Practice - High-Risk Newborn

65. The neonatalogist has ordered 12.5 micrograms of digoxin po for a neonate in congestive heart failure. The medication is available in the following elixir—-0.05 mg/mL. How many milliliters (mL) should the nurse administer? __________ mL.

0.25 mL 0.05 mg/mL = 12.5 microgram/x mL (0.05 mg = 50 microgram) 50/1 = 12.5/x 50 x = 12.5 x = 0.25 mL TIP: Digoxin is administered in very small dosages to infants and neonates. If the nurse calculates a quantity that is larger than 1 mL, it is very likely that the calculation is incorrect. The nurse should recalculate the quantity and, for safety safe, ask another nurse to check the arithmetic.

9. Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? 1. Hematocrit 24%. 2. Leukocyte count 45,000 cells/mm3. 3. Sodium 125 mEq/L. 4. Potassium 5.5 mEq/L.

1 1. The baby with erythroblastosis fetalis would exhibit signs of severe anemia, which a hematocrit of 24% reflects. 2. Erythroblastosis fetalis is not an infectious condition. Leukocytosis is not a part of the clinical picture. 3. Hyponatremia is not part of the disorder. 4. Hyperkalemia is not part of the disorder. TIP: The test taker must be familiar with the pathophysiology of Rh incompatibility. If a mother who is Rh negative has been sensitized to Rh positive blood, she will produce antibodies against the Rh positive blood. If she then becomes pregnant with an Rh positive baby, her anti-Rh antibodies will pass directly through the placenta into the fetal system. Hemolysis of fetal red blood cells results, leading to severe fetal anemia.

60. A baby has been admitted to the neonatal intensive care unit with a diagnosis of symmetrical intrauterine growth restriction. Which of the following pregnancy complications would be consistent with this diagnosis? 1. Severe preeclampsia. 2. Chromosomal defect. 3. Infarcts in an aging placenta. 4. Premature rupture of the membranes.

2 1. Severe preeclampsia is associated with asymmetrical IUGR. 2. Chromosomal abnormalities are associated with symmetrical IUGR. 3. An aging placenta is associated with asymmetrical IUGR. 4. PPROM is associated with asymmetrical IUGR. TIP: There is a distinct difference between symmetrical and asymmetrical IUGR. Babies with chromosomal defects often grow poorly from the time of conception. Their entire bodies, therefore, will grow poorly and will be small. Babies that are exposed to complications like preeclampsia or an aging placenta during the pregnancy will grow normally during the beginning of the pregnancy but start to grow poorly at the time of the insult. Their growth, therefore, will be disproportionally affected.

90. A child has been diagnosed with a small ventricular septal defect (VSD). Which of the following symptoms would the nurse expect to see? 1. Cyanosis and clubbing of the fingers. 2. Respiratory distress and extreme fatigue. 3. Systolic murmur with no other obvious symptoms. 4. Feeding difficulties with marked polycythemia.

3 1. Cyanosis and clubbing are seen in children suffering from severe cyanotic defects and are not likely to develop with a small ventricular septal defect (VSD). 2. These symptoms will unlikely develop with a small VSD. 3. This response is correct. 4. Feeding difficulties and polycythemia are seen in children suffering from severe cyanotic defects. TIP: The VSD—-an opening between the ventricles of the heart-—is the most common acyanotic heart defect seen. The defect leads to a left-to-right shunt since the left side of the heart is more powerful than the right side of the heart, causing a murmur. Small VSDs rarely result in severe symptoms and, in fact, often close over time without any treatment.

44. The staff on the maternity unit is developing a protocol for nurses to follow after a baby is delivered who fails to breathe spontaneously. Which of the following should be included in the protocol as the first action for the nurse to take? 1. Prepare epinephrine for administration. 2. Provide positive pressure oxygen. 3. Administer chest compressions. 4. Rub the back and feet of the baby.

4 1. Epinephrine is administered only after other resuscitation measures have been instituted. 2. Positive pressure oxygen is administered only after initial interventions of tactile stimulation and warmth have failed. 3. Chest compressions are administered only after initial interventions have failed. 4. The first interventions when a neonate fails to breathe include providing tactile stimulation. TIP: When a neonate fails to breathe, the nurse should: dry the baby and provide tactile stimulation, place the child in the "sniff" position under a radiant warmer, and suction the mouth and nose of any mucus. Only after these initial actions fail—since the vast majority of the time the baby will respond—should further intervention be begun. http://pediatrics.aappublications.org/cgi/content/full/117/5/e1029

66. A neonatalogist prescribes Platinol-AQ (cisplatin) for a neonate born with a neuroblastoma. The baby's current weight is 3476 grams and the baby is 57 centimeters long. The drug reference states: Children: IV 30 mg/m2 q week. Calculate the safe dosage of this medication. __________ mg q week.

