An asymmetrical Moro reflex can be due to a local injury such as a fracture of the clavicle which causes inhibition of the reflex on the affected side. Increased intracranial pressure in newborns shows a full or tight fontanel or an increase in the circumference of the head. The newborn may also exhibit signs of lethargy and irritability with increased ICP. The early manifestations of congenital hypothyroidism include lethargy, hypotonia, large anterior and posterior fontanels, feeding difficulties, prolonged jaundice, poor or hoarse cry, constipation, and hypothermia. It does not affect the Moro reflex of a newborn. Talipes equinovarus is characterized by deformities of the foot, including cavus midfoot arch, adduction of the forefoot, hindfoot varus, and equinus. The foot is not involved in the Moro reflex.

9. A. Assessing for signs of hemorrhage.

Rationale: Bleeding is the most common complication of circumcision, with an incidence of 1% in a large retrospective review. Bleeding becomes more common during the “mini puberty” of infancy that begins at four weeks of age and extends to three months of age. This is thought to be due to a hormonally mediated increase in penile and prepuce size and vascularity. Providing comfort for the newborn is also essential, however, this can be done after ensuring that the newborn is not at risk for hemorrhage. Chances of dehydration due to circumcision is minimal, therefore, administering intravenous fluids is not a priority. Management of hemorrhage after circumcision involves packed RBC transfusions and fibrin glue, not intravenous fluids. Wound infection is also a complication of circumcision typically associated with the method of circumcision used. However, due to the superb dual blood supply of the penis, wound infection occurs infrequently.

10. D. Recognize that this is a normal finding.

Rationale: The respiratory rate of a newborn in the first few minutes of life may be as high as 90 breaths per minute. As respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths per minute. Newborns are obligate nose breathers and show signs of nostrils flaring when breathing. Additionally, the newborn’s breathing primarily involves the use of the diaphragm and abdominal muscles, resulting in mild intercostal retractions, which is also a normal finding during this period. Short periods of apnea with grunting at the end of expiration, called periodic respirations, are also common and normal during this time. Administering supplemental oxygen is unnecessary because the newborn is not in distress. Since the newborn’s assessment findings are normal, there is no need to inform the healthcare provider; however, these findings must be documented. Suctioning is not warranted because the newborn is breathing as appropriate to the period of reactivity.

11. C. “Water and soap can be used if the stump is dirty.”

Rationale: The dry care method using only soap and water for umbilical cord care has been recommended by the WHO as it is effective and more practical than using antiseptics. Additionally, dry care is less expensive for healthy newborns in hospital settings in high-income countries. Daily bathing of the newborn results in longer cord separation times, increasing the risk of infection. Cleaning the stump daily with antiseptics is only applicable if the newborn is at a high risk of developing an infection, such as newborns who were born at home. Furthermore, the application of antiseptic solutions can delay the separation of the umbilical cord and does not provide any benefit. The use of antibiotic ointments is only indicated when an infection is present and is not a part of the routine cord care of a newborn.

12. B. 3.5 ounces

Rationale: The needs of infants determine the amount of nutrition required to maintain and support adequate growth and optimal health while maintaining homeostasis with other nutrients. Neonatal caloric requirements are higher at about 110-135 kcal/kg/day. To calculate the newborn’s caloric needs, the newborn’s weight is converted from grams to kilograms. 3.8 kgs is multiplied by the given caloric requirement of 110 kcal/kg/day (24 hours). The answer is 418 kcal/day. The newborn is fed every four hours, therefore, 24 hours is divided into four hours; the newborn must receive six feedings per day. To identify the number of calories to provide per feeding, 418 kcal/day is divided into six feedings; the newborn must receive 69.7 kcal/feeding. Since the newborn needs the feeding in 20 kcal/oz of formula, 69/7 kcal/feeding is divided by 20 kcal/oz. The newborn must receive 3.5 ounces of formula for every feeding.

