Nursing Interventions in Newborn Assessment

Total Questions : 4

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Question 1:

A nurse is preparing to perform a newborn assessment.

What is the first step that the nurse should take?

Explanation

C. Perform hand hygiene or use an alcohol-based hand sanitizer.

This is the first step that the nurse should take before performing a newborn assessment to prevent the transmission of infection.According to the CDC, hand hygiene is the most important measure to prevent healthcare-associated infections.

Choice A is wrong because informed consent from the parents or guardians is not required for a routine newborn assessment.Consent is implied when the parents bring the newborn to the health care facility.

Choice B is wrong because positioning the newborn in a supine position on a flat surface is not the first step, but rather the second step after performing hand hygiene.The supine position allows for a complete head-to-toe examination of the newborn.

Choice D is wrong because administering prophylactic medications to the newborn is not part of the newborn assessment, but rather a separate intervention that requires a physician’s order and informed consent from the parents or guardians.

Prophylactic medications may include vitamin K injection, eye ointment, and hepatitis B vaccine.


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Question 2:

A nurse is assessing a newborn’s vital signs.

What is the normal range for a newborn’s heart rate?

Explanation

The normal range for a newborn’s heart rate is 120 to 160 beats per minute.

This reflects the high metabolic rate and oxygen consumption of the newborn.

Choice A is wrong because 60 to 80 beats per minute is too low for a newborn and may indicate bradycardia, which can be caused by hypoxia, hypothermia, or heart block.

Choice B is wrong because 80 to 100 beats per minute is also below the normal range for a newborn and may indicate poor perfusion or cardiac dysfunction.

Choice C is wrong because 100 to 120 beats per minute is at the lower end of the normal range for a newborn and may indicate hypothermia, dehydration, or sepsis.


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Question 3:

A nurse is auscultating a newborn’s lung sounds.

What type of breath sounds should the nurse expect to hear in a healthy newborn?

Explanation

Vesicular breath sounds are soft and low-pitched and are heard over most of the lung fields.

They indicate normal air movement in and out of the alveoli.

Bronchial breath sounds are loud and high-pitched and are heard over the trachea and larynx.

They indicate increased airway resistance or consolidation.

Bronchovesicular breath sounds are medium-pitched and are heard over the main bronchi.

They indicate partial obstruction of the airways or atelectasis.

Adventitious breath sounds are abnormal sounds such as crackles, wheezes, rhonchi, or stridor.

They indicate various lung disorders such as pneumonia, asthma, bronchitis, or foreign body aspiration.

Choice B is wrong because bronchial breath sounds are not normal in a healthy newborn and indicate a lung problem.

Choice C is wrong because bronchovesicular breath sounds are not normal in a healthy newborn and indicate a lung problem.

Choice D is wrong because adventitious breath sounds are not normal in a healthy newborn and indicate a lung problem.


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Question 4:

A nurse is evaluating a newborn’s feeding and elimination patterns.

How many wet diapers should a newborn have per day by the fourth day of life?

Explanation

A newborn should have at least six wet diapers per day by the fourth day of life. This indicates that the baby is well hydrated and getting enough milk.

Choice A is wrong because one wet diaper per day is too low and could mean that the baby is dehydrated or not feeding well.

Choice B is wrong because three wet diapers per day is also too low and could indicate insufficient milk intake or dehydration.

Choice D is wrong because nine wet diapers per day is more than the average range and could indicate that the baby is overfed or has a urinary tract infection.


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