Question 1

The nurse IS reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation- Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor, no antibiotic given.” Considering this information, the nurse should observe her 15-hour-old newborn closely for which finding?

Accepted Answer

Answer reason: Newborn infection can present subtly in the first 24 hours, and abnormal thermoregulation (hypothermia or fever) is a classic early sign requiring close monitoring and prompt evaluation. In contrast, pink “brick dust” urate crystals are commonly benign in early newborn urine, and meconium stools can be normal in the first days of life. Erythema toxicum is a common, self-limited newborn rash and is not a sepsis indicator.

Question 2

The nurse completes teaching in preparation to discharge a mother and her 48-hour-old, full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn’s father is overhead making which statement?

Accepted Answer

Answer reason:  Rear-facing infant car seats should be placed in the back seat because the front seat is a high-risk location in a crash, especially with airbags. Even if an airbag is “disarmed,” placement in the rear seat is still the safest standard recommendation for newborns due to proximity to the dashboard and impact forces. A 45-degree recline is appropriate to help maintain airway patency and reduce head flexion. Rear-facing orientation is correct, and infant-seat use is typically based on manufacturer height/weight limits rather than a single cutoff alone.

Question 3

A neonate who has been receiving formula feedings is discharged from the neonate nursery. Twenty-four hours later, the mother calls the hospital, stating that the neonate is vomiting most of his feedings. The nurse determines further instruction is necessary when the mother makes which statement?

Accepted Answer

Answer reason: “I feed him every time he cries. Sometimes, he eats 4 oz at a time every couple of hours.” Newborn vomiting/spitting up commonly results from overfeeding and air swallowing, so parent teaching focuses on appropriate volumes and feeding cues. This statement indicates feeding on demand for any crying (not distinguishing hunger cues) and giving a large volume very frequently, which increases gastric distention and promotes regurgitation. In contrast, small spit-ups are often normal, and frequent burping during feeds is an appropriate technique to reduce swallowed air. The large, frequent feedings described are therefore the key modifiable cause requiring further instruction.

Question 4

A nurse in the neonatal nursery is serving as preceptor for a student nurse. The student asks the nurse why a neonate’s head is cone shaped. Which response is accurate?

Accepted Answer

Answer reason: “It results from molding. Overriding of the cranial sutures allows the neonate’s head to pass though the birth canal.” Cone-shaped head after birth is most commonly due to normal birth-related molding, where the unfused cranial bones temporarily overlap to facilitate passage through the birth canal. This change is expected after vaginal delivery and typically resolves spontaneously over days as the bones return to their usual alignment. Caput succedaneum causes diffuse scalp edema that can cross suture lines but does not explain the characteristic cone shape from bone overlap. Cephalohematoma is a subperiosteal bleed limited by suture lines, and hydrocephalus causes progressive head enlargement rather than an acute cone-shaped appearance post-delivery.

Question 5

A home health nurse assesses a neonate who is 48 hours old and was discharged from the hospital 24 hours ago. Which assessment finding indicates a potential problem?

Accepted Answer

Answer reason: Newborn reflexes should be present in the immediate neonatal period, and absence suggests neurologic dysfunction or illness requiring further evaluation. Stroking the cheek should elicit the rooting reflex, with the infant turning the head toward the stimulus to help locate the nipple. Failure to demonstrate this reflex at 48 hours is not expected and can indicate CNS depression, prematurity, effects of medications, or neurologic injury. By contrast, absence of tears is normal in early infancy, erythema toxicum papules are a common benign newborn rash, and greenish-brown transitional stools are expected in the first days after birth.

Question 6

Which is an important consideration regarding the storage of breast milk?

Accepted Answer

Answer reason: Freezer storage is a standard long-term option, and a commonly tested guideline is that breast milk can be stored frozen for about 6 months under typical home-freezer conditions. Thawed milk should not be refrozen, making that option unsafe. Exclusive glass storage is unnecessary because approved BPA-free hard plastic containers or breast milk storage bags are also acceptable when properly cleaned and sealed.