13. B. Monitor the newborn’s respiratory rate.

Rationale: Newborns with meconium-stained amniotic fluid can have difficulty establishing respirations at birth. After the initiation of respirations, the newborn’s respiratory rate may remain rapid and coarse bronchial sounds may be heard on auscultation, therefore, monitoring respiratory rate is essential to prevent respiratory distress. The newborn’s bowel sounds do not need monitoring, but they must be assessed during the routine physical examination to identify any developing gastrointestinal problems. Meconium is non-irritating and can be washed off the skin. It is not infectious and is in fact, sterile. The passage of meconium indicates that the intestines of the newborn are intact and patent, therefore, it is unnecessary to monitor the intake and output. However, assessing intake and output is still routine during physical assessment.

14. A. Administers on the vastus lateralis muscle

Rationale: Because almost all newborns can be predicted to have this diminished blood coagulation ability, vitamin K is usually administered intramuscularly into the lateral anterior thigh, or the vastus lateralis muscle, the preferred site for all injections in newborns., immediately after birth. If the parents object to an injection, vitamin K can be administered orally, although it is not as effective. Oral vitamin K is less effective than IM vitamin K in preventing vitamin K deficiency bleeding. Vitamin K must be administered routinely to all newborns within the first six hours after birth and following initial stabilization and appropriate maternal-newborn interactions.

15. A. Monitor the temperature carefully.

Rationale: The newborn’s axillary temperature must be monitored to prevent the newborn from overheating under bright lights and developing hyperthermia. The newborn may also develop dehydration due to hyperthermia. Newborns receiving phototherapy may be removed from under the lights for feeding so they continue to have interaction with their mother. Additionally, early feeding, either formula or breast milk, stimulates bowel peristalsis and helps excrete the excess bilirubin through the feces. The stool of a newborn under phototherapy is often bright green because of the excessive bilirubin being excreted as a result of the therapy. Therefore, this is a normal finding for a newborn in phototherapy and there is no need to inform the provider. This finding must be documented, however. Continuous exposure to bright lights by phototherapy may be harmful to a newborn’s retina, so the newborn’s eyes must always be covered while under bilirubin lights. Commercial phototherapy masks or eye coverings must be used at all times when the newborn is under phototherapy.

16. C. The arms, legs, and neck extend then brings the arms together.

Rationale: The startle, or Moro, reflex, occurs when the newborn is startled by something loud or abrupt. The newborn extends his arms, legs, and neck, and then rapidly brings both arms together. This reflex disappears after two months. The Babinski reflex is elicited when the sole of the foot is stroked, then the big toe bends backward (dorsiflexion) toward the top of the foot and the other toes fan out. This is a normal reflex up to about two years of age. The palmar grasp reflex occurs when the palm of a newborn is stroked, then the newborn closes their fingers in a grasp. The tonic neck reflex is elicited when the newborn’s head is turned to one side and the arm on that side stretches out, while the opposite arm bends at the elbow. This is often called the “fencing” position.

17. D. Apply gentle pressure to the affected site with sterile gauze.

Rationale: If there is ongoing bleeding at the circumcision site, the nurse may apply gentle but firm pressure using a sterile gauze pad for several minutes without checking to see if the bleeding has stopped. If the bleeding continues, the nurse must inform the healthcare provider for medical management. Tightening the diaper around the waist area does not help apply pressure over the circumcision site and would do nothing to stop the bleeding. This could also result in a diaper rash. Reassessing after 30 minutes may take too long while the bleeding continues. Immediate nursing action is required to promptly diffuse the bleeding.

18. B. “High-pitched speech with variations in tone best stimulate babies.”

Rationale: Newborns prefer a higher-pitched voice than a low-sounding voice. The exaggerated high pitch, repetition, rhythm, and even pauses in baby talk can give babies important acoustical information about how language works. Experiments have shown that newborns listen longer to songs when they are sung in a higher pitch. There is also evidence that human mothers raise their voice pitch when they want to get the attention of a seemingly bored infant. It is also easier for newborns to pick out high-pitched voices against background noise and perceive them as less aggressive.

