14 original SNLE questions on neonatal nursing, each with an explanation for all four options. Part of Maternal-Child Nursing, worth 30% of the Saudi Nursing Licensure Examination.
Q01 / 10medium0 correct
Maternal-Child Nursingmediumq043
A community health nurse is conducting a home visit for a 2-day-old infant and the mother. The infant was born at 38 weeks gestation via uncomplicated vaginal delivery and was discharged home 24 hours after birth. The mother is breastfeeding. Which assessment finding requires immediate intervention?
All 14 questions
Every question below, with the reasoning for all four options. Try to answer before you open one.
Neonatal nursing · medium
A community health nurse is conducting a home visit for a 2-day-old infant and the mother. The infant was born at 38 weeks gestation via uncomplicated vaginal delivery and was discharged home 24 hours after birth. The mother is breastfeeding. Which assessment finding requires immediate intervention?
AInfant's axillary temperature is 36.0°C (96.8°F).
BInfant has a small, flat, bluish discoloration on the lower back.
CInfant has lost 5% of birth weight since delivery.
DInfant has had 4 wet diapers in the past 24 hours.
Show the answer and why the others fail
Answer: A. Infant's axillary temperature is 36.0°C (96.8°F).
A — correct
An axillary temperature of 36.0°C (96.8°F) is below the normal newborn range and indicates cold stress, which can lead to hypoglycemia and metabolic acidosis; immediate intervention is required.
B
A small, flat, bluish discoloration on the lower back is a typical Mongolian spot, a benign congenital finding that does not require intervention.
C
A weight loss of up to 7% from birth weight is expected in the first few days for breastfed infants; 5% is within normal limits and does not require immediate intervention.
D
By day 2 of life, an infant should have at least 2–3 wet diapers per day; 4 wet diapers indicates adequate hydration and is a normal finding.
TakeawayAn axillary temperature of 36.0°C (96.8°F) in a newborn indicates cold stress, which can lead to hypoglycemia and metabolic acidosis; immediate warming and further evaluation are necessary.
Neonatal nursing · medium
A nurse is assessing a 2-hour-old newborn who was born at 39 weeks' gestation weighing 4,200 g to a mother with gestational diabetes. The newborn is jittery and has a weak cry. Which action should the nurse take first?
APlace the newborn under a radiant warmer for thermoregulation.
BObtain a capillary blood glucose level.
CInitiate phototherapy for hyperbilirubinemia.
DAdminister 10% dextrose in water intravenously.
Show the answer and why the others fail
Answer: B. Obtain a capillary blood glucose level.
A
While thermoregulation is important and cold stress can worsen hypoglycemia, the immediate priority is to assess blood glucose to confirm and treat the likely cause of the symptoms. Thermoregulation can be addressed concurrently but does not replace the need for glucose assessment.
B — correct
Jitteriness and weak cry are classic signs of neonatal hypoglycemia. Given the risk factor of maternal diabetes and large size, checking blood glucose is the priority to confirm and guide immediate treatment.
C
Jitteriness and weak cry are not signs of hyperbilirubinemia; they are classic indicators of hypoglycemia. Jaundice appearing within the first 24 hours is pathological, but this newborn is not described as jaundiced, so phototherapy is not indicated.
D
Intravenous dextrose may be needed if hypoglycemia is confirmed, but it is not the first action. The nurse must first assess the blood glucose level to determine if intervention is required.
TakeawayIn newborns with risk factors for hypoglycemia (e.g., maternal diabetes, LGA), signs such as jitteriness, weak cry, or lethargy warrant immediate blood glucose assessment to confirm and treat hypoglycemia promptly.
Neonatal nursing · medium
A 2-hour-old term newborn, born to a mother with gestational diabetes, has a blood glucose level of 35 mg/dL (1.9 mmol/L). The infant is asymptomatic. What is the priority nursing action?
AEncourage breastfeeding or provide formula feeding.
BRecheck blood glucose in 30 minutes.
CNotify the physician immediately.
DAdminister IV dextrose 10% bolus.
Show the answer and why the others fail
Answer: A. Encourage breastfeeding or provide formula feeding.
A — correct
For asymptomatic hypoglycemia in a term infant, the first-line intervention is enteral feeding to raise blood glucose, followed by rechecking the level.