Question 7

Number of visits in home based new born care in case of home delivery?

Accepted Answer

Answer reason: Standard public-health newborn care protocols recommend more frequent follow-up for home births than for facility births because immediate postpartum observation and access to urgent care are typically less reliable. Seven visits align with common HBNC schedules (early visits in the first week plus additional follow-ups through the neonatal period) designed to reduce morbidity and mortality. Options with fewer visits (e.g., 2 or 4) are generally insufficient to cover the high-risk early neonatal window when most preventable complications present. Therefore, the higher visit count is the best-supported preventive care answer.

Question 8

After birth, care of eye of newborn is by?

Accepted Answer

Answer reason: Credé’s method refers to routine ocular prophylaxis given soon after birth, historically using silver nitrate and now commonly using antibiotic eye ointments/drops depending on local policy. This approach is a standardized preventive newborn intervention rather than simple cleansing with saline. Normal saline may remove debris but does not provide effective antimicrobial prophylaxis against these pathogens, and listing “AgNO3 eye drop” alone is an older specific agent rather than the broader, correct named procedure.

Question 9

How many daily feeding are considered normal for a newborn?

Accepted Answer

Answer reason: Typical guidance is about every 2–3 hours, which corresponds to roughly 8–12 feeds per day, especially for breastfed infants. This range supports adequate hydration, caloric intake, and stimulation of milk production. Options like 6–8 can be insufficient for many newborns in the early weeks, while 12–14 is more consistent with cluster feeding patterns rather than the usual expected daily baseline.

Question 10

Nurse advised to give injection vitamin K for new born baby. The route and dose of vitamin K is?

Accepted Answer

Answer reason: Standard prophylaxis is a single intramuscular dose shortly after birth because IM administration provides reliable absorption and sustained levels for hepatic clotting-factor synthesis. Subcutaneous dosing is less reliable and is not the recommended routine route. IV dosing and a 10 mg dose are inappropriate for prophylaxis and increase risk of adverse effects and dosing error, while intradermal administration is not an accepted route for this purpose.

Question 11

When teaching a new mother how to breastfeed, the nurse should include which of the following interventions?

Accepted Answer

Answer reason: Proper breastfeeding technique includes breaking the latch before removing the infant to prevent nipple trauma and pain. Inserting a clean finger into the corner of the infant’s mouth releases negative pressure safely, reducing risk of cracked nipples and bleeding that can interfere with continued breastfeeding. Washing nipples with soap can dry and irritate tissue, increasing soreness. Always starting on the same breast can contribute to uneven emptying and engorgement, and routine formula supplementation can reduce demand-driven milk production.

Question 12

The patient should be taught that when her infant falls asleep after feeding for only a few minutes, she should do which of the following?

Accepted Answer

Answer reason: Newborns often fatigue quickly during feeds, and short, ineffective feeding can lead to inadequate intake, dehydration, and poor weight gain. Gentle stimulation (e.g., unwrapping, rubbing the back/feet) helps maintain alertness long enough to complete a more effective feeding while keeping the feeding routine supportive of breastfeeding. Waiting an hour or putting the infant down delays needed calories and fluids and may worsen fatigue or reduce overall intake. Switching to a bottle as the next step is not first-line teaching and can interfere with breastfeeding establishment if used unnecessarily.

Question 13

Which statement made by a new mother should be a cause of concern to the nurse?

Accepted Answer

Answer reason: ” Infant crying is a primary communication method, and consistent, responsive caregiving supports attachment, emotional regulation, and trust development. Interpreting crying as “spoiling” can lead to unmet needs (hunger, pain, discomfort) and undermines bonding, making it a nursing concern that warrants education on infant cues. The other statements are generally consistent with safe infant care guidance (e.g., supine sleep positioning reduces SIDS risk; a room temperature around 72°F is typically acceptable; introducing solids around 4–6 months is commonly recommended depending on readiness). A key teaching point is to assess the reason for crying and respond appropriately rather than routinely withholding comfort.

