Question

The following newborns are three-hours old and are sleeping. The registered nurse should notify the provider about which newborn?

Answer 1

Correct Answers:

The newborn with a respiratory rate of 72 breaths/minute

Rationale :

💓 A respiratory rate of 72 breaths/minute is significantly higher than the expected range for a newborn.

💓 Normal respiratory rates for newborns are typically between 30–60 breaths/minute.

💓 A rate of 72 breaths/minute can indicate respiratory distress, possibly due to factors such as infection, hypoxia, or other complications.

💓 This elevated respiratory rate should be addressed immediately as it may signal an underlying issue, requiring further assessment and possibly intervention.

💓 The provider should be notified promptly to ensure the newborn's respiratory status is evaluated.

The newborn with a red raised capillary hemangioma on left forearm

💓 Capillary hemangiomas are common in newborns and often resolve on their own.

💓 They are generally harmless and do not require immediate medical intervention unless they become problematic (e.g., rapid growth or interfering with function).

The newborn with a heart rate of 154 beats/minute

💓 A heart rate of 154 beats/minute is within the normal range for a newborn, which typically ranges from 120–160 beats/minute.

💓 This heart rate indicates normal newborn circulation and does not raise concern.

The newborn with whitish, hardened nodules on the gums of the mouth

💓 These are likely epstein pearls, which are common in newborns and usually harmless.

💓 They appear as small white nodules on the gums and typically resolve within a few weeks without intervention.

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Answer 2

Correct Answers:

Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements

Rationale :

🍽️ Pancreatic enzymes are necessary for children with cystic fibrosis (CF) because they help break down food and absorb nutrients.

🍽️ Even if a child with CF has a good appetite and regular bowel movements, the lack of pancreatic enzyme production from the pancreas means the body cannot properly digest and absorb fats and proteins.

🍽️ CF patients typically have pancreatic insufficiency, which requires pancreatic enzyme replacement therapy with every meal and snack to ensure proper nutrition and growth.

🍽️ Diet and regular bowel movements alone do not indicate that the pancreas is functioning properly.

🍽️ Discontinuing pancreatic enzyme therapy can lead to malnutrition, poor weight gain, and gastrointestinal issues.

A high protein, high calorie diet may need to be supplemented with a high-calorie formula

🍽️ This is appropriate for CF patients as they often need more calories and nutrients due to the increased energy requirements from the disease.

🍽️ A high-calorie diet supports growth and helps maintain body weight and strength.

Playing on the backyard swings and running around outside are exercises our child will really enjoy

🍽️ Physical activity is essential for children with cystic fibrosis to help with lung function and overall health.

🍽️ CF patients can benefit from exercise that promotes mobility and respiratory health.

Three to four times a day we will perform chest therapy and postural drainage on our child

🍽️ Chest therapy and postural drainage are key interventions to clear mucus from the lungs and improve breathing.

🍽️ This statement is correct as chest physiotherapy is crucial for managing lung function in children with CF.

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Answer 3

Correct Answers:

Encourage the client to empty her bladder.

Rationale :

💡 A firm fundus located at the umbilical level and in the midline suggests that uterine tone is adequate.

💡 The presence of large amounts of lochia rubra and small clots may indicate uterine congestion or retained blood that is common immediately postpartum.

💡 Full bladder can displace the uterus and impair its ability to contract effectively, potentially leading to increased lochia flow and clot formation.

💡 Encouraging the client to empty her bladder helps the uterus contract more effectively and reduces the risk of excessive bleeding.

💡 This action is the most appropriate next step to help manage bleeding and support uterine recovery.

Increase the frequency of fundal massage.

💡 Fundal massage is typically indicated if the uterus is boggy or soft, but the fundus is already firm.

💡 Over-massaging a firm fundus can be counterproductive and cause trauma to the uterine tissue.

Document the findings and continue to monitor the client.

💡 While monitoring is important, this approach overlooks the potential impact of a full bladder on uterine tone.

💡 Addressing the bladder issue first may prevent further complications related to bleeding.

Notify the provider immediately.

💡 There is no immediate indication that this situation requires a provider’s urgent intervention since the fundus is firm and in the midline.

💡 Monitoring and bladder emptying are appropriate initial steps before involving the provider.

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Answer 4

Correct Answers:

Document the findings in the electronic health record

Rationale :

📝 The blue-gray discoloration across the sacrum is likely a mongolian spot, a common and benign birthmark often seen in newborns, especially in infants of Asian descent.