6.9 mg q week The formula for calculating the safe dosage per body surface area in meters squared is: To calculate the body surface area for this baby the test taker must take the square root of the product of the baby's weight times its length. sqrt(3.476 x 57) ---------------- = 0.23 m2 3600 Then, to calculate the safe dosage, a ratio and proportion equation must be solved. 30 mg = x mg 1 m2 0.23 m2 x = 6.9 mg q week TIP: When calculating a safe dosage for a child using the body surface area formula, it is important for the test taker to note whether the child's statistics are written in the metric system or the English system. If in the metric system, the divisor for the formula is 3600. If the statistics are in the English system, however, the divisor is 3131. And it is important for the test taker to remember to take the square root of the calculation. It is very easy to forget that step.

103. Four babies are born with distinctive skin markings. Identify which marking matches its description: 1. Café au lait spot A. Raised, blood vessel-filled tumor. 2. Hemangioma B. flat, sharply demarcated red-to-purple lesion. 3. Mongolian spots C. Multiple grayish blue hyperpigmented skin areas. 4. Port wine stain D. Pale tanto coffee-colored marking.

The term in column 1 is matched to the description in column 2. 1. Café au lait spot matches with D. A café au lait spot is a pale tan to coffee-colored skin marking. 2. Hemangioma matches with A. A hemangioma is a raised blood vessel-filled lesion. 3. Mongolian spot matches with C. Mongolian spots are multiple grayish blue hyperpigmented skin areas. 4. Port wine stain matches with B. A port wine stain is a flat, sharply demarcated red-to-purple lesion. TIP: This is simply a matching question. The test taker is asked to match the lesion that is seen in neonates with the description of the lesion. In the NCLEX-RN, this would be a drag and drop type of question. The test taker will be asked to drag the corresponding definition and drop it next to the name of the lesion.

73. For which of the following reasons would a nurse in the well baby nursery report to the neonatalogist that a newborn appears to be preterm? 1. Baby has a square window angle of 90°. 2. Baby has leathery and cracked skin. 3. Baby has popliteal angle of 90°. 4. Baby has pronounced plantar creases.

1 1. A baby whose square window sign is 90˚ is preterm. 2. A baby whose skin is cracked and leathery is exhibiting a sign of postmaturity. 3. A baby whose popliteal angle is 90˚ is full term. 4. A baby whose plantar creases are pronounced is full term. TIP: A number of neonatal characteristics are assessed to determine the gestational age of a neonate. Four of those characteristics are square window sign, appearance of the skin, popliteal angle, and presence of plantar creases. The test taker should be familiar with the Ballard Scale and the many characteristics on which gestational age is measured.

25. A full-term infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. Which of the following actions should the nurse perform at this time? 1. Feed the baby formula or breast milk. 2. Assess the baby's blood pressure. 3. Tightly swaddle the baby. 4. Monitor the baby's urinary output.

1 1. A baby with a blood glucose of 35 mg/dL is hypoglycemic. The action of choice is to feed the baby either formula or breast milk. 2. The baby's blood pressure is not a relevant factor at this time. 3. Tightly swaddling the baby may disguise a common finding, jitters or tremors, seen in babies who are hypoglycemic. 4. The baby's urinary output is not a relevant factor at this time. TIP: Although the test taker may believe that glucose water should be fed to the baby at this time, the substance of choice is either formula or breast milk. The sugars in the milk will elevate the baby's blood values in the short term and the proteins and fats in the milk will help to maintain the glucose values in the normal range.

83. A baby in the NICU, who is exhibiting signs of congestive heart failure from an atrioventricular canal defect, is receiving a diuretic. In the plan of care, the nurse should include that the desired outcome for the child will be which of the following? 1. Loss of body weight. 2. Drop in serum sodium level. 3. Rise in urine specific gravity. 4. Increase in blood pressure.

1 1. A diuretic will increase urinary output which in turn will lead to weight loss. 2. A drop in sodium is not a goal of diuretic therapy. 3. Rather than an increase in specific gravity, the nurse would expect to see a drop in specific gravity. 4. An increase in blood pressure is not a goal of diuretic therapy. TIP: The heart is pumping inefficiently when a baby has congestive heart failure. Because of this pathology, the kidneys are poorly perfused leading to fluid retention and weight gain. Diuretics are administered to improve the excretion of the fluid. When the urinary output is increased, the weight will drop and the urine will be less concentrated.

10. 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? 1. Type O negative. 2. Type A negative. 3. Type B positive. 4. Type AB positive.

1 1. ABO incompatibility can arise when the mother is type O and the baby is either type A or type B. 2. Hemolytic jaundice from ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can only occur if the mother is Rh negative and the baby is Rh positive. 3. Hemolytic jaundice from ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can only occur if the mother is Rh negative and the baby is Rh positive. 4. Hemolytic jaundice from ABO incompatibility is rarely seen when the maternal blood type is anything other than type O. Rh incompatibility can only occur if the mother is Rh negative and the baby is Rh positive. TIP: 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.

43. During neonatal cardiopulmonary resuscitation, which of the following actions should be performed? 1. Provide assisted ventilation at 40 to 60 breaths per minute. 2. Begin chest compressions when heart rate is 0 to 20 beats per minute. 3. Compress the chest using the three-finger technique. 4. Administer compressions and breaths in a 5 to 1 ratio.

