Maternal Newborn Nursing Test Newborn Assessment and Care 2 — Questions and Answers
Question 1: A newborn receives vitamin K (phytonadione) intramuscularly at birth. What is the primary rationale for this administration?
- To prevent neonatal infection
- To stimulate the immune system
- To prevent hemorrhagic disease of the newborn due to low clotting factors (Correct answer)
- To promote bilirubin conjugation
Correct answer: To prevent hemorrhagic disease of the newborn due to low clotting factors
Newborns lack intestinal bacteria needed to synthesize vitamin K, resulting in low clotting factors II, VII, IX, and X, making them susceptible to hemorrhagic disease without prophylaxis.
Question 2: The nurse is assessing a 24-hour-old newborn and observes yellow discoloration of the skin and sclera. The total bilirubin level is 6 mg/dL. How should the nurse interpret this finding?
- Pathological jaundice requiring immediate phototherapy
- Physiological jaundice, expected at this age (Correct answer)
- Sign of ABO incompatibility requiring exchange transfusion
- Hepatic failure requiring further investigation
Correct answer: Physiological jaundice, expected at this age
Physiological jaundice typically appears after 24 hours of life with bilirubin peaking at 3–5 days, and a level of 6 mg/dL at 24 hours is within physiological range for a term infant.
Question 3: A newborn is placed under phototherapy for hyperbilirubinemia. Which nursing intervention is MOST important during phototherapy?
- Keep the infant bundled warmly to maintain temperature
- Cover the eyes with opaque shields to protect from retinal damage (Correct answer)
- Restrict feedings to 3-hour intervals only
- Position the infant prone for maximum light exposure
Correct answer: Cover the eyes with opaque shields to protect from retinal damage
Eye shields must be applied during phototherapy to protect the newborn's retinas and corneas from intense light exposure that can cause permanent damage.
Question 4: Which newborn weight loss in the first few days of life is considered within normal limits?
- Up to 5% of birth weight
- Up to 10% of birth weight (Correct answer)
- Up to 15% of birth weight
- Any weight loss is abnormal
Correct answer: Up to 10% of birth weight
A term newborn may lose up to 10% of birth weight in the first 3–5 days due to fluid shifts, meconium passage, and establishing feeding, and should regain birth weight by 10–14 days.
Question 5: At 12 hours of life, a newborn has not passed meconium. Which assessment finding would most concern the nurse?
- Passage of transitional stool instead of meconium
- Abdominal distention with absent bowel sounds (Correct answer)
- Presence of vernix in the groin folds
- Mild acrocyanosis of the hands and feet
Correct answer: Abdominal distention with absent bowel sounds
Abdominal distension with absent bowel sounds in a newborn who has not passed meconium may indicate intestinal obstruction such as Hirschsprung disease or meconium ileus.
Question 6: The nurse is teaching a new parent about the newborn's umbilical cord care. Which instruction is most current and evidence-based?
- Apply alcohol to the cord stump with each diaper change
- Keep the cord stump moist with petroleum jelly
- Allow the cord to dry naturally and keep it clean and dry (Correct answer)
- Apply antibiotic ointment to the cord base daily
Correct answer: Allow the cord to dry naturally and keep it clean and dry
Current evidence-based guidelines recommend dry cord care — keeping the stump clean and dry — as it promotes natural separation without increasing infection risk.