📝 These spots are not painful or harmful and typically fade over time, usually disappearing by the age of 4–5 years.

📝 Mongolian spots are not a sign of abuse and should not trigger concerns like bruising might in other areas.

📝 The nurse should document the finding in the electronic health record to ensure accurate communication and record-keeping for future reference.

📝 This documentation also serves as a point of reference to avoid misinterpretation by other healthcare providers in the future.

Report parents to Child Protective Services

📝 Mongolian spots are a common and non-abusive finding, especially in newborns of certain ethnic backgrounds.

📝 There is no need to report abuse unless there is additional concern or evidence beyond normal physical findings.

Notify the healthcare provider

📝 While the healthcare provider should be informed about any unusual findings, mongolian spots do not require immediate concern or intervention.

📝 It is typically safe to document the finding without needing to immediately notify the healthcare provider unless further abnormal signs appear.

Review clotting studies lab report

📝 The presence of mongolian spots does not correlate with any clotting disorder or abnormal findings.

📝 There is no clinical indication that a clotting study is necessary for this observation.

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Answer 5

Correct Answers:

Pain

Rationale :

💉 Pain is the hallmark symptom of sickle cell crisis, which occurs when sickled red blood cells obstruct blood flow, causing ischemia and intense pain in the affected areas.

💉 The pain typically occurs in bones, joints, and abdomen and can range from mild to severe.

💉 This crisis occurs in episodes and can last for hours to days, often requiring opioid analgesics for pain management.

💉 Pain is a direct result of hypoxia, ischemia, and microvascular occlusion due to sickled cells blocking blood vessels.

💉 Managing pain during a sickle cell crisis is a priority intervention for improving the patient's comfort and preventing further complications.

Bradycardia

💉 Bradycardia is not a typical sign of sickle cell crisis.

💉 The body often compensates for pain and hypoxia with tachycardia (increased heart rate) to improve oxygen delivery.

High fever

💉 A fever can occur with infections, but it is not a hallmark of sickle cell crisis unless infection is present as a complication.

💉 Sickle cell crisis itself typically causes pain, not a fever, unless there is an associated infection or inflammation.

Constipation

💉 Constipation is not a defining feature of sickle cell crisis.

💉 While medication use or dehydration may contribute to constipation, pain is the primary concern in a sickle cell crisis.

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Answer 6

Correct Answers:

Massage the fundus until it firms

Rationale :

💠 A soft and spongy fundus indicates that the uterus is not contracted, which can lead to uterine atony and postpartum hemorrhage.

💠 The first intervention in this case is to massage the fundus to stimulate uterine contraction and help the uterus firm up, reducing the risk of excessive bleeding.

💠 Massaging the fundus encourages the release of oxytocin, which enhances uterine tone and helps prevent hemorrhage.

💠 If the fundus does not firm after massage, further interventions, such as administering oxytocin, may be necessary to support uterine contraction.

💠 Firming the fundus is a key step in ensuring the postpartum uterus remains contracted and minimizes the risk of complications.

Notify the healthcare provider

💠 While notifying the provider is important if the condition does not improve with massage, the immediate first step is to attempt massage to promote uterine contraction.

💠 Waiting for the provider could delay the necessary intervention to address uterine atony and potential hemorrhage.

Administer Oxytocin IV per MD orders

💠 Oxytocin may be necessary if the fundus does not firm after massage, but it is not the first intervention.

💠 Fundal massage is the first step, as it can often stimulate the uterus to contract on its own before medication is needed.

Document the fundal height and consistency

💠 Documentation is important but does not address the immediate issue.

💠 The priority action is to massage the fundus to initiate uterine contraction, not simply document the findings.

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Answer 7

Correct Answers:

This position prevents stomach juice from going into the lungs

Rationale :

💠 Elevating the head at a 45-degree angle in an infant with a tracheoesophageal fistula (TEF) is critical to prevent aspiration.

💠 The elevated head position helps reduce the risk of gastric contents or stomach acid from entering the lungs, which could lead to aspiration pneumonia or further respiratory complications.

💠 This position also allows gravity to help keep the stomach contents in the stomach, especially when feeding is introduced.

💠 Preventing aspiration is a key concern for infants with a TEF because of the abnormal connection between the trachea and esophagus.

