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?

Obtain a capillary blood glucose level.

Initiate phototherapy for hyperbilirubinemia.

Administer 10% dextrose in water intravenously.

Place the newborn under a radiant warmer for thermoregulation.

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?

Encourage breastfeeding or provide formula feeding.

Administer IV dextrose 10% bolus.

Recheck blood glucose in 30 minutes.

Notify the physician immediately.

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?

Obtain a transcutaneous or serum bilirubin level.

Advise the mother to switch to formula feeding.

Reassure the mother and schedule a follow-up in 2 days.

Admit the infant for immediate phototherapy.

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?

Initiate intravenous access and administer dextrose as prescribed.

Notify the healthcare provider of the findings.

Recheck the blood glucose level in 30 minutes.

Encourage breastfeeding and reassess glucose in 30 minutes.

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?

Swaddle the newborn and minimize environmental stimulation.

Administer naloxone as prescribed.

Initiate phototherapy and monitor bilirubin levels.

Obtain a capillary blood glucose level immediately.

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?

Assess the newborn using a standardized neonatal abstinence scoring system.

Obtain a urine toxicology screen to confirm exposure.

Administer naloxone as prescribed to reverse withdrawal.

Administer morphine as prescribed for severe withdrawal.

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?

Notify the healthcare provider and prepare for a sepsis evaluation.

Encourage the mother to breastfeed to provide warmth and passive immunity.

Administer oral glucose gel to treat possible hypoglycemia.

Swaddle the newborn in warm blankets and recheck the temperature in 30 minutes.

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?

Notify the healthcare provider of the finding.

Perform passive range-of-motion exercises on the hip.

Document the finding as a normal variant.

Apply double diapers to maintain hip abduction.

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?

Document the screening as a pass.

Notify the healthcare provider immediately.

Obtain four-extremity blood pressure measurements.

Repeat the screening in 1 hour.