Question 14

As the nurse assists a new mother with breastfeeding, the mother asks, “If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” The nurse responds that it contains?

Accepted Answer

Answer reason: Human milk provides passive immune protection, especially secretory IgA, which helps protect the infant’s mucosal surfaces and reduces gastrointestinal and respiratory infections. This immunologic benefit is a key advantage beyond basic macronutrient and micronutrient content. Standard formula can be designed to approximate calories and many nutrients but does not replicate the full range and activity of maternal antibodies and other immune factors. Calcium, calories, and essential amino acids are present in both and are not the primary distinguishing “better” feature for newborn protection.

Question 15

When assessing infant reflexes the nurse documents a startled response and extension of the arms and legs as which reflex?

Accepted Answer

Answer reason: A documented startled response with extension of the extremities matches this classic pattern. Rooting is a feeding-related response (turning head/opening mouth) and does not produce limb extension. Tonic neck/fencing involves posturing with head turning and asymmetric limb extension rather than a startle-induced generalized extension.

Question 16

A nurse teaches new parents that the best way to help prevent infections in the newborn is which of the following?

Accepted Answer

Answer reason: It also supports a healthy gut microbiome and improves mucosal barrier defenses, which lowers rates of common respiratory and gastrointestinal infections. Limiting visitors can reduce exposure, but it is less comprehensive and harder to control than providing ongoing immunologic protection with feeds. Keeping the baby indoors for a month is not necessary and does not directly address transmission in the home environment. Warmth supports thermoregulation but does not prevent pathogen exposure or enhance immune protection in the same way.

Question 17

Over the past twelve hours, the newborn blood glucose levels have averaged on the low end of normal. Which statement by the mother indicates further teaching is needed?

Accepted Answer

Answer reason: Newborns with lower-end glucose readings need reliable, frequent caloric intake to prevent hypoglycemia and its neurologic risks. Being a larger infant does not reduce feeding needs; in fact, large-for-gestational-age infants (often related to maternal diabetes) can be at higher risk for hypoglycemia due to hyperinsulinemia. The statement reflects a misconception that size protects against low glucose, which could lead to underfeeding and worsening glycemic instability. The other statements support appropriate feeding intervals and acceptable methods of providing expressed breast milk.

Question 18

A new mother asks whether she should feed her newborn colostrum because it is not "real milk." The nurse's best answer includes which information?

Accepted Answer

Answer reason: Colostrum is the newborn’s first milk and provides concentrated immune protection, particularly secretory IgA, which helps protect the infant’s GI and respiratory mucosa from infection. It is also nutrient-dense and supports early stabilization of glucose and gut maturation while promoting passage of meconium. Saying it is unnecessary is incorrect because early breastfeeding and colostrum reduce infection risk and support bonding and lactation establishment. Routine supplementation with formula is not indicated solely due to lower volume/calories, since the newborn stomach capacity is small and colostrum volume is appropriate in the first days.

Question 19

The nurse is caring for a newborn immediately following birth. Which of the following actions by the nurse will prevent radiant heat loss in the newborn?

Accepted Answer

Answer reason: Radiant heat loss occurs when an infant loses heat to cooler solid surfaces in the environment without direct contact (e.g., cold windows or exterior walls). Moving the bassinet away from outside windows reduces exposure to these colder surfaces, decreasing radiative heat transfer. Drying the skin primarily prevents evaporative heat loss, while a padded surface mainly addresses conductive heat loss from contact with a cold surface. Warmed, humidified oxygen helps prevent respiratory heat loss but is not the primary intervention for radiant heat loss in routine immediate newborn care.

Question 20

At what point should the nurse expect a healthy newborn to pass meconium?

Accepted Answer

Answer reason: This timeframe is used clinically as a screening expectation because delayed passage can be an early sign of intestinal obstruction or functional motility disorders. The 12–18 hour window can occur but is not the standard benchmark nurses use for expected passage across all healthy newborns. Passage within 1–2 hours is not required for normality, and passage before birth is abnormal and associated with fetal stress and meconium-stained amniotic fluid.

