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
Which communication framework is commonly used to report a change in an infant's condition to a provider?
Answer: SBAR
SBAR stands for Situation, Background, Assessment, Recommendation.
When plotting a newborn's bilirubin level for risk assessment, what must be documented along with the value?
Answer: Infant's age in hours at time of sample
Bilirubin is interpreted against hour-specific nomograms, so age in hours is essential.
When weighing diapers for output, approximately how much urine does 1 gram of weight represent?
Answer: 1 mL
One gram of urine is roughly 1 mL.
Which are components of the LATCH breastfeeding assessment tool?
Answer: Latch, Audible swallowing, Type of nipple, Comfort, Hold
LATCH scores Latch, Audible swallowing, Type of nipple, Comfort, and Hold positioning.
What should be included when documenting a newborn's temperature?
Answer: Value, route, and any interventions with the follow-up recheck
Route and interventions with rechecks complete the clinical picture.
Which handoff practice best supports safety and is documented in many units?
Answer: Bedside report with the parents when appropriate and a review of the plan of care
Bedside handoff improves accuracy and family involvement.
The nurse should document a parent's statement about feeding concerns by:
Answer: Using quotation marks for the parent's exact words where relevant
Direct quotes preserve accuracy of subjective data.
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