19. B. Move the newborn’s incubator closer to the viewing windows.

Rationale: Moving the newborn’s incubator closer to the windows causes radiant heat loss. Radiation is the transfer of body heat to a cooler solid object not in contact with the newborn, such as a cold window or air conditioner. Placing the newborn on an uncovered weighing scale is a form of heat loss through conduction. Conduction is the transfer of body heat to a cooler solid object in contact with the newborn. Convection is the flow of heat from the newborn’s body surface to the cooler surrounding air. Eliminating drafts and increasing room temperature to an acceptable level for the newborn is an important way to reduce convection heat loss. A room with low humidity promotes evaporative heat loss. Evaporation is the loss of heat through the conversion of a liquid to a vapor.

20. C. The newborn smacks their lips loudly during breastfeeding.

Rationale: The newborn who smacks its lips when breastfeeding shows the poor attachment and may cause injury to the mother’s nipples. If the newborn is well-attached at the breast, then the newborn can suck effectively. The newborn shows a good latch when their mouth grasps the nipple with the tongue reaching well underneath the breast tissue. The newborn is able to suck effectively when they take slow, deep suckles followed by a visible or audible swallow about once per second. Sometimes the newborn may pause for a few seconds, allowing the ducts to sill up with milk again. To stimulate the newborn’s rooting reflex before breastfeeding, the mother may brush the newborn’s cheek with a breast nipple. The newborn will then turn toward the breast.

21. B. “Sexually transmitted diseases such as gonorrhea can be avoided.”

Rationale: Most birth settings in the United States and Canada still administer prophylactic eye treatment of erythromycin ointment to help prevent gonorrheal and chlamydia conjunctivitis. Such infections are acquired from the mother as the newborn passes through the birth canal. Syphilis is treated in a pregnant woman with one injection of benzathine penicillin G. The newborn also needs penicillin therapy at birth as well. If a woman contracts herpes simplex virus type 2 during pregnancy, it can be transmitted across the placenta to cause congenital infection in the newborn. To avoid transmission, women with active lesions are usually scheduled for cesarean birth. Additionally, viruses do not respond to antibiotics, as the appropriate pharmacologic agent must be antiviral such as acyclovir or valacyclovir. Oral metronidazole is responsible for eradicating trichomonas infections in pregnant women. Although classified as a Class B pregnancy drug, it may not be prescribed during the first semester of pregnancy to avoid detrimental fetal effects.

22. A. Instruct the mother to pause feeding and comfort the newborn.

Rationale: Ineffective suckling could cause the newborn to become frustrated, causing them to refuse to feed. The mother should pause first before continuing with feeding and comforting the newborn. Once the newborn has calmed, the mother may resume breastfeeding as guided by the nurse for proper attachment and effective sucking. Risks associated with pacifiers are an increased incidence of acute otitis media, possibly a negative impact on breastfeeding, and dental malocclusion, particularly if the usage is greater than 2 to 3 years. A frustrated and improperly attached newborn would not be able to suck effectively despite keeping the head firmly against the breast and the mouth on the nipple. It may lead to an engorged breast, a cracked nipple, or an overstimulated but hungry newborn.

23. C. Obtain serum glucose level.

Rationale: The newborn is exhibiting signs of hypoglycemia, therefore, the nurse must first determine the newborn’s glucose level. Large-for-gestational age (LGA) newborns require large amounts of nutritional stores to sustain their weight. If the mother had poorly controlled diabetes, the newborn would have had an increased blood glucose level in utero to match the mother’s glucose level, causing the newborn to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, causing rebound hypoglycemia. Before any intervention is initiated, the nurse must initially check the blood glucose level to determine the appropriate intervention to implement.

24. D. “Consistent breastfeeding stops ovulation and my period.”

Rationale: Suckling affects the release of pituitary hormones such as gonadotropin-releasing hormone, follicle-stimulating hormone, and luteneizing hormone, which results in the suppression of ovulation and menstruation. Alcohol and caffeine can affect the newborn and should be avoided by the breastfeeding mother. Cigarette smoking is not a contraindication to breastfeeding, but the client should be aware that some nicotine is carried in breast milk. Nicotine has the potential to decrease the mother’s milk supply. Sore nipples are not a contraindication to breastfeeding as long as a proper latch is obtained. If the latch is too painful, the mother can pump to provide expressed breast milk to her newborn and ensure her milk supply is protected.

