Learn NCLEX PN Questions with Rationale 68th Edition

Learn NCLEX PN Questions with Rationale 68th Edition

1. In caring for a preterm newborn’s skin, the nurse must understand the special characteristics that exist. These include a:

A. Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture
B. Thin and gelatinous skin with a flexed posture and decreased subcutaneous fat
C. Thin and gelatinous skin with a flexed posture and increased amounts of brown fat
D. Fine downy hair on a thin epidermal and dermal layer with flexed posture and increased amount of brown fat

Answer: A. Thin and gelatinous skin with decreased amounts of subcutaneous fat and an open posture

Rationale: The skin of a newborn plays a significant role in thermoregulation and as a barrier against infection. The skin is immature in contrast to a term newborn. The skin of a preterm newborn is thin and gelatinous. There are decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborns lose heat because of the high body surface area in relation to their weight and because their posture is more relaxed with less flexion. For these reasons, preterm newborns are less able to generate heat. This places the preterm newborn at risk for increased heat loss and increased fluid requirements.

Test-Taking Strategy: Use the process of elimination. Options 2, 3, and 4 are incorrect. Preterm newborns have open posture (option 1), which contributes to heat loss. Also, they have decreased amounts of subcutaneous and brown fat. Option 4 is partially correct in that the newborn may have fine downy hair, but the remainder of this option is incorrect. Review the characteristics of a preterm newborn if you had difficulty with this question.

Level of Cognitive Ability: Comprehension

Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.).
Philadelphia: W.B. Saunders, p. 306.

2. A nurse is caring for a newborn who has hyperbilirubinemia. Which of the following actions is recommended for a newborn that is being breast-fed and who has hyperbilirubinemia?

A. Alternate feeding with supplemental formula.
B. Stop breast-feeding for 48 hours and have the mother pump the breasts.
C. Add additional feedings with bottled glucose.
D. Increase the frequency of breast-feeding.

Answer: D. Increase the frequency of breast-feeding.

Rationale: The greater the number of breast-feedings, the lower the bilirubin. Breast-feeding should be initiated early and frequently. Supplementation with water does not reduce hyperbilirubinemia. Water, glucose, or formula supplements should be discouraged.

Test-Taking Strategy: Use the process of elimination. Options 1 and 2 are incorrect because these options do not encourage continuation of breast-feeding and can cause nipple confusion in the newborn. Option 3 is incorrect. Bilirubin is excreted in the stool, and the addition of bottled glucose will only cause an increase in urination. Review this disorder if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 300.
Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 312.

3. A nurse observes slight facial jaundice in a 2-day-old full-term neonate. The nurse interprets this finding using which of the following guidelines?

A. Facial jaundice is common from birth to 5 days old.
B. Bilirubin is produced at minimal rates in the neonate immediately following delivery.
C. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dl, which are not abnormal in a 2-day-old neonate.
D. The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin following delivery.

Answer: C. Jaundice is visible on the skin of a neonate at bilirubin levels from 4 to 6 mg/dl, which are not abnormal in a 2-day-old neonate.

Rationale: Neonatal bilirubin levels below 12 mg/dl on the second to seventh day following birth are considered normal in the full-term neonate. The amount of the enzyme necessary for the conjugation of bilirubin may be decreased. Additionally the delayed passage through the gastrointestinal tract and the rapid production of bilirubin from the breakdown of excess fetal red blood cells may lead to rising levels of unconjugated bilirubin and jaundice in the neonate.

Test-Taking Strategy: A thorough understanding of the principles of normal physiological jaundice in the full-term neonate is necessary to answer this question correctly. Remember neonatal bilirubin levels below 12 mg/dl on the second to seventh day following birth are considered normal in the full-term neonate. If you had difficulty with this question, review the content related to normal physiological jaundice.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 312.

4. A nursing student is preparing to instill a medication into the eyes of a newborn as a preventive measure against ophthalmic neonatorum. The nursing instructor asks the student to identify the medication for the prophylaxis of ophthalmic neonatorum and gonococcal infection. The student correctly replies by telling the instructor that this medication is:

A. Erythromycin
B. Neomycin
C. Penicillin
D. Silver nitrate

Answer: A. Erythromycin

Rationale: Erythromycin ophthalmic 0.5% ointment is a broad spectrum antibiotic and is used prophylactically to prevent ophthalmic neonatorum, an eye infection acquired from the baby’s passage through the birth canal. Ophthalmic neonatorum is caused mostly by the presence of gonococci and/or chlamydia. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against both chlamydia and gonococci. None of the other medications are effective against both bacteria.

Test-Taking Strategy: Knowledge of newborn care and the prevention of ophthalmic neonatorum are necessary to answer this question. Remember erythromycin ophthalmic 0.5% ointment is a broad spectrum antibiotic and is used prophylactically to prevent ophthalmic neonatorum. Review this content and newborn care if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 159.

Source : NCLEX Questions and answer

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Read also:

• NCLEX PN Questions 67th Edition 2019 / 2020
• NCLEX PN Examination 66th Edition (Update September 2019)
• Free NCLEX PN Examination (Example and Answer) 66th Edition

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