1 1. Assisted ventilations should be administered at a rate of 40 to 60 per minute. 2. Chest compressions should be begun when the heart rate is below 60 beats per minute. 3. The chest should be compressed using either the "2-thumb" or the "2-finger" techniques. 4. The compressions and ventilations should be administered in a 3 to 1 ratio. TIP: The correct answer could be deduced by the test taker by remembering the normal respiratory rate of the neonate (30 to 60 breaths per minute). During a resuscitation, the nurses and other health care practitioners would be attempting to simulate normal functioning. http://pediatrics.aappublications.org/cgi/content/full/117/5/e1029

74. A full-term neonate in the NICU has been diagnosed with congestive heart failure secondary to a cyanotic heart defect. Which of the following activities is most likely to result in a cyanotic episode? 1. Feeding. 2. Sleeping in the supine position. 3. Rocking in an infant swing. 4. Swaddling.

1 1. Babies who have cardiac defects frequently feed poorly. And when they do feed, they frequently become cyanotic. 2. Sleeping is unlikely to trigger a cyanotic spell. 3. Rocking is unlikely to trigger a cyanotic spell. 4. Although the baby may be aroused when swaddled, it is unlikely to trigger a cyanotic spell. TIP: Any activity that requires an increased oxygen demand can trigger a cyanotic spell in a neonate with a heart defect. The two activities that require the greatest amount of oxygen and energy are feeding and crying. In fact, because feeding demands that the baby be able to suck, swallow, and breathe rhythmically and without difficulty, many sick babies refuse to eat because it is such a demanding activity.

93. The neonatalogist assesses a newborn for Hirschsprung's disease after the baby exhibited which of the following signs/symptoms? 1. Passed meconium at 50 hours of age. 2. Apical heart rate of 200 beats per minute. 3. Maculopapular rash. 4. Asymmetrical leg folds.

1 1. Babies who have delayed meconium excretion may have Hirshsprung's disease. 2. Tachycardia is not associated with Hirshsprung's disease. 3. Rashes are not associated with Hirshsprung's disease 4. Asymmetrical leg folds are related to developmental dysplasia of the hip, not to Hirshsprung's disease. TIP: Hirshsprung's disease is defined as a congenital lack of parasympathetic innervation to the distal colon. Peristalsis, therefore, ceases at the end of the intestine. Because of the absence of peristalsis, the passage of meconium is delayed.

81. A neonate that is admitted to the neonatal nursery is noted to have a 2-vessel cord. The nurse notifies the neonatalogist to get an order for which of the following assessments? 1. Renal function tests. 2. Echocardiogram. 3. Glucose tolerance test. 4. Electroencephalogram.

1 1. Babies with 2-vessel cords are at high risk for renal defects. 2. There is no relationship between a 2-vessel cord and a cardiac defect. 3. There is no relationship between a 2vessel cord and glucose tolerance. 4. There is no relationship between a 2vessel cord and the brain. TIP: The umbilical cord is developed in fetal life at approximately the same time as the renal system. Because of this fact, when a defect is seen in the umbilical cord, there may also be a defect in the renal system.

97. The nurse suspects that a newborn in the nursery has a clubbed right foot because the foot is plantar flexed and because the nurse also notices which of the following? 1. Inability to move the foot into proper alignment. 2. Notes positive Ortolani sign on the right. 3. Notes shortened right metatarsal arch. 4. Elicits positive Babinski reflex on the right.

1 1. During the neonatal physical assessment, the nurse is unable to move a club foot into proper alignment. 2. A positive Ortolani sign indicates the presence of DDH. 3. A shortened metatarsal arch is not diagnostic of clubfoot. 4. The Babinski reflex is positive in all neonates. TIP: The most common form of clubfoot is talipes equinovarus, when the baby's foot is in a state of inversion and plantar flexion. It is important for the nurse to distinguish between positional clubfoot that occurs from the baby's position in utero and resolves spontaneously, and pathology that requires orthopedic therapy.

94. The nurse assessed four newborns admitted to the neonatal nursery and called the neonatalogist for a consult on the baby who exhibited which of the following? 1. Excessive amounts of frothy saliva from the mouth. 2. Blood-tinged discharge from the vaginal canal. 3. Secretion of a milk-like substance from both breasts. 4. Heart rate that sped during inhalation and slowed with exhalation.

1 1. Excessive amounts of frothy saliva may indicate that the child has esophageal atresia. 2. Blood-tinged vaginal discharge is a normal finding in female neonates. 3. Milk-like secretion from the breast is a normal finding in neonates. 4. It is normal for a baby's heart rate to speed slightly during inhalation and slow slightly during exhalation. TIP: If the test taker is familiar with the characteristics of the normal neonate, the answer to this question is obvious. A baby whose esophagus ends in a blind pouch is unable to swallow his or her saliva. Instead, the mucus bubbles and drools from the mouth. Healthy babies, on the other hand, swallow without difficulty.

