NURS368 Final Exam

A baby has just been born to a type 1 diabetic mother with retinopathy and nephropathy. Which of the following neonatal findings would the nurse expect to see? A. Hyperalbuminemia. B. Polycythemia. C. Hypercalcemia. D. Hypoinsulinemia.

B. Polycythemia. Because the placenta is likely to be functioning less than optimally, it is highly likely that the baby will be polycythemic. The increase in red blood cells would improve the baby's oxygenation in utero.

Which finding should the nurse expect when assessing a client with placenta previa? A. Severe occipital headache. B. History of renal disease. C. Previous premature delivery. D. Painless vaginal bleeding.

D. Painless vaginal bleeding.

The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? a. Alcohol b. Tobacco c. Marijuana d. Heroin

a. Alcohol

In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect: a. Hypovolemia and/or shock. b. A nonneutral thermal environment. c. Central nervous system injury. d. Pending renal failure.

a. Hypovolemia and/or shock. (The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.)

While completing a newborn assessment, the nurse should be aware that the most common birth injury is: a. To the soft tissues. b. Caused by forceps gripping the head on delivery. c. Fracture of the humerus and femur. d. Fracture of the clavicle.

d. Fracture of the clavicle. (The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.)

6. A 6-month-old child developed kernicterus immediately after birth. Which of the following tests should be done to determine whether or not this child has developed any sequelae to the illness? 1. Blood urea nitrogen and serum creatinine. 2. Alkaline phosphotase and bilirubin. 3. Hearing and vision assessments. 4. Peak expiratory flow and blood gas assessments

3. Hearing and vision assessments. Because the central nervous system (CNS) may have been damaged by the high bilirubin levels, testing of the senses as well as motor and cognitive assessments are appropriate.

A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first? A. Assess deep tendon reflexes. B. Obtain complete blood count. C. Assess baseline weight. D. Obtain routine urinalysis.

A. Assess deep tendon reflexes. The nurse should check the client's patellar reflexes. The most common way to assess the deep tendon reflexes is to assess the patellar reflexes. Preeclampsia is a very serious complication of pregnancy. The nurse must assess for changes in the blood count, for evidence of marked weight gain, and for changes in the urinalysis. By assessing the patellar reflexes first, however, the nurse can make a preliminary assessment of the severity of the preeclampsia. For example, if the reflexes are 2, the client would be much less likely to become eclamptic than a client who has 4 reflexes with clonus.

A 6-month-old child is being seen in the pediatrician's office. The child was born preterm and remained in the neonatal intensive care unit for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to the prematurity? Select all that apply. A. Bronchopulmonary dysplasia. B. Cerebral palsy. C. Retinopathy. D. Hypothyroidism. E. Seizure disorders

A. Bronchopulmonary dysplasia. B. Cerebral palsy. C. Retinopathy. E. Seizure disorders

A client with 4+ protein and 4+ reflexes is admitted to the hospital with severe preeclampsia. The nurse must closely monitor the woman for which of the following? A. Grand mal seizure. B. High platelet count. C. Explosive diarrhea. D. Fractured pelvis.

A. Grand mal seizure. A client who is diagnosed with severe preeclampsia is high risk for becoming eclamptic. Clients who become eclamptic have had at least one seizure.

In anticipation of a complication that may develop in the second half of pregnancy, the nurse teaches an 18-week gravid client to call the office if she experiences which of the following? A. Headache and decreased output. B. Puffy feet. C. Hemorrhoids and vaginal discharge. D. Backache.

A. Headache and decreased output. Headache and decreased output are signs of preeclampsia. It is important for the test taker to realize that, although some symptoms like puffy feet may seem significant, they are normal in pregnancy, while other symptoms like headache, which in a nonpregnant woman would be considered benign, may be potentially very important in a pregnant woman.

A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome. Which of the following signs/symptoms is the nurse observing? Select all that apply. A. Hyperphagia. B. Lethargy. C. Prolonged periods of sleep. D. Hyporeflexia. E. Persistent shrill cry.

A. Hyperphagia. E. Persistent shrill cry. Babies with signs of neonatal abstinence syndrome repeatedly exhibit signs of hunger. Babies with signs of neonatal abstinence syndrome often have a shrill cry that may continue for prolonged periods.

