NCLEX-RN : Care

Study concepts, example questions & explanations for NCLEX-RN

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Example Questions

Example Question #51 : Care

At what time after birth is the APGAR score calculated?

Possible Answers:

At five minutes only

At one, five, and ten minutes

At one and five minutes

At one minute only

Correct answer:

At one and five minutes

Explanation:

The APGAR score is calculated one minute after birth, and then again at five minutes after birth. It is common for infants to be born with depressed respiration, cyanosis, and other physical signs of struggle that are quickly resolved within five minutes after birth. If signs of respiratory or cardiovascular distress do not improve by this time, however, emergency intervention may be required. 

Example Question #11 : Infant And Postpartum Care

You have just calculated a newborn's five minute APGAR score as 5. What is the proper response?

Possible Answers:

Do nothing: this is a normal score

Monitor closely: this is a moderately depressed score

Emergency intervention: this is a severely depressed score

Do nothing: this is a perfect score

Correct answer:

Monitor closely: this is a moderately depressed score

Explanation:

The APGAR scale goes from 0-10. A score of 0-3 would indicate severe depression of function, 4-6 would indicate moderate depression, and 7-10 would be a normal, healthy score. In the case of moderate depression, the newborn should be monitored closely. Immediate emergency intervention may not be required, as healthy neonates can have moderately low APGAR score indicators that improve in the first few hours of life.  

Example Question #101 : Procedures And Care

What is a normal heart rate for a newborn two hours postpartum?

Possible Answers:

110-160 bpm

60-90 bpm

80-110 bpm

140-190 bpm

Correct answer:

110-160 bpm

Explanation:

A newborn's heart rate is significantly higher than that of an adult. Normal heart rate for a newborn two hours postpartum is 110-160 beats per minute. Heart rate decreases in the first year of life to 80-140 beats per minute.

Example Question #11 : Infant And Postpartum Care

A nurse assists in the delivery of a healthy 7 lb, 4 oz infant. Six days later the parents call the clinic with some concern. They state that their daughter has begun to lose weight - she has lost nearly 10 oz since birth, despite breastfeeding regularly. How should the nurse counsel this couple? 

Possible Answers:

This is an emergency; the couple should bring their infant to the emergency department

This is not normal but not yet a cause for concern

This is normal - a breastfed baby will generally lose 5-10% of their birthweight in the first week of life.

This is abnormal and cause for serious concern

Correct answer:

This is normal - a breastfed baby will generally lose 5-10% of their birthweight in the first week of life.

Explanation:

It is normal for infants to lose 5-10% of their birth weight in the first seven days of their lives. In a healthy baby, this weight will be regained by the end of their second week. Infants who are born ill or premature may take longer to regain this weight. If an infant has passed the second week of life and it has not returned to or surpassed it's birthweight, the family may need to seek lactation counseling or bring the infant in for further evaluation.

Example Question #51 : Care

Which of the following is a test for hip dysplasia in an infant?

Possible Answers:

Ortolani test

Thomas test

Faber test

Ober test

Correct answer:

Ortolani test

Explanation:

An examiner can look for hip dysplasia in an infant using the Ortolani test. This is performed by placing the child supine, then flexing the hip and knee to 90 degrees. They would then gently abduct the leg while placing downward pressure on the greater trochanter. In a healthy joint, the hip will move freely. In hip dysplasia, there will be a feeling of a "clunk" as the femoral head is relocated into the acetabulum. The Ober test, Thomas test, and Faber test all check for hip stability and injury in adult populations, rather than pediatric.

Example Question #31 : Patient Specific Care

A new mother is holding her infant just moments after delivery. After she is able to rest for a short time, she looks down and notices that her newborn is covered in fine, but fairly dark hair. This is on the infant's arms, legs, and back. She is startled and asks the nurse if this is a sign of any disorder. How should the nurse reply? 

Possible Answers:

This is normal - it should be shed in a few days

This is a sign of a serious metabolic disorder

This may be normal - the child should be monitored

This is abnormal - a hormone profile is required to rule out hormonal disorder

Correct answer:

This is normal - it should be shed in a few days

Explanation:

Fine, downy hair, called lanugo, generally appears on the fetus around five months of gestation. It is often shed before birth, but some infants are born with this hair still intact. The hair is normally shed within the first 1-3 weeks of life. In most cases it is entirely normal and not a sign of hormone or metabolic disorder.

Example Question #52 : Care

A young couple presents to a clinic with a seven year old who has varicella (chicken pox). The child is not in any distress and the virus seems to be progressing normally. They are concerned, however, because one of them is currently pregnant with their second child. They are at 31 weeks of gestation. The carrying mother had chicken pox when she was 2 years old. They ask the nurse if they should be concerned for the health of the unborn child. Which of the following is the most appropriate response?

Possible Answers:

There is mild need for concern - fetal monitoring is recommended 

The mother should not be in contact with the 7 year old till the last lesion is scabbed over

There is no need for concern

Frequent hand washing is recommended to prevent passing of the viral load to the fetus

Correct answer:

There is no need for concern

Explanation:

As long as the carrying mother has had varicella, she will be able to pass the antibodies to the virus through the placenta to the unborn child. This will confer passive immunity to the fetus. This immunity lasts for the first few months after birth, so newborns delivered by mothers with immunity to varicella will remain immune for some time even after delivery. Increased immunity to this and other pathogens is conferred by breast milk, which contains maternal antibodies (mostly IgA).

Example Question #53 : Care

By five months of age, what change would be expected in an infant's weight?

Possible Answers:

Triple

Double

Increase by at least 50%

Increase by at least 70%

Correct answer:

Double

Explanation:

An infant would be expected to double it's birth weight by five months. Some infants may double their birth weight by three to four months. An infant that has surpassed five months without approaching twice their birth weight may need to be evaluated for feeding difficulties or failure to thrive.

Example Question #103 : Procedures And Care

At what time does molding (the elongation of the baby's head as it passes through the birth canal) resolve in a newborn?

Possible Answers:

10-14 days

1-5 days

Less than 24 hours

2-3 weeks

Correct answer:

1-5 days

Explanation:

Molding, or the elongation of the infants head during labor and delivery, is a normal adaptation allowing the relatively large skull to traverse the narrow space of the birth canal. It generally resolves in 1-5 days.

Example Question #53 : Care

How long after birth should a newborn pass meconium?

Possible Answers:

24 hours

2 weeks

3-5 days

2-6 hours

Correct answer:

24 hours

Explanation:

Meconium is a sticky, dark-green to black stool that is the first stool passed by neonates after birth. It is composed of the content of the infant's digestive tract before it has begun drinking milk - primarily water, mucus, bile, lanugo, and intestinal epithelial cells. A newborn that has begun to feed on breastmilk or formula should pass a normal stool (yellow to mustard-green and creamy rather than sticky) within 24 hours.

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