20. 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? 1. Poor suck reflex. 2. Ambiguous genitalia. 3. Webbed neck. 4. Absent Moro reflex.

1 1. FAS babies usually have a very weak suck. 2. Ambiguous genitalia is not a characteristic anomaly seen in FAS. 3. A webbed neck is not a characteristic anomaly seen in FAS. 4. FAS babies usually have an intact CNS system with a positive Moro reflex. TIP: 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.

104. A baby, admitted to the nursery, was diagnosed with galactosemia from an amniocentesis. Which of the following actions must the nurse take? 1. Feed the baby a specialty formula. 2. Monitor the baby for central cyanosis. 3. Do hemoccult testing on every stool. 4. Monitor baby for signs of abdominal pain.

1 1. Galactosemia is one of the few diseases that is a contraindication for the intake of breast milk or any milkbased formula. 2. Galactosemia is a metabolic defect. There is no cardiovascular component. 3. Diarrhea and other malabsorption symptoms will be seen over time, but bloody stools would not be seen in the nursery. 4. Although vomiting and diarrhea do occur, the baby is unlikely to have abdominal pains. TIP: There are many genetic metabolic diseases that may affect the neonate. Galactosemia, an autosomal recessive disease, is characterized by an inability to digest galactose, a by-product of lactose digestion. Since breast milk and milk-based formulas are very high in lactose, affected babies must be switched to a soy-based formula.

52. 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? 1. The baby whose mother cultured positive for group B strep during her third trimester. 2. The baby whose mother had gestational diabetes. 3. The baby whose mother was hospitalized for 3 months with complete placenta previa. 4. The baby whose mother previously had a stillbirth.

1 1. Group B streptococcus causes severe infections in the newborn. A sign of neonatal sepsis is hypothermia. 2. Babies whose mothers had gestational diabetes (GDM) should be carefully monitored for hypoglycemia rather than for hypothermia. 3. There is no relationship between placenta previa and neonatal hypothermia. 4. There is no evidence from the question that the stillbirth was related to a gestational infection. TIP: It is important for the test taker not to confuse terms. Babies with neonatal sepsis often become hypothermic, while babies born to mothers with GDM become hypoglycemic. The two conditions are very different, although the prefix-—hypo-—is the same.

16. A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid volume deficit. For which of the following client outcomes should the nurse plan to monitor the baby? 1. 6 saturated diapers in 24 hours. 2. Breastfeeds 6 times in 24 hours. 3. 12% weight loss since birth. 4. Apical heart rate of 176 bpm.

1 1. Healthy, hydrated neonates saturate their diapers a minimum of 6 times in 24 hours. 2. In order to consume enough fluid and nutrients for growth and hydration, babies should breastfeed at least 8 times in 24 hours. 3. A weight loss of over 10% is indicative of dehydration. 4. Tachycardia can indicate dehydration. TIP: This is an evaluation question. The test taker is being asked to identify signs that would indicate a baby the test taker to know the expected intake and output of the neonate and to understand the evaluation phase of the nursing process.

49. 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? 1. Hypothermia. 2. Mottling. 3. Omphalocele. 4. Stomatitis.

1 1. Hypothermia in a neonate may be indicative of sepsis. 2. Mottling is commonly seen in neonates. It is considered a normal finding. 3. Oomphalocele is not related to group B strep exposure. 4. Stomatitis is not a sign associated with group B strep exposure. TIP: 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.

4. Four babies are in the newborn nursery. The nurse pages the neonatalogist to see the baby who exhibits which of the following? 1. Intracostal retractions. 2. Erythema toxicum. 3. Pseudostrabismus. 4. Vernix caseosa.

1 1. Intracostal retractions are symptomatic of respiratory distress syndrome. 2. Erythema toxicum is the normal newborn rash. 3. Pseudostrabismus is a normal newborn finding. 4. Vernix caseosa is the cheesy material that covers many babies at birth. TIP: It is important for the test taker to be familiar with the signs of respiratory distress in the neonate. Babies who are stressed by, for example, cold, sepsis, or prematurity will often exhibit signs of respiratory distress. The neonatologist should be called promptly.

62. A woman is visiting the NICU to see her 26-week-gestation baby for the first time. Which of the following methods would the nurse expect the mother to use when first making physical contact with her baby? 1. fingertip touch. 2. Palmar touch. 3. Kangaroo hold. 4. Cradle hold.

1 1. Most mothers, even those of full-term bonding as well as promoting growth and development of the neonate. 4. Cradle hold is the classic hold of a mother with her baby. This hold follows other touch contact. TIP: The delivery of a preterm infant is very stressful and frightening. In fact, the appearance of the premature can be overwhelming to new parents. In order to become familiar with their baby, all parents proceed through a pattern of touch behaviors. When the baby is preterm, the procession through touch responses is often slowed.

29. A neonate is being given intravenous fluids through the dorsal vein of the wrist. Which of the following actions by the nurse is essential? 1. Tape the arm to an arm board. 2. Change the tubing every 24 hours. 3. Monitor the site every 5 minutes. 4. Infuse the fluid intermittently.