A baby was just born to a mother who had positive vaginal cultures for group B streptococcus. The mother was admitted to the labor room 2 hours before the birth. For which of the following should the nursery nurse closely observe this baby? A. Hypothermia. B. Mottling. C. Omphalocele. D. Stomatitis.

A. Hypothermia. Hypothermia in a neonate may be indicative of sepsis. Group B streptococci can seriously adversely affect neonates. In fact, group B strep has been called "the baby killer." To prevent a severe infection from the bacteria, mothers are given intravenous antibiotics every 4 hours from admission, or from rupture of membranes, until delivery. A minimum of 2 doses is considered essential to protect the baby. Since this woman arrived only 2 hours prior to the delivery, there was not enough time for 2 doses to be administered.

A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. A. Perform hemoccult test on stools. B. Monitor for an increase in abdominal girth. C. Measure gastric contents before each feed. D. Assess bowel sounds before each feed. E. Assess for anal fissures daily.

A. Perform hemoccult test on stools. B. Monitor for an increase in abdominal girth. C. Measure gastric contents before each feed. D. Assess bowel sounds before each feed.

Based on maternal history of alcohol addiction, a baby in the neonatal nursery is being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess this baby for which of the following? A. Poor suck reflex. B. Ambiguous genitalia. C. Webbed neck. D. Absent Moro reflex

A. Poor suck reflex. The characteristic facial signs of fetal alcohol syndrome— shortened palpebral (eyelid) fissures, thin upper lip, and hypoplastic philtrum (median groove on the external surface of the upper lip)—are rarely evident in the neonatal period. They typically appear later in the child's life. Rather the behavioral characteristics of the FAS baby, such as weak suck, irritability, tremulousness, and seizures, are present at birth.

Four full-term babies were admitted to the neonatal nursery. The mothers of each of the babies had labors of 4 hours or less. The nursery nurse should carefully monitor which of the babies for hypothermia? A. The baby whose mother cultured positive for group B strep during her third trimester. B. The baby whose mother had gestational diabetes. C. The baby whose mother was hospitalized for 3 months with complete placenta previa. D. The baby whose mother previously had a stillbirth.

A. The baby whose mother cultured positive for group B strep during her third trimester. Group B streptococcus causes severe infections in the newborn. A sign of neonatal sepsis is hypothermia.

A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? A. Tightly swaddle the baby. B. Place the baby prone in the crib. C. Provide needed stimulation to the baby. D. Feed the baby half-strength formula.

A. Tightly swaddle the baby. Tightly swaddling drug-addicted babies often helps to control the hyperreflexia that they may exhibit.

A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother has which of the following blood types? A. Type O negative. B. Type A negative. C. Type B positive. D. Type AB positive.

A. Type O negative. A mother whose blood type is O, the blood type that is antigen negative, will produce anti-A and/or antiB antibodies against blood types A and/or B, respectively. The anti-A (and/or anti-B) that passes into the baby's bloodstream via the placenta can attack the baby's red blood cells if he or she is type A or B. As a result of the blood cell destruction, the baby becomes jaundiced.

Which type of IUGR has better developmental outcomes? A: Asymmetric B: Symmetric

A: Asymmetric Weight is the only abnormal measurement

Which intervention is the most important to prevent necrotizing enterocolitis? A: Exclusive human milk feeding B: Surfactant C: Oxygen D: Ventilator support

A: Exclusive human milk feeding

Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? A. 30-week gestation with prolapsed mitral valve (PMV). B. 32-week gestation with urinary tract infection (UTI). C. 34-week gestation with gestational diabetes (GDM). D. 36-week gestation with deep vein thrombosis (DVT).

B. 32-week gestation with urinary tract infection (UTI). Although the exact mechanism is not well understood, clients who have urinary tract infections are high risk for PPROM. This is particularly important since pregnant clients often have urinary tract infections that present either with no symptoms at all or only with urinary frequency, a complaint of many pregnant clients.

