NCLEX TASK -1
1. A neonate weighing 1,503 g is born at 32 weeks’ gestation. During assessment 12 hours after birth, the nurse notices these signs and symptoms: hyperactivity, persistent shrill cry, frequent yawning and sneezing, and jitteriness. These symptoms indicate:
1. sepsis.
2. hepatitis.
3. drug dependence.
4. hypoglycemia.
2. A neonate was delivered 1 hour ago. He’s pink with acrocyanosis and exhibits occasional shivering movements of his upper extremities. Which nursing action should take priority?
1. Obtain vital signs.
2. Provide warmth with swaddling.
3. Perform a neurologic assessment.
4. Evaluate blood glucose.
3. A nurse is assessing a 4-hour-old neonate. Which finding should be a cause of concern?
1. Anterior fontanel is 3/4" (1.9 cm) wide, head is molded, and sutures are overriding.
2. Hands and feet are cyanotic, abdomen is rounded, and the neonate hasn’t voided or passed meconium.
3. Color is dusky, axillary temperature is 97° F (36.1° C), and the neonate is spitting up excessive mucus.
4. The neonate exhibits irregular abdominal respirations and intermittent tremors in the extremities.
4. Which neonate is at greatest risk for developing respiratory distress syndrome?
1. A neonate with a history of intrauterine growth retardation.
2. A neonate born at less than 35 weeks’ gestation
3. A neonate born at less than 35 weeks’ gestation A neonate whose mother experienced prolonged rupture of membranes
4.A neonate born at 38 weeks’ gestation
5. A nurse is doing a neurologic assessment on a 1-day-old neonate in the nursery. Which findings indicate possible asphyxia in utero? Select all that apply.
1.The neonate grasps the nurse’s finger when she puts it in the palm of his hand.
2. The neonate does stepping movements when help upright with the sole of his foot touching a surface.
3. The neonate’s toes don’t curl downward when the soles of his feet are stroked.
4. The neonate doesn’t respond when the nurse claps her hands above him.
5. The neonate turns toward the nurse’s finger when she touches his cheek.
6. The neonate displays weak, ineffective sucking.