1 1. Neonates are incapable of controlling their movements. In order to maintain a safe IV site, it is essential to tape the baby's arm to an arm board. 2. IV tubing is usually changed every 72 hours, not every 24 hours. 3. The IV site should be assessed regularly, at least once an hour, but it is not necessary to check it every 5 minutes. 4. IV infusions are usually continuous, unless a medication, like an antibiotic, is being administered. and arm boards are often unnecessary when caring for older children and adults, to be assured that the intravenous remains intact, the use of restraints and/or arm boards is often necessary when caring for infants, toddlers, and other young children.

88. A baby is born with a suspected coarctation of the aorta. Which of the following assessments should be done by the nurse? 1. Check blood pressures in all four limbs. 2. Palpate the anterior fontanel for bulging. 3. Assess hematocrit and hemoglobin values. 4. Monitor for harlequin color changes.

1 1. The blood pressures in all four quadrants should be assessed. 2. A bulging fontanel, not coarctation of the aorta, is indicative of hydrocephalus. 3. At delivery, the hematocrit and hemoglobin will likely be the same as in a healthy baby. 4. Harlequin coloration is a normal finding. TIP: The pathophysiology of coarctation of the aorta provides the rationale for the assessment of the blood pressures. Since the narrowing of the aorta is usually distal to the ascending aorta, blood is able to pass unimpeded into the upper body but is unable to pass through the descending aorta toward the lower body. The blood pressures of the upper body, therefore, are much higher than the blood pressures in the lower extremities.

26. A nurse is inserting a gavage tube into a preterm baby who is unable to suck and swallow. Which of the following actions must the nurse take during the procedure? 1. Measure the distance from the tip of the ear to the nose. 2. Lubricate the tube with an oil-based solution. 3. Insert the tube quickly if the baby becomes cyanotic. 4. Inject a small amount of sterile water to check placement.

1 1. The gavage tubing must be measured to approximate the length of the insertion. 2. The tubing should be lubricated with sterile water or a water-soluble lubricant, not an oil-based solution. 3. If the child becomes cyanotic, the tubing should be removed immediately. 4. A small amount of air should be injected into the tubing while the nurse listens with a stethoscope over the baby's stomach area. TIP: The placement of gavage tubing is potentially dangerous. Not only must the distance between the nose and the ear be measured, but also the length from the ear to the point midway between the ear and the xiphoid process. This entire distance is the tubing insertion length. To assess placement, air should be injected into the tubing rather than water because the tubing may mistakenly have been inserted into the trachea.

98. The parents of a baby born with bilateral talipes equinovarus ask the nurse what medical care the baby will likely need. Which of the following should the nurse tell the parents? 1. Need a series of leg casts until the correction is accomplished. 2. Have a Harrington rod inserted when the child is about three years old. 3. Have a Pavlik harness fitted before discharge from the nursery. 4. Need to wear braces on both legs until the child begins to walk.

1 1. The initial treatment plan for clubfoot usually includes a series of casts that slowly move the foot into proper alignment. 2. Harrington rod insertion has been used to treat scoliosis, not talipes equinovarus. 3. Pavlik harness is a therapy for a baby with DDH. 4. Long-term bracing is not a common therapy for clubfoot. TIP: This is an example of a question that may include a term that the test taker is unfamiliar with. If the test taker slowly breaks down the words into their component parts, the meaning of the term will become clear. The word "bilateral," of course, means that "both sides" of the body are affected. The word "talipes" is a word that contains two roots: talis, meaning "ankle" and pes, meaning "foot." The word, therefore, refers to a deformity of the foot and ankle—clubfoot. The term "equinovarus" specifically defines the type of clubfoot but, since the therapy is the same no matter which type of clubfoot the child suffers from, further analysis is not necessary to answer this question. (Talipes equinovarus clubfoot refers to a foot that is plantar flexed and turned inward.)

53. Four 38-week-gestation gravidas have just delivered. Which of the babies should be monitored closely by the nurse for respiratory distress? 1. The baby whose mother has diabetes mellitus. 2. The baby whose mother has lung cancer. 3. The baby whose mother has hypothyroidism. 4. The baby whose mother has asthma.

1 1. The lung maturation of infants of diabetic mothers is often delayed. These babies must be monitored at birth for respiratory distress. 2. A maternal diagnosis of lung cancer will not affect her neonate's pulmonary function. 3. A maternal diagnosis of hypothyroidism does not put the baby at high risk for respiratory distress. 4. A maternal diagnosis of asthma does not put the baby at high risk for respiratory distress. TIP: Two answers to this question relate to maternal pulmonary diagnoses, i.e., lung cancer and asthma. Simply because a mother has a pulmonary problem does not mean, however, that her neonate will have a similar problem. Even if the neonate has respiratory distress, it may not be related to the mother's problem. The test taker should not be swayed by this association. Babies born to diabetic mothers, however, are at risk for delayed lung maturation and should be monitored for respiratory distress.