← Maternal-Child Nursing

Neonatal nursing

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 has a small, flat, bluish discoloration on the lower back.
- BInfant has lost 5% of birth weight since delivery.
- CInfant has had 4 wet diapers in the past 24 hours.
- DInfant's axillary temperature is 36.0°C (96.8°F).
Show the answer and why the others fail
Answer: D. Infant's axillary temperature is 36.0°C (96.8°F).
A
A small, flat, bluish discoloration on the lower back is a typical Mongolian spot, a benign congenital finding that does not require intervention.
B
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.
C
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.
D — 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.
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?
- AObtain a capillary blood glucose level.
- BInitiate phototherapy for hyperbilirubinemia.
- CAdminister 10% dextrose in water intravenously.
- DPlace the newborn under a radiant warmer for thermoregulation.
Show the answer and why the others fail
Answer: A. Obtain a capillary blood glucose level.
A — 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.
B
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.
C
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.
D
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.
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?
- AAdminister IV dextrose 10% bolus.
- BRecheck blood glucose in 30 minutes.
- CNotify the physician immediately.
- DEncourage breastfeeding or provide formula feeding.
Show the answer and why the others fail
Answer: D. Encourage breastfeeding or provide formula feeding.
A
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.
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 — correct
For asymptomatic hypoglycemia in a term infant, the first-line intervention is enteral feeding to raise blood glucose, followed by rechecking the level.
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?
- AAdvise the mother to switch to formula feeding.
- BObtain a transcutaneous or serum bilirubin level.
- CReassure the mother and schedule a follow-up in 2 days.
- DAdmit the infant for immediate phototherapy.
Show the answer and why the others fail
Answer: B. Obtain a transcutaneous or serum bilirubin level.
A
Breastfeeding is not contraindicated in neonatal jaundice; routine formula supplementation is not indicated, and the priority is to assess the bilirubin level.
B — 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.
C
Reassurance without bilirubin quantification is unsafe because visual estimation is unreliable; a bilirubin level must be obtained first to rule out significant hyperbilirubinemia.
D
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.
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.
- BRecheck the blood glucose level in 30 minutes.
- CInitiate intravenous access and administer dextrose as prescribed.
- DEncourage breastfeeding and reassess glucose 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
Rechecking glucose in 30 minutes delays essential treatment for a symptomatic newborn with critically low glucose; immediate intervention is required.
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
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.
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?
- AAdminister naloxone as prescribed.
- BInitiate phototherapy and monitor bilirubin levels.
- CSwaddle the newborn and minimize environmental stimulation.
- DObtain a capillary blood glucose level immediately.
Show the answer and why the others fail
Answer: C. Swaddle the newborn and minimize environmental stimulation.
A
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.
B
Phototherapy is used to treat hyperbilirubinemia. The newborn's symptoms are not indicative of jaundice, and phototherapy would not address the withdrawal symptoms.
C — 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.
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?
- AObtain a urine toxicology screen to confirm exposure.
- BAdminister naloxone as prescribed to reverse withdrawal.
- CAdminister morphine as prescribed for severe withdrawal.
- DAssess the newborn using a standardized neonatal abstinence scoring system.
Show the answer and why the others fail
Answer: D. Assess the newborn using a standardized neonatal abstinence scoring system.
A
Toxicology screening may confirm exposure but does not guide immediate management; assessment of withdrawal symptoms is the priority.
B
Naloxone is contraindicated in opioid-dependent newborns because it can precipitate acute withdrawal and seizures.
C
Pharmacologic treatment with morphine is reserved for infants with severe withdrawal unresponsive to non-pharmacologic interventions, and requires prior assessment.
D — 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.
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?
- AEncourage the mother to breastfeed to provide warmth and passive immunity.
- BAdminister oral glucose gel to treat possible hypoglycemia.
- CSwaddle the newborn in warm blankets and recheck the temperature in 30 minutes.
- DNotify the healthcare provider and prepare for a sepsis evaluation.
Show the answer and why the others fail
Answer: D. Notify the healthcare provider and prepare for a sepsis evaluation.
A
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.
B
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.
C
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.
D — 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.
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.
- BDocument the finding as a normal variant.
- CNotify the healthcare provider of the finding.
- DApply double diapers to maintain hip abduction.
Show the answer and why the others fail
Answer: C. 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
A positive Ortolani sign is an abnormal finding that indicates hip instability and possible DDH; it should not be documented as a normal variant.
C — correct
A positive Ortolani sign requires immediate communication with the healthcare provider so that further evaluation, such as an orthopedic consultation, can be arranged.
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?
- ANotify the healthcare provider immediately.
- BObtain four-extremity blood pressure measurements.
- CDocument the screening as a pass.
- DRepeat the screening in 1 hour.
Show the answer and why the others fail
Answer: C. Document the screening as a pass.
A
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.
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 — correct
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.
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?
- AApply an ice pack to the swelling.
- BNotify the healthcare provider immediately.
- CDocument the finding as a normal variant.
- DMonitor the newborn for jaundice.
Show the answer and why the others fail
Answer: D. Monitor the newborn for jaundice.
A
Cold application is not indicated for a cephalohematoma; it may cause discomfort and does not reduce the risk of complications.
B
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.
C
A cephalohematoma is a birth injury, not a normal variant. It requires monitoring and documentation, but it is not considered a normal finding.
D — 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.
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?
- AErb's palsy
- BKlumpke's palsy
- CFractured clavicle
- DFractured humerus
Show the answer and why the others fail
Answer: A. Erb's palsy
A — 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.
B
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.
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?
- AInsert a nasogastric tube and initiate tube feedings for all feeds until surgical repair.
- BInstruct the mother to stop breastfeeding and use a standard bottle with a regular nipple.
- CEncourage the mother to continue breastfeeding without any modifications.
- 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
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.
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
Without modifications, the infant will continue to have difficulty transferring milk, leading to inadequate intake and potential failure to thrive.
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?
- ATransient tachypnea of the newborn
- BRespiratory distress syndrome
- CMeconium aspiration syndrome
- DCongenital pneumonia
Show the answer and why the others fail
Answer: A. Transient tachypnea of the newborn
A — 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.
B
Respiratory distress syndrome is primarily a condition of preterm infants due to surfactant deficiency; this term newborn is at low risk.
C
Meconium aspiration syndrome typically occurs in the presence of meconium-stained amniotic fluid and fetal distress, neither of which is described in this scenario.
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.