Question 21

A nurse is preparing to give a newborn their first vaccine. Which vaccine should the nurse prepare?

Accepted Answer

Answer reason: This first dose is recommended within 24 hours of life to reduce the risk of chronic infection if exposure occurred around delivery. The other listed vaccines are initiated later in infancy/childhood (influenza starting at 6 months; varicella at 12–15 months; hepatitis A at 12–23 months). Therefore, this is the appropriate first vaccine to prepare for a newborn.

Question 22

Based on an understanding of Erikson’s stages of psychosocial development, which of the following is a priority to communicate to the parents of an infant to assist them in meeting the basic needs of infancy?

Accepted Answer

Answer reason: Prompt, predictable responses to hunger, discomfort, and the need for warmth and security help the infant experience the environment as dependable. This directly supports trust formation more than enrichment activities, which are beneficial but secondary to foundational needs. Options emphasizing stimulation or talking are supportive measures, but they do not replace the priority of consistent comfort and basic care. Holding preferences can aid soothing, yet it is one element within the broader goal of meeting basic needs consistently.

Question 23

A nurse is instructing a mother of a newborn with hyperbilirubinemia who is being breastfed. Which statement by the nurse is appropriate?

Accepted Answer

Answer reason: " Frequent feeding promotes hydration and stooling, which increases bilirubin elimination through the gastrointestinal tract and helps prevent enterohepatic recirculation. In uncomplicated physiologic jaundice, breastfeeding should generally be encouraged rather than reduced, because inadequate intake can worsen hyperbilirubinemia. Advising less frequent feeds increases the risk of dehydration and decreased stool output, raising bilirubin levels. Routine permanent cessation of breastfeeding is not indicated; temporary supplementation is reserved for select cases of poor intake/excessive weight loss or specific breastfeeding-associated jaundice patterns under provider guidance.

Question 24

A boy with patent ductus arteriosus was delivered 6 hours earlier and is being held by his mother. As the nurse enters the room to assess the neonate’s vital signs, the mother says, “The physician says that my baby has a heart murmur. Does that mean he has a bad heart?” Which response by the nurse would be the most appropriate?

Accepted Answer

Answer reason: In the immediate newborn period, a patent ductus arteriosus (PDA) can be part of normal transitional circulation. Functional murmurs may be heard within the first hours of life as the ductus arteriosus begins to close. The nurse should provide accurate, reassuring, and developmentally appropriate education without dismissing concerns. Option A increases anxiety without providing helpful context. Option B is inappropriate and not indicated. Option C is falsely reassuring and dismissive. Option D gives a clear, physiologic explanation and supports parental understanding while maintaining reassurance.

Question 25

Newborns' eyes are treated with an antibiotic?

Accepted Answer

Answer reason: Prophylactic antibiotic eye treatment (e.g., erythromycin ophthalmic ointment) is routinely administered to all newborns shortly after birth to prevent ophthalmia neonatorum, most commonly caused by Neisseria gonorrhoeae and Chlamydia trachomatis. This is a universal preventive measure, not dependent on confirmed maternal infection status, because untreated infection can lead to severe complications including blindness.

Question 26

A newborn with acrocyanosis will have a bluish discoloration of which body part(s)?

Accepted Answer

Answer reason: It presents as bluish discoloration limited to the hands and feet while the central body remains pink with adequate oxygenation. Central cyanosis would involve the lips, tongue, and trunk and suggests hypoxemia requiring urgent evaluation. Unilateral cyanosis (e.g., one side) is not the typical pattern for acrocyanosis and would prompt concern for localized vascular issues.

Question 27

According to standard references, what is the average birth weight of a normal newborn?

Accepted Answer

Answer reason: The average birth weight of a healthy full-term newborn is approximately 3 kg. Although the normal range typically spans from about 2.5 to 4 kg, 3 kg is widely accepted as the standard reference value.

