A nurse is caring for a preterm newborn who has a nasogastric tube and who recently began intermittent gavage feedings of formula. The nurse notes increased abdominal distention, lethargy, bloody stools, and increasing gastric residuals before feedings. The nurse should suspect which of the following?

Intraventricular hemorrhage

Need for placement of a gastrostomy tube

Overstimulation

Necrotizing enterocolitis

Answer and Explanation

The Correct Answer is D

A. Intraventricular hemorrhage presents with neurological signs like apnea or seizures, not primarily gastrointestinal symptoms.
B. Increased gastric residuals alone may indicate a need for tube placement, but the full symptom set suggests NEC.
C. Overstimulation may cause irritability but does not typically result in bloody stools or abdominal distension.
D. NEC is a life-threatening gastrointestinal disorder in preterm infants characterized by intestinal inflammation, abdominal distension, lethargy, bloody stools, and increased gastric residuals. Immediate intervention is necessary.

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Correct Answer is D

Explanation

A. Elevated hemoglobin and bilirubin: These findings are more consistent with jaundice or polycythemia, not sepsis.
B. Acrocyanosis and unstable thermoregulation: Acrocyanosis is normal in newborns; thermoregulation issues are concerning but nonspecific for sepsis.
C. Generalized mottling and uncoordinated suck: These may occur in sepsis but are less specific compared to lethargy and pallor.
D. Lethargy and pallor: These are classic signs of neonatal sepsis, a potentially life-threatening condition requiring immediate intervention.

A. "We will not wash the circumcision area until it is healed." B. "We will retract the remaining foreskin to clean around the shaft of the penis." C. "We will notify the pediatrician if we notice any bright red bleeding." D. "We will gently scrub off the yellow crusted area as it heals."

Correct Answer is C

Explanation

A. The circumcision area should be gently cleaned with warm water, not avoided.

B. Retraction of the foreskin is inappropriate as the foreskin is removed during circumcision.

C. Bright red bleeding is abnormal and requires immediate medical attention.

D. The yellow crust is part of normal healing and should not be scrubbed off.

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Naxlex Comprehensive Predictor Exams

A 1-day old newborn was born to a mother who had positive vaginal cultures for Group Beta Strep. The mother was only in labor for 1 hour prior to birth. What findings would indicate possible neonatal sepsis?

Correct Answer is D

Explanation

The nurse is reinforcing education about circumcision care. Which statement by the parents demonstrates an understanding?

Correct Answer is C

Explanation

A 3-day-old infant is slightly jaundiced and has an elevated bilirubin level. What is the most probable cause for these changes?

The nurse is assessing a term newborn and finds a rash of firm pustules with a red base on the face and trunk. Based on the assessment findings, the nurse determines this about the rash:

A nurse is reinforcing teaching about newborn care with a postpartum client. Which of the following statements by the client indicates a need for further teaching?

Newborn heat loss through evaporation can be reduced by:

A nurse admitted a neonate born less than 2 hours ago to a mother with gestational diabetes. The neonate weighs 4.5 kg. What is the priority nursing action for this neonate?

The nurse completing a gestational exam using the Ballard assessment tool understands that this assesses which two maturity components?

A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

The nurse is caring for a 26-week-gestation infant diagnosed with periventricular hemorrhage and currently intubated. What is the most appropriate nursing action(s) for this infant?