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lbs 2 oz, 21 inches long, TPR: 96.6ºF, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following actions should the nurse perform first? A. Swaddle the baby to provide warmth. B. Assess the glucose level of the baby. C. Take the baby to the mother for feeding. D. Administer the neonatal medications

B. Assess the glucose level of the baby. The test taker should note that this baby is macrosomic and hypothermic, both of which make the baby at high risk for hypoglycemia. Plus, jitters are a classic symptom in hypoglycemic babies. In order to make an accurate assessment of the problem, the baby's glucose level must be assessed.

A newborn nursery nurse notes that a baby's body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? A. Maintain a warm ambient environment. B. Have the mother feed the baby frequently. C. Have the mother hold the baby skin to skin. D. Place the baby naked by a closed sunlit window

B. Have the mother feed the baby frequently. Bilirubin is excreted through the bowel. The more the baby consumes, the more stools, and therefore the more bilirubin the baby will expel.

A neonate is in the warming crib for poor thermoregulation. Which of the following sites is appropriate for the placement of the skin thermal sensor? A. Xiphoid process. B. Forehead. C. Abdominal wall. D. Great toe.

C. Abdominal wall. It is essential that the test taker be prepared safely to perform relatively simple procedures for the premature infant. To monitor the temperature of the premature, the probes should be placed on a nonbony and wellperfused tissue site. The abdominal wall is the site of choice.

A 42-week gravida is delivering her baby. A nurse and pediatrician are present at the birth. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? A. Stimulate the baby to breathe. B. Assess neonatal heart rate. C. Assist with intubation. D. Place the baby in the prone position.

C. Assist with intubation. Before breathing, the baby must be intubated so that the meconium-contaminated fluid can be aspirated from the baby's airway.

Which of the following findings should the nurse expect when assessing a client, 8 weeks' gestation, with gestational trophoblastic disease (hydatiform mole)? A. Protracted pain. B. Variable fetal heart decelerations. C. Dark brown vaginal bleeding. D. Suicidal ideations

C. Dark brown vaginal bleeding. The condition is usually diagnosed after a client complains of brown vaginal discharge early in the "pregnancy."

A neonate, whose mother is HIV positive, is admitted to the NICU. A nursing diagnosis: Risk for infection related to perinatal exposure to HIV/AIDS is made. Which of the following interventions should the nurse make in relation to the diagnosis? A. Monitor daily viral load laboratory reports. B. Check the baby's viral antibody status. C. Obtain an order for antiviral medication. D. Place the baby on strict precautions

C. Obtain an order for antiviral medication. The standard of care for neonates born to mothers with HIV/AIDS is to begin them on anti-AIDS medication in the nursery. The mother will be advised to continue to give the baby the medication after discharge.

A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? A. Thrombocytopenia. B. Neutropenia. C. Polycythemia. D. Hyperglycemia

C. Polycythemia. Even if the test taker were unfamiliar with the expected lab findings of a neonate that had been born after living with an aging placenta, deductive reasoning could assist the test taker to choose the correct response. Aging placentas function poorly, and therefore the fetuses receive less nutrition and oxygenation. The baby's body, therefore, must compensate for the losses by metabolizing glycogen stores in the liver and producing increased numbers of red blood cells. The neonate, therefore, is often polycythemic and hypoglycemic.

A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal factors would predispose the baby to this diagnosis? Select all that apply. A. Hyperopia. B. Gestational diabetes. C. Substance abuse. D. Chronic hypertension. E. Advanced maternal age.

C. Substance abuse. D. Chronic hypertension. E. Advanced maternal age. Any condition that inhibits the flow of blood, including illicit drug use, hypertension, cigarette smoking, and the like, can lead to fetal IUGR—that is, a fetus smaller than expected for the gestational period.

Surfactant replacement therapy is used in the medical management of: A: Bronchopulmonary dysplasia (BPD) B: Patent ductus arteriosus (PDA) C: Respiratory distress syndrome (RDS) D: Necrotizing enterocolitis (NEC)

C: Respiratory distress syndrome (RDS)

A 26-week-gestation woman is diagnosed with severe preeclampsia with HELLP syndrome. The nurse will assess for which of the following signs/symptoms? A. Low serum creatinine. B. High serum protein. C. Bloody stools. D. Epigastric pain.