Question 28

Apgar scoring is done by—?

Accepted Answer

Answer reason: It is commonly performed by trained delivery-room clinicians, including nurses/midwives and physicians, because it requires prompt observation of heart rate, respiratory effort, tone, reflex irritability, and color. Either professional can accurately score and communicate findings as part of routine neonatal transition monitoring. A parent is not the appropriate scorer because the task requires clinical training, timing, and integration into resuscitation decision-making if needed.

Question 29

Exclusive breastfeeding is recommended for?

Accepted Answer

Answer reason: Introducing other liquids or solids earlier can increase infectious diarrhea risk and may displace needed breast milk intake. After 6 months, complementary foods are added while breastfeeding continues as desired because micronutrient needs (e.g., iron) increase. Options shorter than 6 months do not align with standard public health guidance, while “1 year” confuses the duration of exclusive breastfeeding with the recommendation to continue breastfeeding alongside complementary foods.

Question 30

By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which type of heat loss?

Accepted Answer

Answer reason: Warming the nursery reduces the temperature gradient between the infant and the ambient air, decreasing heat transfer away from the skin. Wrapping in blankets limits air movement across the skin and traps a layer of warmed air, further reducing convective loss. A common distractor is conduction, which involves direct contact with cold surfaces (e.g., a cold scale or mattress) rather than room air temperature and drafts.

Question 31

Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following?

Accepted Answer

Answer reason: The Ortolani maneuver elicits a palpable/audible “clunk” as a dislocated femoral head is reduced back into the acetabulum, making it a classic finding expected during newborn assessment. A limp and a Trendelenburg gait are typically seen later when the child is walking, not in a newborn. Symmetrical gluteal folds are not an expected finding in DDH; asymmetry can be a clue but is less specific than instability maneuvers.

Question 32

A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is expected?

Accepted Answer

Answer reason: Peeling (desquamation) is therefore a classic expected physical finding in a postmature infant. In contrast, lanugo and abundant vernix are more typical of preterm or earlier-term infants, not post-term. Sleepiness/lethargy is nonspecific and can reflect illness or medication exposure rather than a normal post-term physical characteristic.

Question 33

Kangaroo Mother Care (KMC) start if baby weight is...?

Accepted Answer

Answer reason: Baby weight < 2.5 kg Kangaroo mother care is an evidence-based thermoregulation and bonding intervention primarily indicated for low-birth-weight infants. The 2.5 kg or >3 kg miss the key risk group that KMC is designed to benefit most. A narrow band like 2.5–2.7 kg is not a standard criterion and would inappropriately exclude many eligible low-birth-weight babies.

Question 34

After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse anticipate as a potential problem in the neonate?

Accepted Answer

Answer reason: This can reduce respiratory drive and muscle tone immediately after birth, increasing the risk of hypoventilation or apnea and the need for resuscitative support. The nurse should anticipate lower Apgar scores related to poor respiratory effort and be prepared for close monitoring of respirations and oxygenation. By contrast, jitteriness is more consistent with neonatal hypoglycemia or withdrawal rather than magnesium exposure, and tachycardia is not a typical direct neonatal effect of magnesium toxicity.

Question 35

Key features of kangaroo mother care are all of the following EXCEPT?

Accepted Answer

Answer reason: Kangaroo mother care includes skin-to-skin contact, exclusive breastfeeding, and continuation at home. It is not limited to cyanotic infants; it is primarily used for low birth weight and preterm infants.

Question 36

The nurse is instructing new parents on how to prevent sudden infant death syndrome (SIDS). What should the nurse include as the best way to put an infant to sleep in order to prevent SIDS?

Accepted Answer

Answer reason: The core SIDS risk-reduction principle is the ABCs of safe sleep: infants should sleep Alone, on their Back, in a safety-approved Crib/bassinet with a firm, flat surface. Supine positioning decreases the risk of airway obstruction and rebreathing exhaled CO2 compared with prone positioning. Soft bedding and objects (blankets, toys, pillows) increase suffocation and entrapment risk and are therefore avoided in the sleep environment. Prone sleeping is a common distractor because it may seem comfortable, but it is associated with higher SIDS risk and is not recommended for routine sleep.