💠 The mother's understanding of this position demonstrates awareness of how it prevents potential complications related to stomach contents entering the lungs.

This position keeps pressure off the stomach

💠 While this position may have some effect on the stomach's contents, the primary reason for the positioning is to prevent aspiration, not just reduce pressure.

💠 The focus is on keeping gastric juices from entering the lungs, rather than relieving pressure on the stomach.

This position helps my baby breathe better by opening the lungs

💠 While an elevated head position can help with breathing, the primary purpose for this position in TEF is to prevent aspiration rather than directly improving lung function.

💠 The position is more about preventing gastric reflux than improving lung expansion.

This position allows food to be easily digested by the stomach

💠 The position may help with digestion by promoting gravity drainage, but the most important reason for the 45-degree angle is to prevent stomach contents from entering the airway.

💠 The main concern is preventing aspiration rather than facilitating digestion.

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Answer 8

Correct Answers:

Accurately measure intake and output
Provide for several periods of uninterrupted rest
Encourage periods of bonding
Maintain a thermoneutral environment

Rationale :

💠 It is important to measure intake and output for infants following cardiac surgery, including the repair of an atrial septal defect (ASD). This helps to monitor for fluid retention, kidney function, and the infant’s cardiovascular status post-surgery.

💠 Close monitoring ensures that any electrolyte imbalances or complications related to fluid management are detected early and managed appropriately.

💠 This intervention is a key part of the post-operative care in assessing the infant's renal function and response to surgery.

💠 Accurate measurement allows the healthcare team to make informed decisions regarding fluid management and medication dosing.

💠 Provide for several periods of uninterrupted rest

💠 Following surgery, the infant needs ample rest to allow the body to heal and reduce the demand on the cardiovascular system.

💠 Uninterrupted rest promotes optimal healing and reduces the stress on the body as it recovers from surgery.

💠 Reducing stimulation during the recovery phase helps the infant conserve energy and promote healing of the surgical site.

💠 Limiting activity is important to prevent strain on the heart during the early post-operative period.

Encourage periods of bonding

💠 Bonding with the parents is essential for emotional and psychological well-being, even for an infant recovering from cardiac surgery.

💠 Positive parent-child interaction helps to improve the infant’s overall development and can have beneficial effects on the infant's stress levels.

💠 Encouraging bonding also strengthens the parent's role in the care process, which is important for both emotional support and confidence in managing the infant’s recovery.

Maintain a thermoneutral environment

💠 Thermoregulation is crucial for infants, especially after surgery. Maintaining a thermoneutral environment helps prevent the body from expending extra energy to maintain body temperature.

💠 This is particularly important in infants who are more susceptible to temperature fluctuations, which can lead to stress and compromise healing after surgery.

💠 Ensuring the infant is in a stable temperature environment promotes better healing, comfort, and overall well-being.

Incentive spirometer 10 times every hour

💠 An incentive spirometer is typically used for older children or adults to encourage deep breathing and prevent atelectasis after surgery.

💠 Infants do not typically use an incentive spirometer as part of their post-operative care due to their size and developmental stage.

💠 Instead, gentle encouragement of breathing through swaddling or positioning, along with proper rest, is the preferred intervention for infants.

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Answer 9

Correct Answers:

0.3

Rationale :

Step 1: Convert the child's weight from pounds to kilograms.

1 kg = 2.2 pounds

Child's weight = 19 pounds

Weight in kg = 19 / 2.2 = 8.64 kg

Step 2: Calculate the total daily dose of Lanoxin.

Prescribed dose = 0.07 mg/kg/day

Total daily dose = 0.07 mg × 8.64 kg = 0.6048 mg/day

Step 3: Divide the total daily dose into two doses.

Dose per administration = 0.6048 mg / 2 = 0.3024 mg

Step 4: Round to the nearest appropriate dose.

Dose per administration = 0.3 mg

Final answer: The maximum dose to administer per dose = 0.3 mg

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Answer 10

Correct Answers:

"I play games with my child every day to keep them as independent as possible"
"I use utensils with large, padded handles to help my child feed themselves more easily."

Rationale :

💠 "I play games with my child every day to keep them as independent as possible."

💠 Playing games and encouraging independence is an essential part of the care plan for a child with spastic cerebral palsy. Engagement in activities that promote independence fosters emotional well-being, improves motor skills, and helps the child develop self-confidence.

💠 It is important to focus on the child's strengths and abilities, as this helps build self-esteem and provides opportunities for socialization and learning.