58. A baby is born to a type 1 diabetic mother. Which of the following lab values would the nurse expect the neonate to exhibit? 1. Plasma glucose 30 mg/dL. 2. Red blood cell count 1 million/mm3. 3. White blood cell count 2000/mm3. 4. Hemoglobin 8 g/dL.

1 1. The nurse should anticipate that the plasma glucose levels would be low. 2. The nurse would expect to see elevated red blood cell counts rather than low red blood cell counts. 3. The white blood cell count should be within normal limits. 4. The nurse would expect to see elevated hemoglobin levels rather than low levels of hemoglobin. TIP: The fetus, responding to elevated glucose levels from the mother, produces large quantities of insulin. After the birth, however, the placenta no longer is providing the baby with the mother's glucose. It takes the baby some time to adjust his or her extrauterine insulin production to be in synchrony with the sugars provided by the breast milk or formula feedings. Until the baby makes the adjustment, he or she will exhibit hypoglycemia (<40 mg/dL).

22. A baby was born 24 hours ago to a mother who received no prenatal care. The infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill, high-pitched cry. The baby's serum glucose levels are normal. For which of the following should the nurse request an order from the pediatrician? 1. Urine drug toxicology test. 2. Biophysical profile test. 3. Chest and abdominal ultrasound evaluations. 4. Oxygen saturation and blood gas assessments.

1 1. The symptoms are characteristic of neonatal abstinence syndrome. A urine toxicology would provide evidence of drug exposure. 2. Biophysical profiles are done during pregnancy to assess the well-being of the fetus. 3. There is no indication from the question that this child has any chest or abdominal abnormalities. 4. This child is not exhibiting signs of respiratory distress. TIP: It is important for the test taker to attend to the fact that this child has normal serum glucose levels. When babies exhibit tremors, the first thing the nurse should consider is hypoglycemia. Once that has been ruled out, and since the baby is exhibiting other signs of drug withdrawal, the nurse should consider drug exposure.

36. A 42-week-gestation baby, 2400 grams, whose mother had no prenatal care, is admitted into the NICU. The neonatalogist orders blood work. Which of the following laboratory findings would the nurse expect to see? 1. Blood glucose 30 mg/dL. 2. Leukocyte count 1000 cells/mm3. 3. Hematocrit 30%. 4. Serum pH 7.8.

1 1. This baby is small-for-gestational age. Full-term babies (40 weeks' gestation) should weigh between 2500 and 4000 grams. It is very likely that this baby used up his glycogen stores in utero because of an aging placenta. An aging placenta is unable to deliver sufficient nutrients to the fetus. As a result the fetus must use its glycogen stores to sustain life and, therefore, is high risk for hypoglycemia after birth. 2. There is no indication from this scenario that this baby is leukopenic. 3. Rather than being anemic, it is likely that this baby is polycythemic to compensate for the poor oxygenation from a poorly functioning placenta. 4. It is unlikely that this baby would be alkalotic. Rather he may be acidotic from chronic hypoxemia and the metabolism of brown adipose tissue. TIP: The test taker must attend carefully to the gestational age in any question relating to neonates. Postterm and preterm babies are at high risk for certain problems. Postterm babies are especially at high risk for hypoglycemia and chronic hypoxia because the aging placenta has not supplied sufficient quantities of oxygen and nutrients.

18. A baby is in the NICU whose mother was addicted to heroin during the pregnancy. Which of the following nursing actions would be appropriate? 1. Tightly swaddle the baby. 2. Place the baby prone in the crib. 3. Provide needed stimulation to the baby. 4. Feed the baby half-strength formula.

1 1. Tightly swaddling drug-addicted babies often helps to control the hyperreflexia that they may exhibit. 2. Placing hyperactive babies on their abdomens can result in skin abrasions on the face and knees from rubbing against the linens. 3. Drug-exposed babies should be placed in a low-stimulation environment. 4. The babies should be given small frequent feedings either of formula or of breast milk. TIP: Drug-exposed babies exhibit signs of neonatal abstinence syndrome: hyperactivity, hyperreflexia, and the like. The test taker should look for a nursing intervention that would minimize those behaviors. Tightly swaddling the baby would help to reduce the baby's behavioral responses.

95. The nurse is caring for a baby diagnosed with developmental dysplasia of the hip (DDH). Which of the following therapeutic interventions should the nurse expect to perform? 1. Place the baby's legs in abduction. 2. External rotation of the baby's hips. 3. Assist with bilateral leg casting. 4. Monitor pedal pulses bilaterally.

1 1. To treat developmental dysplasia of the hip, babies' legs are maintained in a state of abduction. 2. External rotation of the hips is part of Ortolani test, which is a screening test for DDH. This action is not therapeutic. 3. Casting is only done in cases where splinting is ineffective. 4. There is no need to assess pedal pulses because they are unaffected in babies with DDH. TIP: Since the pathology of DDH is related to the laxity of the hip joint, the rationale for the therapy is to maintain physiological positioning of the hip joint until the ligaments strengthen and mature. Keeping the legs in a state of abduction, the hip joint is maintained with the trochanter centered in the acetabulum.

