Documentation & Health Records Flashcards
7 cards from real Low Risk Neonatal Nurse Exam practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Documentation & Health Records flashcards as text
When is the ideal timing for collecting a newborn screening blood spot, which should be documented with date and time?
Answer: Between 24 and 48 hours of age
Collection at 24-48 hours balances detection accuracy and early discharge.
A CCHD pulse oximetry screen is documented as a pass when:
Answer: SpO2 is at least 95% in the right hand or foot with a 3% or less difference between them
Per the AAP-endorsed protocol, ≥95% in either site with ≤3% difference is a pass.
Which of these must be recorded when documenting a hepatitis B vaccine?
Answer: Lot number, expiration date, site, and VIS date
Federal law requires vaccine lot number, manufacturer, administration date, site, and VIS information.
What is the standard IM vitamin K dose for a term newborn?
Answer: 1 mg
Term and larger infants (1,500 g or more) receive 1 mg IM, while smaller infants receive 0.5 mg.
Parents decline erythromycin eye prophylaxis. What is the nurse's best documentation step?
Answer: Document the refusal with education provided and obtain a signed informed refusal per policy
Informed refusal requires documented education and, per policy, a signed form.
How should the result of a newborn hearing screen be documented?
Answer: Separate pass or refer result for each ear, with the method used
Each ear is screened and recorded individually, with a refer result requiring follow-up.
Which entry about a newborn's skin is most objective?
Answer: Skin pink, warm, dry, with acrocyanosis of hands and feet
Objective entries describe observable findings without opinion.
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Sources & references
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