💠 "I use utensils with large, padded handles to help my child feed themselves more easily."

💠 Using adaptive equipment like large, padded handles for utensils is a great way to help the child with spastic cerebral palsy develop fine motor skills and become more independent in daily activities like eating.

💠 This intervention helps improve functionality and reduces the frustration that might come from difficulty with self-feeding, ultimately enhancing the child's quality of life.

"I perform range of motion exercises every 4 hours to help prevent contractures."

💠 While performing range of motion (ROM) exercises is important to prevent contractures, they should typically be done more frequently and according to the child's specific needs as prescribed by the healthcare provider or physical therapist.

💠 ROM exercises should be tailored to the child's level of mobility and comfort to ensure that they are both effective and safe.

"I limit my child's interactions with peers to avoid overstimulation and frustration."

💠 It is important for children with cerebral palsy to have social interactions with peers to promote social development and prevent isolation. Limiting social interactions can lead to emotional and social challenges.

💠 Although stimulation should be managed, it is critical to offer a balanced environment where the child can socialize and learn to cope with different stimuli.

"I give my child carbidopa so that they will stop drooling."

💠 Carbidopa is typically used in combination with levodopa to treat symptoms of Parkinson's disease and is not generally used to address drooling in children with spastic cerebral palsy.

💠 Anticholinergic medications or botulinum toxin may be more appropriate for managing excessive drooling, but this should be guided by a healthcare provider.

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Custom NUR209 Final Assessment SP1.2026

No.

1 :
The following newborns are three-hours old and are sleeping. The registered nurse should notify the provider about which newborn?

2 :
The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home. Which statement made by the parents suggests that additional education is necessary?

3 :
A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad. The client's fundus is firm and located at the umbilical level, in the midline. What action should the nurse take next?

4 :
When preforming an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

5 :
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

6 :
A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?

7 :
The nurse places an infant with a tracheoesophageal fistula under a radiant warmer with the infant's head elevated at a 45-degree angle. Which statement by the mother indicates an understanding of the most important reason for this position?

8 :
The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

9 :
A child with a heart defect has been prescribed a maintenance dose of Lanoxin elixir at 0.07 mg/kg/day, divided into two doses. The child weighs 19 pounds. What is the maximum dose of medication the nurse should administer in each dose?

10 :
Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)

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Custom NUR209 Final Assessment SP1.2026

No.

1 : The following newborns are three-hours old and are sleeping. The registered nurse should notify the provider about which newborn?

2 : The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home. Which statement made by the parents suggests that additional education is necessary?

3 : A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad. The client's fundus is firm and located at the umbilical level, in the midline. What action should the nurse take next?

4 : When preforming an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

5 : A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

6 : A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?

7 : The nurse places an infant with a tracheoesophageal fistula under a radiant warmer with the infant's head elevated at a 45-degree angle. Which statement by the mother indicates an understanding of the most important reason for this position?

8 : The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

9 : A child with a heart defect has been prescribed a maintenance dose of Lanoxin elixir at 0.07 mg/kg/day, divided into two doses. The child weighs 19 pounds. What is the maximum dose of medication the nurse should administer in each dose?

10 : Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)

1 :
The following newborns are three-hours old and are sleeping. The registered nurse should notify the provider about which newborn?

2 :
The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home. Which statement made by the parents suggests that additional education is necessary?

3 :
A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad. The client's fundus is firm and located at the umbilical level, in the midline. What action should the nurse take next?

4 :
When preforming an initial assessment on a full-term infant whose parents are Asian, the nurse notes a blue-gray discoloration across the sacrum of the newborn. What is the most appropriate action for the nurse to take?

5 :
A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect?

6 :
A nurse is assessing the fundus of a postpartum client one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to preform?

7 :
The nurse places an infant with a tracheoesophageal fistula under a radiant warmer with the infant's head elevated at a 45-degree angle. Which statement by the mother indicates an understanding of the most important reason for this position?

8 :
The nurse is caring for an infant following the surgical repair of an atrial septal defect. Which nursing interventions are appropriate for this infant? (Select All that Apply.)

9 :
A child with a heart defect has been prescribed a maintenance dose of Lanoxin elixir at 0.07 mg/kg/day, divided into two doses. The child weighs 19 pounds. What is the maximum dose of medication the nurse should administer in each dose?

10 :
Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)