91. A newborn in the NICU has just had a ventriculoperitoneal shunt inserted. Which of the following signs indicates that the shunt is functioning properly? 1. Decrease of the baby's head circumference. 2. Absence of cardiac arrhythmias. 3. Rise of the baby's blood pressure. 4. Appearance of setting sun sign.

1 1. Ventriculoperitoneal (VP) shunts are inserted for the treatment of hydrocephalus. A positive finding, therefore, would be decreasing head circumferences. 2. VP shunts are not inserted for the treatment of cardiac arrhythmias or cardiac anomalies. 3. VP shunts are not inserted for the treatment of hypertension. 4. Setting sun sign is a sign of hydrocephalus. Appearance of setting sun sign would indicate that the shunt is functioning improperly. TIP: One of the first signs of hydrocephalus in the neonate is increasing head circumferences because, since the fetal head is unfused, excess fluid in the brain forces the skull to expand. Once the diagnosis of hydrocephalus has been made, a ventriculoperitoneal (VP) shunt is usually inserted. The shunt is designed to remove excess cerebral spinal fluid from the ventricles of the brain. With the reduction in fluid, the size of the baby's head decreases.

7. A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide safe newborn care, which of the following actions should the nurse perform? 1. Cover the baby's eyes with eye pads. 2. Turn the lights on for ten minutes every hour. 3. Clothe the baby in a shirt and diaper only. 4. Tightly swaddle the baby in a baby blanket.

1 1. When phototherapy is administered, the baby's eyes must be protected from the light source. 2. Although the lights should be turned off and the pads removed periodically during the therapy, the lights should be on whenever the baby is in his or her crib. 3. The therapy is most effective when the skin surface exposed to the light is maximized. The shirt should be removed while the baby is under the lights. 4. The blanket should be removed while the baby is under the lights. TIP: There is a difference between phototherapy administered by fluorescent light and phototherapy administered via fiber optic tubing to a biliblanket. When a bili-blanket is used, the baby can be clothed and the baby's eyes do not need to be protected.

19. 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. 1. Hyperphagia. 2. Lethargy. 3. Prolonged periods of sleep. 4. Hyporeflexia. 5. Persistent shrill cry.

1 and 5 are correct. 1. Babies with signs of neonatal abstinence syndrome repeatedly exhibit signs of hunger. 2. Babies with neonatal abstinence syndrome are hyperactive, not lethargic. drome often exhibit sleep disturbances rather than prolonged periods of sleep. 4. Babies with signs of neonatal abstinence syndrome are hyperreflexic, not hyporeflexic. 5. Babies with signs of neonatal abstinence syndrome often have a shrill cry that may continue for prolonged periods. TIP: The baby who is exhibiting signs of neonatal abstinence syndrome is craving an addicted drug. The baby's body is agitated because the illicit narcotics he or she has been exposed to are central nervous system depressants and their removal has agitated him or her. The test taker, therefore, should consider symptoms that reflect central nervous stimulation as correct responses.

69. A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following actions by the nurse is appropriate? Select all that apply. 1. Perform hemoccult test on stools. 2. Monitor for an increase in abdominal girth. 3. Measure gastric contents before each feed. 4. Assess bowel sounds before each feed. 5. Assess for anal fissures daily.

1, 2, 3, and 4 are correct. 1. Babies with necrotizing enterocolitis (NEC) have blood in their stools. 2. The abdominal girth measurements of babies with NEC increase. 3. When babies have NEC, they have increasingly larger undigested gastric contents after feeds. 4. The neonates' bowel sounds are diminished with NEC. 5. The presence of anal fissures is unrelated to NEC. TIP: NEC is an acute inflammatory disorder seen in preterm babies. It appears to be related to the shunting of blood from the gastrointestinal tract, which is not a vital organ system, to the vital organs. The baby's bowel necroses with the shunting and the baby's once normal flora become pathological. Resection of the bowel is often necessary.

63. 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. 1. Bronchopulmonary dysplasia. 2. Cerebral palsy. 3. Retinopathy. 4. Hypothyroidism. 5. Seizure disorders.

1, 2, 3, and 5 are correct. 1. Bronchopulmonary dysplasia often is a consequence of the respiratory therapy that preemies receive in the NICU. 2. Cerebral palsy results from a hypoxic insult that likely occurred as a result of the baby's prematurity. 3. Retinopathy of the premature is a disease resulting from the immaturity of the vascular system of the eye. 4. Hypothyroidism is one of the diseases assessed for in the neonatal screen. It is very unlikely that this problem resulted from the baby's stay in the NICU. 5. Seizure disorders can result either from a hypoxic insult to the brain or from a ventricular bleed. Both of these conditions likely occurred as a result of the prematurity. TIP: Many parents are of the opinion that babies, even when born many weeks prematurely, will be healthy as they mature because there are so many machines and medications that can be given to the babies. Unfortunately, many babies suffer chronic problems as a result of their prematurity even when they receive excellent medical and nursing care.