D. Epigastric pain. When the liver is deprived of sufficient blood supply, as can occur with severe preeclampsia, the organ becomes ischemic. The client experiences pain at the site of the liver as a result of the hypoxia in the liver.

A 12-week-gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. What should the nurse assess this client for? A. Shortness of breath. B. Enlarging abdominal girth. C. Hyperreflexia and clonus. D. Fetal heart dysrhythmias

D. Fetal heart dysrhythmias This client is showing signs of spontaneous abortion. The nurse should check the fetal heart rate. It is essential that the test taker carefully read the weeks of gestation when answering this question. If the client were in the third trimester, it would be appropriate to check the fetal heart as well as to monitor for increasing abdominal girth measurements. At 12 weeks, however, the latter assessment is not appropriate.

A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following? A. Severe anemia. B. Hypoprothrombinemia. C. Craniosynostosis. D. Intrauterine growth restriction.

D. Intrauterine growth restriction. Perfusion to the placenta drops when clients are preeclamptic because the client's hypertension impairs adequate blood flow. When the placenta is poorly perfused, the baby is poorly nourished. Without the nourishment provided by the mother through the umbilical vein, the fetus' growth is affected

32. A woman, 8 weeks pregnant, is admitted to the obstetric unit with a diagnosis of threatened abortion. Which of the following tests would help to determine whether the woman is carrying a viable or a nonviable pregnancy? A. Luteinizing hormone level. B. Endometrial biopsy. C. Hysterosalpinogram. D. Serum progesterone level.

D. Serum progesterone level. One relatively easy way to determine the viability of the conceptus is by performing a serum progesterone test; high levels indicate a viable baby while low levels indicate a pregnancy loss. Ultrasonography to assess for a beating heart may also be performed.

A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b. "The drug keeps your baby from requiring too much sedation." c. "Surfactant is used to reduce episodes of periodic apnea." d. "Your baby needs this medication to fight a possible respiratory tract infection."

a. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." (Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.)

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse's best response would be: a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby."

a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." (Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their children. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the woman's husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.)

A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol b. Cocaine c. Heroin d. Marijuana

a. Alcohol (The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.)

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (Select all that apply): a. Amphetamine. b. Heroin. c. Nicotine. d. PCP. e. Morphine.

a. Amphetamine. b. Heroin. c. Nicotine. d. PCP. (Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.)

An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment? a. Extracorporeal membrane oxygenation b. Respiratory support with a ventilator c. Insertion of a laryngoscope and suctioning of the trachea d. Insertion of an endotracheal tube

a. Extracorporeal membrane oxygenation (Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, thus allowing the infant's lungs to rest and recover. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath. An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation.)

The most important nursing action in preventing neonatal infection is: a. Good handwashing. b. Isolation of infected infants. c. Separate gown protocol d. Standard Precautions.

a. Good handwashing. (Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.)

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. b. Erb palsy is damage to the lower plexus. c. Parents of children with brachial palsy are taught to pick up the child from under the axillae. d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. (If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.)

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action would be to: a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. b. Continue to observe and make no changes until the saturations are 75%. c. Continue with the admission process to ensure that a thorough assessment is completed. d. Notify the parents that their infant is not doing well.

a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. (Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.)

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate: a. Meconium aspiration, hypoglycemia, and dry, cracked skin. b. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome. c. Golden yellow- to green stained-skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat. d. Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.

a. Meconium aspiration, hypoglycemia, and dry, cracked skin. (Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.)

A careful review of the literature on the various recreational and illicit drugs reveals that: a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. b. Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not. c. Mothers should discontinue heroin use (detox) any time they can during pregnancy. d. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. (Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More long-range studies are needed. Just about all these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.)

Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply): a. Polycythemia. b. Anemia. c. Congenital heart disease. d. Bronchopulmonary dysphasia. e. Retinopathy.

a. Polycythemia. b. Anemia. c. Congenital heart disease. (Risk factors for NEC include asphyxia, respiratory distress syndrome, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus, congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection.)

Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply): a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

a. Problems with thermoregulation b. Cardiac distress d. Sepsis (Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. AWHONN launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.)