B
Rechecking without intervening does not address the low glucose level; feeding should be provided first, then glucose rechecked per protocol.
C
While the physician should be informed, the nurse can and should initiate feeding as the priority intervention according to standard hypoglycemia protocols.
D
IV dextrose is indicated for symptomatic hypoglycemia or blood glucose <25 mg/dL (1.4 mmol/L), not for an asymptomatic infant with a level of 35 mg/dL.
TakeawayAsymptomatic neonatal hypoglycemia is often managed initially with enteral feeding to raise blood glucose, reserving IV dextrose for symptomatic or severe cases.
Neonatal nursing · medium
A 96-hour-old term infant is brought to the clinic with yellowing of the skin. The mother reports the infant is breastfeeding well, has 6–8 wet diapers per day, and is passing yellow stools. On examination, the infant is alert and active, with jaundice visible from the face to the upper chest. What is the most appropriate initial action?
AReassure the mother and schedule a follow-up in 2 days.
BAdmit the infant for immediate phototherapy.
CObtain a transcutaneous or serum bilirubin level.
DAdvise the mother to switch to formula feeding.
Show the answer and why the others fail
Answer: C. Obtain a transcutaneous or serum bilirubin level.
A
Reassurance without bilirubin quantification is unsafe because visual estimation is unreliable; a bilirubin level must be obtained first to rule out significant hyperbilirubinemia.
B
Phototherapy is indicated only when the bilirubin level exceeds hour-specific thresholds based on gestational age and neurotoxicity risk factors; without a measured level, immediate admission is premature.
C — correct
The first step in evaluating neonatal jaundice is to measure the bilirubin level (transcutaneous or serum) and interpret it using hour-specific thresholds that account for gestational age and neurotoxicity risk factors, as recommended by the 2022 AAP guideline.
D
Breastfeeding is not contraindicated in neonatal jaundice; routine formula supplementation is not indicated, and the priority is to assess the bilirubin level.
TakeawayIn a jaundiced neonate, always obtain a bilirubin level (transcutaneous or serum) and interpret it using hour-specific thresholds that consider gestational age and neurotoxicity risk factors, as per the 2022 AAP guideline, before deciding on management.
Neonatal nursing · medium
A nurse is caring for a 3-hour-old term newborn whose mother has type 1 diabetes. The newborn is jittery, has a weak cry, and is difficult to arouse. Blood glucose level is 25 mg/dL. Which of the following actions should the nurse take first?
ANotify the healthcare provider of the findings.
BEncourage breastfeeding and reassess glucose in 30 minutes.
CInitiate intravenous access and administer dextrose as prescribed.
DRecheck the blood glucose level in 30 minutes.
Show the answer and why the others fail
Answer: C. Initiate intravenous access and administer dextrose as prescribed.
A
While the provider must be informed, the priority is to initiate treatment for hypoglycemia to prevent harm, following standing orders or protocol.
B
Breastfeeding is appropriate for asymptomatic newborns with borderline low glucose, but this newborn is symptomatic with a critically low glucose level of 25 mg/dL, which requires immediate intravenous dextrose.
C — correct
Symptomatic hypoglycemia (glucose <40 mg/dL) is a medical emergency requiring prompt intravenous dextrose to prevent neurological injury. The nurse's first action is to establish IV access and administer dextrose as prescribed.
D
Rechecking glucose in 30 minutes delays essential treatment for a symptomatic newborn with critically low glucose; immediate intervention is required.
TakeawaySymptomatic neonatal hypoglycemia (glucose <40 mg/dL) is a medical emergency requiring prompt intravenous dextrose administration. The nurse's first action is to establish IV access and administer dextrose as prescribed to prevent neurological damage. Asymptomatic newborns with low glucose may be managed with feeding and monitoring.
Neonatal nursing · medium
A nurse is caring for a 36-hour-old newborn whose mother used heroin daily during pregnancy. The newborn exhibits a high-pitched cry, tremors, and frequent yawning, and has been difficult to console during feedings. Which of the following actions should the nurse take first?
ASwaddle the newborn and minimize environmental stimulation.
BAdminister naloxone as prescribed.
CInitiate phototherapy and monitor bilirubin levels.
DObtain a capillary blood glucose level immediately.