Question 37

A baby is delivered 45 seconds after a shoulder dystocia has been called. The nurse’s first action should be?

Accepted Answer

Answer reason: Drying and stimulating reduces heat loss and can initiate effective respirations, while simultaneously allowing rapid assessment of tone, breathing effort, and heart rate to determine need for neonatal resuscitation. Skin-to-skin is appropriate only after the newborn is stable and does not replace the initial stabilization/assessment steps. Assessing for clavicle fracture is important after shoulder dystocia but is a secondary assessment once cardiopulmonary stability is confirmed.

Question 38

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?

Accepted Answer

Answer reason: Epidemiologically, most cases occur between 1 month and 4 months, with the peak around 2–4 months, aligning with immature autonomic and arousal control. Ages beyond 12 months are outside the diagnostic definition, making those ranges incorrect. A narrow window such as 6–8 weeks is too restrictive and misses the broader high-risk period in the first year.

Question 39

Nurse Instructor Davis is supervising a student nurse who is about to administer a vitamin K injection to a newborn. The student nurse asks about the purpose of the injection. What is the correct explanation Nurse Davis should provide?

Accepted Answer

Answer reason: " Newborns have low vitamin K stores and limited gut flora to synthesize vitamin K, so they are at risk for vitamin K deficiency bleeding. Vitamin K is required for hepatic synthesis of clotting factors (especially II, VII, IX, and X), so prophylaxis reduces the risk of serious hemorrhage (e.g., intracranial bleeding). Options about jaundice or hyperbilirubinemia confuse vitamin K with bilirubin metabolism and are not the indication for the injection. Active immunity is provided by vaccines; vitamin K is not an immunization.

Question 40

If secretions are present after delivery of the head, what is the nurse’s priority action to promote effective breathing?

Accepted Answer

Answer reason: Airway patency is essential for effective newborn respiration. Current guidelines do not recommend routine suctioning; however, if visible secretions are present or airway obstruction is suspected, gentle suctioning of the mouth and nose helps clear the airway and supports spontaneous breathing. Other actions such as stimulation, cord clamping, and color assessment are secondary to establishing a patent airway when obstruction is present.

Question 41

Mr. and Mrs. Baker’s only daughter is diagnosed with heart failure. Which of the following interventions would be appropriate to promote optimal nutrition for the infant?

Accepted Answer

Answer reason: Using an easy-to-suck nipple decreases the effort needed to feed, helping the infant take in adequate volume/calories before becoming exhausted or tachypneic. Prolonged feeding times increase energy expenditure and can worsen respiratory distress, so allowing feeds to last an hour is counterproductive. Large, infrequent feedings also increase fatigue and may precipitate intolerance, while high-sodium formula can worsen fluid retention and heart failure even if higher-calorie density may be desired.

Question 42

A nurse is caring for an infant who has a hydrocele. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Hydrocele in infants is typically a benign collection of fluid around the testicle that commonly resolves spontaneously during the first year of life as the processus vaginalis closes. The appropriate nursing action is parent education and reassurance with routine observation, including advising them to report increasing size, pain, redness, or signs suggesting an associated inguinal hernia. Immediate surgery is not indicated unless the hydrocele persists beyond infancy, becomes very large/symptomatic, or is communicating with a hernia. Foreskin retraction is inappropriate in infants due to risk of trauma, and genetic counseling is not a standard intervention for an isolated hydrocele.

Question 43

Which of the following is considered as the "silent killer" of neonates?

