Chapter 23

A) obtain hemoglobin and hematocrit laboratory tests B) provide early feedings to prevent hypoglycemia C) maintain oxygen saturation parameters D) monitor urinary output

A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? Select all that apply A) obtain hemoglobin and hematocrit laboratory tests B) provide early feedings to prevent hypoglycemia C) maintain oxygen saturation parameters D) monitor urinary output E) insert a peripheral IV

C) appropriate-for-gestational-age (AGA) newborns

A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A) small-for-gestational-age (SGA) newborns B) large-for-gestational-age (LGA) newborns C) appropriate-for-gestational-age (AGA) newborns D) low-birth-weight newborns

B) "if our newborn's skin turns yellow, it is from the treatments and our newborn is okay"

A late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement? A) "we will call 911 if we start to see that our newborn's lips or skin are looking bluish" B) "if our newborn's skin turns yellow, it is from the treatments and our newborn is okay" C) "if our newborn does not have a wet diaper in 12 hours, we will call our pedaitrician" D) "we will let the pediatrician know if our newborn's temperature goes above 100.4 F (38 C)

A) wasted extremity appearance C) sunken abdomen E) narrow skull sutures

A nurse is assessing a newborn who has been classified as small for gestational age. Which characteristics would the nurse expect to find? Select all that apply. A) wasted extremity appearance B) increased amount of breast tissue C) sunken abdomen D) adequate muscle tone over buttocks E) narrow skull sutures

C) thin umbilical cord

A nurse is assessing a post-term newborn. Which finding would the nurse correlate with this gestational age variation? A) moist, supple, plum skin appearance B) abundant lanugo and vernix C) thin umbilical cord D) absence of sole creases

D) sudden high-pitched

A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a preterm newborn is in pain? A) bradycardia B) oxygen saturation level of 94% C) decreased muscle tone D) sudden high-pitched

D) "Forget about what's happened in the past, and focus on the now."

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A) "I'll be here to help you all along the way." B) "What has helped you to deal with stressful situations in the past?" C) "Let me tell you about what you will see when you visit your baby." D) "Forget about what's happened in the past, and focus on the now."

B) low birth weight

A nurse is conducting a class for expectant parents about newborns. As part of the class the nurse describes newborns with birth-weight variations. The nurse determines that the teaching was successful when the class identifies which variation if the newborn weighs 5.2 lb (2,358 g) at any gestational age? A) small for gestational age B) low birth weight C) very low birth weight D) extremely low birth weight

C) administer oxygen using an oxygen hood

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which measure will the nurse include in this plan? A) stimulate the infant with frequent handling B) keep the newborn in an open bassinet C) administer oxygen using an oxygen hood D) give intermittent tube feedings

A) clustering care to promote rest C) using kangaroo care E) providing nonnutritive sucking

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which measures would the nurse include? Select all that apply. A) clustering care to promote rest B) positioning newborn in extension C) using kangaroo care D) loosely covering the newborn with blankets E) providing nonnutritive sucking

A) preventing hypoglycemia with early feedings

A nurse is developing the plan of care for an small-for-gestational-age (SGA) newborn. Which action would the nurse determine as a priority? A) preventing hypoglycemia with early feedings B) observing for respiratory distress syndrome C) promoting bonding between the parents and the newborn D) monitoring vital signs every 2 hours

A) surfactant deficiency C) immaturity of the respiratory control centers

A nurse is preparing a presentation for a group of perinatal nurses about common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the nurse includes which factor as contributing to the newborn's risk? Select all that apply. A) surfactant deficiency B) placental deprivation C) immaturity of the respiratory control centers D) decreased amounts of brown fat E) depleted glycogen stores

A) Administer intravenous glucose

A nurse is providing care to a large for gestational age (LGA) newborn. The newborn's blood glucose level was 32 mg/dL one hour ago. Breast-feeding was initiated. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do next? A) Administer intravenous glucose B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer

C) Pain is frequently mistaken for irritability or agitation.

A nurse is reviewing a journal article about newborn pain prevention and management. Which information would the nurse most likely find discussed in the article? A) Newborn pain is frequently recognized and treated. B) Newborns rarely experience pain with procedures. C) Pain is frequently mistaken for irritability or agitation. D) Newborns may be less sensitive to pain than adult

B) diabetes

A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. Which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? A) drug abuse B) diabetes C) preeclampsia D) infection

A) shallow, slow respirations B) cyanotic hands and feet E) feeble cry

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which findings would support the nurse's suspicion? Select all that apply. A) shallow, slow respirations B) cyanotic hands and feet C) irritability D) hypertonicity E) feeble cry

A) ophthalmologist

A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? A) ophthalmologist B) nephrologist C) cardiologist D) neurologist

B) "We still need to monitor him closely for problems."

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

A) Dry the newborn thoroughly.

After a rapid assessment determines that a newborn is in need of resuscitation, the nurse would perform which action first? A) Dry the newborn thoroughly. B) Suction the airway. C) Administer ventilations. D) Give volume expanders

A) encourage frequent feedings

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next? A) encourage frequent feedings B) feed the newborn 2 ounces of dextrose water C) initiate blow-by oxygen therapy D) place the newborn under a radiant warmer

D) clear the airway with a bulb syringe

Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious secretions. The newborn is dried and placed under a radiant warmer. Which action would the nurse do next? A) intubate with an appropriate-sized endotracheal tube B) give chest compressions at a rate of 80 times per minute C) administer epinephrine intravenously D) clear the airway with a bulb syringe

C) deficiency of surfactant

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which factor? A) inability to clear fluids B) immature respiratory control center C) deficiency of surfactant D) smaller respiratory passages

B) flaying hands

The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which sign would the nurse be most likely to assess? A) increased respirations B) flaying hands C) eupnea D) increased heart rate

C) bulging fontanels

The nurse is assessing a preterm newborn's fluid and hydration status. Which finding would alert the nurse to possible overhydration? A) decreased urine output B) tachypnea C) bulging fontanels D) elevated temperature

B) late preterm.

The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the nurse's understanding of gestational age, the nurse identifies this newborn as: A) preterm. B) late preterm. C) term. D) post-term

D) greater body surface area in proportion to weight

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? A) fewer visible blood vessels through the skin B) more subcutaneous fat in the neck and abdomen C) well-developed flexor muscles in the extremities D) greater body surface area in proportion to weight

B) difficulty in arousing to a quiet alert state

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which characteristic would the nurse correlate with this gestational age variation? A) strong, brisk motor skills B) difficulty in arousing to a quiet alert state C) birthweight of 7 lb 14 oz (3,572 g) D) wasted appearance of extremities

C) Encourage the parents to touch their preterm newborn.

The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge

B) Provide opportunities for them to hold the newborn.

Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic

A) retinopathy of prematurity

While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which condition? A) retinopathy of prematurity B) metabolic acidosis C) infection D) cold stress