Show the answer and why the others fail
Answer: A. Swaddle the newborn and minimize environmental stimulation.
A — correct
Non-pharmacological interventions such as swaddling, gentle handling, and reducing noise and light are first-line measures to soothe the newborn and decrease withdrawal symptoms in neonatal abstinence syndrome.
B
Naloxone is an opioid antagonist used for acute opioid overdose reversal, not for neonatal abstinence syndrome. In a newborn with opioid dependence, naloxone can precipitate severe withdrawal and seizures, and is contraindicated.
C
Phototherapy is used to treat hyperbilirubinemia. The newborn's symptoms are not indicative of jaundice, and phototherapy would not address the withdrawal symptoms.
D
While hypoglycemia can present with jitteriness, the constellation of high-pitched cry, tremors, and irritability in the context of maternal opioid use is more consistent with neonatal abstinence syndrome. Blood glucose monitoring may be indicated but is not the priority action.
TakeawayFor newborns with neonatal abstinence syndrome, non-pharmacological comfort measures (swaddling, low stimulation, small frequent feedings) are the first-line interventions to manage withdrawal symptoms.
Neonatal nursing · medium
A 2-day-old newborn is irritable, has a high-pitched cry, and is sneezing frequently. The mother had no prenatal care and admits to using heroin during pregnancy. What is the nurse's priority action?
AAssess the newborn using a standardized neonatal abstinence scoring system.
BObtain a urine toxicology screen to confirm exposure.
CAdminister morphine as prescribed for severe withdrawal.
DAdminister naloxone as prescribed to reverse withdrawal.
Show the answer and why the others fail
Answer: A. Assess the newborn using a standardized neonatal abstinence scoring system.
A — correct
Assessment is the priority nursing action to determine the severity of withdrawal and guide appropriate interventions, using a validated tool such as the Finnegan Neonatal Abstinence Scoring System or the Eat, Sleep, Console approach.
B
Toxicology screening may confirm exposure but does not guide immediate management; assessment of withdrawal symptoms is the priority.
C
Pharmacologic treatment with morphine is reserved for infants with severe withdrawal unresponsive to non-pharmacologic interventions, and requires prior assessment.
D
Naloxone is contraindicated in opioid-dependent newborns because it can precipitate acute withdrawal and seizures.
TakeawayAssessment is the priority nursing action for a newborn with suspected neonatal opioid withdrawal syndrome. Validated tools such as the Finnegan Neonatal Abstinence Scoring System or the Eat, Sleep, Console (ESC) approach are used to evaluate withdrawal severity and guide care, with non-pharmacologic interventions as the first-line treatment.
Neonatal nursing · medium
A term newborn is 12 hours old. The mother had prolonged rupture of membranes for 26 hours before delivery. The nurse notes the newborn is lethargic, has a weak cry, and an axillary temperature of 36.1°C (97°F). What is the priority nursing action?
AAdminister oral glucose gel to treat possible hypoglycemia.
BEncourage the mother to breastfeed to provide warmth and passive immunity.
CNotify the healthcare provider and prepare for a sepsis evaluation.
DSwaddle the newborn in warm blankets and recheck the temperature in 30 minutes.
Show the answer and why the others fail
Answer: C. Notify the healthcare provider and prepare for a sepsis evaluation.
A
Lethargy and a weak cry can be signs of hypoglycemia, but in the context of prolonged rupture of membranes and hypothermia, sepsis is a more likely cause. Administering glucose gel without first checking blood glucose or addressing the underlying infection is not the priority and could delay essential treatment.
B
While breastfeeding provides immunologic benefits and can help with mild temperature instability, it is not the priority when clinical signs suggest a serious infection. The newborn requires immediate medical evaluation, not just feeding.
C — correct
Prolonged rupture of membranes increases the risk of neonatal sepsis. Subtle signs such as lethargy, weak cry, and temperature instability (hypothermia) are classic early indicators. The priority is to promptly alert the provider and prepare for diagnostic tests (e.g., blood cultures, CBC) and possible antibiotic therapy.
D
While rewarming is appropriate for hypothermia, the presence of risk factors (prolonged rupture of membranes) and additional signs (lethargy, weak cry) suggests possible sepsis. Delaying further evaluation by only providing warmth could allow a serious infection to progress.