Accepted Answer

Answer reason: Hypothermia in neonates is referred to as a “silent killer” because its onset is often subtle and easily overlooked, yet it can rapidly lead to severe complications such as metabolic acidosis, hypoglycemia, respiratory distress, and increased mortality. Newborns, especially preterm infants, have limited thermoregulation and high surface area-to-body weight ratios, making them highly susceptible to heat loss. Without prompt recognition and intervention, hypothermia can progress quickly and compromise multiple organ systems.

Question 44

A nurse is teaching a postpartum client about cord care for the newborn. Which statement by the client indicates a need for further teaching?

Accepted Answer

Answer reason: Umbilical cord care prioritizes keeping the stump clean and dry to promote natural mummification and reduce infection risk. Folding the diaper below the cord prevents friction and moisture trapping from urine, which can delay separation and increase the chance of omphalitis. Expecting the cord to darken, allowing it to fall off spontaneously, and using sponge baths until separation are appropriate teachings. Securing the diaper over the stump does the opposite of recommended care by covering it and increasing irritation and moisture exposure.

Question 45

Sequence of taking vital sign in a newborn infant is?

Accepted Answer

Answer reason: Respirations are counted first because crying or stimulation quickly alters the rate and pattern, making the value unreliable. Next, the pulse is assessed, as it also increases with handling but is still measurable after respirations if the infant remains relatively calm. Temperature is taken last because it requires more handling/undressing and is most likely to stimulate the infant.

Question 46

The nurse performing an initial newborn assessment after birth observes a bluish discoloration of the hands and feet. The trunk has a pink color. What is the nurse's initial action?

Accepted Answer

Answer reason: The safest initial nursing action is to promote warmth and cardiopulmonary stability with skin-to-skin contact, which supports thermoregulation and reduces oxygen consumption. Immediate oxygen administration is not indicated when central color is pink and there are no signs of respiratory distress. Ongoing assessment is appropriate, but the first intervention should address temperature and normal transition.

Question 47

A new mother asks the nurse about stimulating the newborn client to open its eyes. Which action by the nurse is the most effective?

Accepted Answer

Answer reason: Newborns commonly keep their eyes closed or blink in response to bright light because their visual system is immature and they are easily overstimulated. Reducing environmental light decreases glare and allows the infant to become quietly alert, which facilitates spontaneous eye opening for bonding and assessment. Auditory stimulation (speaking) may help with orientation but is typically less effective than lowering excessive light when the infant is light-aversive. Touching near the eyes can trigger protective reflexes and increase distress, making eye opening less likely.

Question 48

What is the normal birth weight of a newborn baby?

Accepted Answer

Answer reason: 2.5–3.5 kg Normal term newborn weight is generally centered around ~3.2–3.4 kg, with a typical normal range roughly 2.5 to 4.0 kg; values below 2.5 kg meet criteria for low birth weight. This range reflects appropriate fetal growth for gestational age and is used clinically to screen for small-for-gestational-age or growth restriction. The 1–2 kg range corresponds to very low birth weight/prematurity and is not normal for a term newborn. Higher ranges such as 4–5 kg and 5–6 kg suggest macrosomia and raise concerns for maternal diabetes and delivery complications rather than normal findings.

Question 49

First bath of newborn is usually given after?

Accepted Answer

Answer reason: Delaying the first bath also supports early skin-to-skin contact and breastfeeding initiation, improving physiologic stability. Many protocols additionally favor postponement to help preserve the protective vernix and reduce unnecessary stress during early adaptation. Earlier time frames such as 2–6 hours may still be too soon for some infants to maintain stable temperature without disruption of bonding and feeding.

Question 50

After assisting with a vaginal delivery, what would the nurse do to prevent heat loss via conduction in the newborn?

Accepted Answer

Answer reason: Conduction is heat transfer from direct contact with a cooler surface, so preventing it focuses on warming any surface the newborn touches. A warm crib pad reduces the temperature gradient between the infant’s skin and the bed, minimizing conductive heat loss. Closing doors primarily reduces drafts (convection), not conduction. Drying addresses evaporative heat loss, and wrapping helps limit ongoing losses but does not directly correct a cold contact surface as effectively as warming the pad.

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