A neonate born by cesarean delivery at 42 weeks' g

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Question 1 of 5

A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?

A. Ineffective airway clearance related to postterm gestational age. B. Hyperthermia related to large size and use of a radiant warmer. C. Decreased cardiac output related to difficult delivery. D. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores.

Correct Answer: D

Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.

Question 2 of 5

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do?

A. Bring in toys for distraction. B. Place a musical mobile over the crib. C. Stroke the neonate's back. D. Use constant, gentle touch.

Correct Answer: D

Rationale: Constant, gentle touch is soothing and minimizes overstimulation for a sick neonate.

Question 3 of 5

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should:

A. Write the results in the chart, and receive confirmation from the caller that the nurse understands the results. B. Repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the chart. C. Indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery. D. Request that the laboratory send the results by email to transfer to the client's electronic record.

Correct Answer: A

Rationale: Writing the results and confirming with the caller ensures accuracy and compliance with documentation protocols.

Question 4 of 5

A neonate born at 38 weeks' gestation is admitted to the neonatal nursery for observation. The neonate's mother, who is positive for human immunodeficiency virus (HIV) infection, has received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following?

A. More than $50 \%$ of neonates born to mothers who are positive for HIV will be positive at 18 months of age.' B. An enlarged liver at birth generally means the neonate is HIV positive.' C. A complete blood count analysis is the primary method for determining whether the neonate is HIV positive.' D. Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time.'

Correct Answer: D

Rationale: Most neonates born to HIV-positive mothers test positive for HIV antibodies at birth due to maternal antibody transfer but are asymptomatic, with true infection status determined later.

Question 5 of 5

A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?

A. Use an appropriate nipple and bottle set. B. Encourage the mother to breast-feed. C. Assess daily weights and wet diapers to monitor intake. D. Allow unlimited length of time for each feeding.

Correct Answer: A

Rationale: Using an appropriate nipple and bottle set designed for cleft palate infants minimizes aspiration risk during feedings.

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NCLEX RN Maternity Questions Questions

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