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.

b. Abdominal distention, temperature instability, and grossly bloody stools. (Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.)

Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC: a. Early enteral feedings b. Breastfeeding c. Exchange transfusion d. Prophylactic probiotics

b. Breastfeeding (A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn's disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.)

A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse's most appropriate action would be to: a. Wait quietly at the newborn's bedside until the parents come closer. b. Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn. c. Leave the parents at the bedside while they are visiting so they can have some privacy. d. Tell the parents only about the newborn's physical condition, and caution them to avoid touching their baby.

b. Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn. (The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents "see" the infant, rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents only about the newborn's physical condition and cautioning them to avoid touching their baby is an inappropriate action.)

The most common cause of pathologic hyperbilirubinemia is: a. Hepatic disease. b. Hemolytic disorders in the newborn. c. Postmaturity. d. Congenital heart defect.

b. Hemolytic disorders in the newborn. (Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.)

With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that: a. In the first trimester diseases or abnormalities result in asymmetric IUGR. b. Infants with asymmetric IUGR have the potential for normal growth and development. c. In asymmetric IUGR weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA. d. Symmetric IUGR occurs in the later stages of pregnancy.

b. Infants with asymmetric IUGR have the potential for normal growth and development. (IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.)

To provide optimal care of infants born to mothers who are substance abusers, nurses should be aware that: a. Infants born to addicted mothers are also addicted. b. Mothers who abuse one substance likely will use or abuse another, thus compounding the infant's difficulties. c. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. d. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

b. Mothers who abuse one substance likely will use or abuse another, thus compounding the infant's difficulties. (Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure.)

To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that: a. Congenital infection progresses more slowly than does nosocomial infection. b. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot. c. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. d. The clinical sign of a rapid, high fever makes infection easier to diagnose.

b. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot. (Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract and progress more rapidly than do nosocomial (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and are similar to those of noninfectious problems, thus making diagnosis difficult.)

The goal of treatment of the infant with phenylketonuria (PKU) is to: a. Cure mental retardation. b. Prevent central nervous system (CNS) damage, which leads to mental retardation. c. Prevent gastrointestinal symptoms. d. Cure the urinary tract infection.

b. Prevent central nervous system (CNS) damage, which leads to mental retardation. (CNS damage can occur as a result of toxic levels of phenylalanine. No known cure exists for mental retardation. Digestive problems are a clinical manifestation of PKU. PKU does not involve any urinary problems.)

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Bronchopulmonary dysplasia (BPD) d. Intraventricular hemorrhage (IVH)

b. Retinopathy of prematurity (ROP) (ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.)

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given prophylactically to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

c. "Erythromycin is given prophylactically to prevent a gonorrheal infection." (With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.)

An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant's mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurse's most appropriate response is: a. "Your baby will develop exactly like your first child did." b. "Your baby does not appear to have any problems at the present time." c. "Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing." d. "Your baby will need to be followed very closely."

c. "Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing." (The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby does not appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.)

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. (Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.)

Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: a. Gonorrhea. b. Herpes simplex virus infection. c. Congenital syphilis. d. Human immunodeficiency virus.

c. Congenital syphilis. (The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities.)

The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. This intervention: a. Is adopted from classical British nursing traditions. b. Helps infants with motor and central nervous system impairment. c. Helps infants to interact directly with their parents and enhances their temperature regulation. d. Gets infants ready for breastfeeding.

c. Helps infants to interact directly with their parents and enhances their temperature regulation. (Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.)

An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. Birth injury. b. Hypocalcemia. c. Hypoglycemia d. Seizures.

c. Hypoglycemia (Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.)

As related to central nervous system injuries that could occur to the infant during labor and birth, nurses should be aware that: a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. c. In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests. d. Spinal cord injuries almost always result from forceps-assisted deliveries.

c. In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests. (Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography scan may reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation.)

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: a. Decreased respiratory rate. b. Bradycardia followed by an increased heart rate. c. Mottled skin with acrocyanosis. d. Increased physical activity.

c. Mottled skin with acrocyanosis. (The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.)