TakeawayIn a newborn with risk factors for sepsis (e.g., prolonged rupture of membranes), subtle signs like temperature instability, lethargy, and weak cry should prompt immediate notification of the provider and preparation for a septic workup, as early treatment is critical to prevent serious complications.
Neonatal nursing · medium
A nurse is performing a routine newborn assessment on a 2-day-old infant. The nurse notes a positive Ortolani sign on the left hip. Which of the following actions should the nurse take?
APerform passive range-of-motion exercises on the hip.
BNotify the healthcare provider of the finding.
CDocument the finding as a normal variant.
DApply double diapers to maintain hip abduction.
Show the answer and why the others fail
Answer: B. Notify the healthcare provider of the finding.
A
Passive range-of-motion exercises are not indicated for a positive Ortolani sign and may worsen hip instability.
B — correct
A positive Ortolani sign requires immediate communication with the healthcare provider so that further evaluation, such as an orthopedic consultation, can be arranged.
C
A positive Ortolani sign is an abnormal finding that indicates hip instability and possible DDH; it should not be documented as a normal variant.
D
Double diapering is an outdated and ineffective practice for developmental dysplasia of the hip (DDH); it does not provide adequate stabilization and may delay proper treatment.
TakeawayA positive Ortolani sign in a newborn indicates hip instability and possible developmental dysplasia of the hip (DDH). The nurse should promptly notify the healthcare provider to initiate appropriate evaluation and management.
Neonatal nursing · medium
A nurse is performing a critical congenital heart disease (CCHD) screening on a newborn who is 25 hours old. The preductal (right hand) oxygen saturation is 98%, and the postductal (foot) oxygen saturation is 95%. Which of the following actions should the nurse take?
Per the AAP CCHD screening algorithm, a pass (screen negative) is defined as both preductal and postductal saturations ≥95% and a difference of ≤3%. This newborn's saturations are 98% and 95% with a difference of 3%, meeting the pass criteria. The nurse should document the result as a pass.
B
Four-extremity blood pressure measurement is used to evaluate for coarctation of the aorta when there is a significant upper-lower extremity blood pressure gradient, not as a routine response to a passed CCHD pulse oximetry screen.
C
Immediate notification is required only for a failed screen, which is defined as an SpO2 <90% at any time, or after the initial screen and two repeat measurements (three total) the saturations remain 90–94% or the difference remains >3%. This newborn's results are a pass, so urgent notification is not indicated.
D
Repeating the screening in 1 hour is indicated when the initial SpO2 is 90–94% in either extremity or the difference between the two is >3%. This newborn's saturations are both ≥95% and the difference is exactly 3%, which does not meet the criteria for a repeat screen.
TakeawayIn CCHD pulse oximetry screening, a preductal-postductal saturation difference of ≤3% with both values ≥95% is considered a pass (screen negative) and requires only documentation. The term 'pass' is preferred over 'normal' because a passed screen does not rule out all forms of CCHD.
Neonatal nursing · medium
A nurse is assessing a 24-hour-old newborn. The nurse notes a soft, fluctuant swelling on the right parietal area that does not cross the suture line. The newborn is otherwise well, with normal vital signs and no jaundice. What is the most appropriate nursing action?
ANotify the healthcare provider immediately.
BDocument the finding as a normal variant.
CMonitor the newborn for jaundice.
DApply an ice pack to the swelling.
Show the answer and why the others fail
Answer: C. Monitor the newborn for jaundice.
A
Immediate notification is not required for an uncomplicated cephalohematoma in an otherwise well newborn. The finding should be documented and monitored, but it is not an emergency.
B
A cephalohematoma is a birth injury, not a normal variant. It requires monitoring and documentation, but it is not considered a normal finding.
C — correct
A cephalohematoma is a collection of blood under the periosteum that does not cross suture lines. As the blood breaks down, it increases bilirubin production, raising the risk of hyperbilirubinemia. Close monitoring for jaundice is essential.
D
Cold application is not indicated for a cephalohematoma; it may cause discomfort and does not reduce the risk of complications.
TakeawayCephalohematoma increases the risk of neonatal jaundice due to red blood cell breakdown; therefore, monitoring for hyperbilirubinemia is essential.