25. D. Document the data as a normal assessment finding.

Rationale: The average closure time of the anterior fontanel ranges from 13 to24 months, therefore, the nurse must document this as a normal assessment finding. When a delay in the closure of the anterior fontanel occurs, the nurse may suspect conditions such as Down syndrome, achondroplasia, congenital hypothyroidism, rickets, and elevated intracranial pressure, which should warrant an intensive neurological examination. Informing the healthcare provider immediately is unnecessary because it is not a life-threatening condition. Referring the newborn to a developmental specialist is inappropriate because there is no developmental delay that should warrant an expert opinion.

26. B. 4 months

Rationale: There is emerging evidence that the introduction of solid foods into an infant’s diet by 4 months may increase their willingness to eat a variety of fruits and vegetables later in life, decrease their risk of having feeding problems later in their life, and decrease their risk of developing food allergies. The early introduction of solid foods into an infant’s diet does not appear to increase their risk of obesity later in childhood. Infants are not ready to digest complex starches until amylase is present in saliva at approximately 2 to 3 months. Biting movements begin at approximately 3 months. The European Society for Pediatric Gastroenterology, Hepatology and Nutrition recommends complementary foods should not be introduced before 4 months but should not be delayed beyond 6 months. There also appears to be a sensitive period during the first several months of life when infants are most receptive to a wide diversity of flavors, and what they taste during this sensitive period can influence their taste preferences later in life.

27. D. Mistrust

Rationale: The first stage of Erikson’s theory of psychosocial development occurs between birth and one year of age and is the most fundamental stage in life. During this stage, infants develop a sense of trust when caregivers provide reliability, care, and affection. A lack of this will lead to mistrust. The third stage of psychosocial development takes place during the preschool years. Children who are successful in asserting their power and control feel capable and able to lead others. Those who fail to acquire these skills are left with a sense of guilt, self-doubt, and lack of initiative. The second stage of Erikson’s theory takes place during the toddler years, wherein children are just starting to gain a little independence. Success during this stage leads to feelings of autonomy; failure results in feelings of shame and doubt. During the early school years (ages 5 to 11), children begin to develop a sense of pride in their accomplishments and abilities. Success leads to a sense of competence, while failure results in feelings of inferiority.

28. C. “The baby would enjoy playing with a colorful busy box with lots of knobs and knickknacks.”

Rationale: Five-month-old infants are ready for a variety of objects to handle, such as a colorful busy box with plastic rings and keys and knobs, or rattles, blocks, squeeze toys and clothespins. However, these items should not be small enough that the infant can lift them with one hand, yet big enough that they cannot possibly swallow them. Small marbles and the button eyes of a teddy pose a risk of aspiration because they are too small that they could be swallowed by the infant. The ability to walk usually starts at 11 months. As soon as they can walk, they will be interested in push-and-pull toys.

29. A. “Comforting a crying baby does not spoil her; they need to be held and cuddled.”

Rationale: At this point in development, the infant is utterly dependent upon adult caregivers for everything they need to survive, including food, love, warmth, safety, and nurturing. If the mother leaves the infant alone crying and does not respond immediately to their cries, the infant may come to feel that they cannot trust or depend on the caregiver. Failure to develop trust will result in fear and a belief that the world is inconsistent and unpredictable. Additionally, a crying infant may also mean that they need to be cuddled and played with, and not just because of their physiological needs such as hunger and hygiene.

30. C. Lifting head and chest when prone

Rationale: A 3-month-old infant lifts the head and shoulders well off the table and looks around when prone. The pelvis is flat on the table, no longer elevated. Some infants can turn from a prone to a side-lying position at this age, but rolling from front to back is achieved by five-month-old infants who are able to rest their weight on their forearms when prone. The rooting reflex is seen in response to light stroking on the cheek or bringing an object into the infant’s visual field. It starts at 32 weeks gestation and decreases after one month. One-month-old infants still have a strong grasp reflex so they hold their hands in fists so tightly that it is difficult to extend their fingers. The grasp reflex fades at two months of age, and by three months, the infant’s grasp is unpracticed so they usually miss when reaching for objects in front of them.

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