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. Pharmacologic treatment. b. Reduction of environmental stimuli. c. Neonatal abstinence syndrome scoring. d. Adequate nutrition and maintenance of fluid and electrolyte balance.

c. Neonatal abstinence syndrome scoring. (Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates central nervous system (CNS), metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.)

As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that: a. Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home. b. Once discharged to home, the high risk infant should be treated like any healthy term newborn. c. Parents of high risk infants need special support and detailed contact information. d. If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

c. Parents of high risk infants need special support and detailed contact information. (High risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high risk infant should spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high risk infants are discharged does not mean that they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.)

For clinical purposes, preterm and post-term infants are defined as: a. Preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA). b. Post-term after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA. c. Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth. d. Preterm, SGA before 38 to 40 weeks, and post-term, LGA beyond 40 to 42 weeks.

c. Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth. (Preterm and post-term are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of size for gestational age.)

Infants of mothers with diabetes (IDMs) are at higher risk for developing: a. Anemia. b. Hyponatremia. c. Respiratory distress syndrome. d. Sepsis.

c. Respiratory distress syndrome. (IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.)

An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a. Rapid bolusing of the entire amount in 15 minutes b. Warm cloths to the abdomen for the first 10 minutes c. Slow, small, warm bolus feedings over 30 minutes d. Cold, medium bolus feedings over 20 minutes

c. Slow, small, warm bolus feedings over 30 minutes (Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Warm cloths to the abdomen for the first 10 minutes would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.)

A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. Administering chloral hydrate for sedation. b. Feeding every 4 to 6 hours to allow extra rest. c. Swaddling the infant snugly and holding the baby tightly. d. Playing soft music during feeding.

c. Swaddling the infant snugly and holding the baby tightly. (The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.)

On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give? a. "Parents are not allowed to hold infants who depend on oxygen." b. "You may hold only your baby's hand during the feeding." c. "Feedings cause more physiologic stress, so the baby must be closely monitored. Therefore, I don't think you should hold the baby." d. "You may hold your baby during the feeding."

d. "You may hold your baby during the feeding." ("You may hold your baby during the feeding" is an accurate statement. Parental interaction via holding is encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions. The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant. Swaddling or kangaroo care during feedings provides positive interactions for the infant.)

Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: a. Suffering from sleep or wakeful apnea. b. Experiencing severe swings in blood pressure. c. Trying to maintain a neutral thermal environment. d. Breathing in a respiratory pattern common to premature infants.

d. Breathing in a respiratory pattern common to premature infants. (This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.)

When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has: a. Few blood vessels visible through the skin. b. More subcutaneous fat. c. Well-developed flexor muscles. d. Greater surface area in proportion to weight.

d. Greater surface area in proportion to weight. (Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.)

What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection b. Tuberculosis c. Candidiasis d. Group B streptococcal infection

d. Group B streptococcal infection (Penicillin has significantly decreased the incidence of group B streptococcal infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and Canada. Candidiasis is a fairly benign fungal infection.)

A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse's most appropriate action is to: a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment to determine whether the infant is large for gestational age. d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

d. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia. (This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.)

Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? a. Delayed growth and development b. Ineffective thermoregulation c. Ineffective infant feeding pattern d. Risk for infection

d. Risk for infection (The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.)

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: a. Hypoglycemia. b. Phrenic nerve injury. c. Respiratory distress syndrome. d. Sepsis.

d. Sepsis. (The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.)

With regard to hemolytic diseases of the newborn, nurses should be aware that: a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions frequently are required in the treatment of hemolytic disorders. d. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

d. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth. (An indirect Coombs' test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.)

When providing an infant with a gavage feeding, which of the following should be documented each time? a. The infant's abdominal circumference after the feeding b. The infant's heart rate and respirations c. The infant's suck and swallow coordination d. The infant's response to the feeding

d. The infant's response to the feeding (Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infant's response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infant's response to the feeding (including attempts to suck).)

Human immunodeficiency virus (HIV) may be perinatally transmitted: a. Only in the third trimester from the maternal circulation. b. By a needlestick injury at birth from unsterile instruments. c. Only through the ingestion of amniotic fluid. d. Through the ingestion of breast milk from an infected mother.

d. Through the ingestion of breast milk from an infected mother. (Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.)