Maternal Newborn Nursing Test Newborn Assessment and Care 2

Question 1

A newborn receives vitamin K (phytonadione) intramuscularly at birth. What is the primary rationale for this administration?

Accepted Answer

To prevent hemorrhagic disease of the newborn due to low clotting factors

Answer

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?

Accepted Answer

Physiological jaundice, expected at this age

Answer

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?

Accepted Answer

Cover the eyes with opaque shields to protect from retinal damage

Answer

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?

Accepted Answer

Up to 10% of birth weight

Answer

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?

Accepted Answer

Abdominal distention with absent bowel sounds

Answer

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.

Maternal Newborn Nursing Test Practice Test

Maternal Newborn Nursing Test Practice Test

Maternal Newborn Nursing Test Newborn Assessment and Care 2