Neonatal nursing · medium
A nurse is assessing a 2-hour-old newborn who was delivered vaginally with shoulder dystocia. The newborn's right arm is adducted and internally rotated, the elbow is extended, the forearm is pronated, and the Moro reflex is absent on the right side. Which condition should the nurse suspect?
AKlumpke's palsy
BErb's palsy
CFractured clavicle
DFractured humerus
Show the answer and why the others fail
Answer: B. Erb's palsy
A
Klumpke's palsy involves injury to the C8-T1 nerve roots, leading to hand paralysis and a claw-hand deformity, not the shoulder and arm positioning described.
B — correct
Erb's palsy results from injury to the C5-C6 nerve roots, producing the classic 'waiter's tip' posture: arm adducted and internally rotated, elbow extended, forearm pronated, and an absent Moro reflex on the affected side.
C
A fractured clavicle may cause decreased arm movement and an asymmetric Moro reflex due to pain, but the arm is not held in the characteristic adducted, internally rotated, and pronated posture; swelling or crepitus over the clavicle is often present.
D
A fractured humerus may cause pseudoparalysis and pain with movement, but the arm is not held in the characteristic adducted, internally rotated, and pronated posture; swelling or crepitus is often noted.
TakeawayErb's palsy (C5-C6 injury) presents with the arm adducted and internally rotated, elbow extended, forearm pronated, and an asymmetric Moro reflex, often following shoulder dystocia.
Neonatal nursing · medium
A nurse is caring for a 2-day-old term newborn who was diagnosed with a cleft palate. The mother reports that the infant has difficulty feeding and is concerned about the infant's nutrition. Which feeding intervention should the nurse implement?
AEncourage the mother to continue breastfeeding without any modifications.
BInstruct the mother to stop breastfeeding and use a standard bottle with a regular nipple.
CInsert a nasogastric tube and initiate tube feedings for all feeds until surgical repair.
DProvide the mother with a specialized cleft palate feeder and teach her how to use it.
Show the answer and why the others fail
Answer: D. Provide the mother with a specialized cleft palate feeder and teach her how to use it.
A
Without modifications, the infant will continue to have difficulty transferring milk, leading to inadequate intake and potential failure to thrive.
B
A standard bottle nipple requires effective suction for milk transfer, which is impaired in infants with cleft palate; this approach is unlikely to resolve the feeding difficulty.
C
Nasogastric tube feeding is invasive and reserved for infants who cannot take any oral feeds; it is not the first-line intervention when oral feeding is possible with specialized equipment.
D — correct
Specialized cleft palate feeders (e.g., Haberman feeder) deliver milk by compression, eliminating the need for strong suction and allowing effective oral feeding.
TakeawayNewborns with cleft palate often have difficulty generating suction for effective feeding. Specialized feeders that deliver milk by compression, such as the Haberman feeder, can allow oral feeding without the need for suction.
Neonatal nursing · medium
A nurse is assessing a term newborn delivered by elective cesarean section without labor at 39 weeks gestation. At 2 hours of age, the newborn has a respiratory rate of 80 breaths/min, mild grunting, and nasal flaring. Oxygen saturation is 90% on room air. The newborn is alert but with mild retractions. Which condition does the nurse suspect?
ARespiratory distress syndrome
BMeconium aspiration syndrome
CTransient tachypnea of the newborn
DCongenital pneumonia
Show the answer and why the others fail
Answer: C. Transient tachypnea of the newborn
A
Respiratory distress syndrome is primarily a condition of preterm infants due to surfactant deficiency; this term newborn is at low risk.
B
Meconium aspiration syndrome typically occurs in the presence of meconium-stained amniotic fluid and fetal distress, neither of which is described in this scenario.
C — correct
Transient tachypnea of the newborn (TTN) results from delayed clearance of fetal lung fluid, commonly seen after cesarean delivery without labor, and presents with tachypnea, grunting, nasal flaring, and retractions in the first hours of life.
D
Congenital pneumonia is typically associated with maternal risk factors such as prolonged rupture of membranes or chorioamnionitis, which are absent in this scenario.
TakeawayTransient tachypnea of the newborn (TTN) is a common cause of respiratory distress in term or late preterm infants, especially after cesarean delivery without labor, due to delayed absorption of fetal lung fluid.