50. A baby in the newborn nursery was born to a mother with spontaneous rupture of membranes for 14 hours. The woman has Candida vaginitis. For which of the following should the baby be assessed? 1. Papular facial rash. 2. Thrush. 3. Fungal conjunctivitis. 4. Dehydration.

2 1. Although Candida can eventually lead to a maculopapular diaper rash, no facial rash is associated with a candidal infection. 2. Thrush is commonly seen in babies whose mothers have Candida vaginitis. 3. A neonatal fungal conjunctivitis is not associated with this problem. 4. Dehydration is not associated with this problem. TIP: The test taker should be familiar with the various presentations of common fungi and bacteria. Candida is a fungus that is a normal vaginal flora. During pregnancy, it is not uncommon for the vaginal flora to shift and the woman to develop Candida vaginitis.

54. A client is seeking preconception counseling. She has type 1 diabetes mellitus and is found to have an elevated glycosylated hemoglobin (HgbA1c) level. Before actively trying to become pregnant, she is strongly encouraged to stabilize her blood glucose to reduce the possibility of her baby developing which of the following? 1. Port wine stain. 2. Cardiac defect. 3. Hip dysplasia. 4. Intussusception.

2 1. Although the etiology of port wine stain is unknown, it is unrelated to a maternal diagnosis of diabetes. 2. The incidence of cardiac defects and neural tube defects is high in infants born to diabetic mothers. 3. The incidence of hip dysplasia is not significantly higher in infants born to diabetic mothers. 4. Intussusception is an invagination of the small intestine. It is unrelated to a maternal diagnosis of diabetes. TIP: The test taker should be familiar with maternal diseases that can seriously impact pregnancy. One of the most significant of the chronic diseases is diabetes. When a woman is in poor diabetic control during the first trimester, the incidence of birth defects is quite high.

8. A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would the nurse expect to see? 1. Ruddy complexion. 2. Anasarca. 3. Alopecia. 4. Erythema toxicum.

2 1. Babies born with erythroblastosis fetalis are markedly anemic. They are not ruddy in appearance. 2. Babies born with erythroblastosis fetalis often are in severe congestive heart failure and, therefore, exhibit anasarca. 3. Babies with erythroblastosis fetalis are not at high risk for alopecia. 4. Erythema toxicum is a normal newborn rash that many healthy newborns have. TIP: A baby with erythroblastosis fetalis has marked red blood cell destruction in utero secondary to the presence of maternal antibodies against the baby's blood. The severe anemia that results often leads to congestive heart failure of the fetus in utero.

79. Which of the following actions would the NICU nurse expect to perform when caring for a neonate with esophageal atresia and tracheoesophageal fistula (TEF)? 1. Position the baby flat on the left side. 2. Maintain low nasogastric suction. 3. Give small frequent feedings. 4. Place on hypothermia blanket.

2 1. Babies with tracheoesophageal fistula (TEF) usually have the heads of their cribs elevated. The babies may be placed on one of their sides but should not be laid flat. 2. Low nasogastric suction is usually maintained to minimize the amount of the baby's oral secretions. 3. Babies that are born with TEF are kept NPO (nothing by mouth). 4. There is no reason to place a TEF baby on a hypothermia blanket. TIP: Because TEF babies' esophagi end in a blind pouch, they excrete large quantities of mucus from their mouths, placing them at high risk for aspiration. To decrease the potential for respiratory insult until surgery can take place, nasogastric suctioning is started and the babies' heads are elevated.

45. A nurse in the newborn nursery suspects that a new admission, 42 weeks' gestation, was exposed to meconium in utero. What would lead the nurse to suspect this? 1. The baby is bradycardic. 2. The baby's umbilical cord is green. 3. The baby's anterior fontanel is sunken. 4. The baby is desquamating.

2 1. Bradycardia is a sign of neonatal distress but it is not related to meconium exposure. 2. Because meconium is a dark green color, when it is expelled in utero, the baby can be stained green. 3. A sunken fontanel is an indication of dehydration, not of meconium exposure. 4. A baby's skin often desquamates when he or she is postterm. Although meconium may be expelled by a postterm baby, desquamation is not related to the meconium. TIP: The test taker may choose "4" because he or she remembers that there is a relationship between babies who expel meconium and those who desquamate. That is true, but it is not a direct relationship. The fact that the baby is postdates is the common denominator between the two. The test taker should choose the response that is clearly correct: because meconium is green it can stain the baby's tissues green. Desquamation is merely a fancy term for skin peeling.

70. A woman whose 32-week-gestation neonate is to begin oral feedings is expressing breast milk (EBM) for the baby. The neonatalogist is recommending that fortifier be added to the milk because which of the following needs of the baby are not met by EBM? 1. Need for iron and zinc. 2. Need for calcium and phosphorus. 3. Need for protein and fat. 4. Need for sodium and potassium.

2 1. Expressed breast milk (EBM) is sufficient in iron and zinc. 2. Calcium and phosphorus in EBM are in quantities that are less than body requirements for the very low birth weight baby. Therefore, a fortifier may need to be added to the EBM. 3. Protein and fat are sufficient in EBM. 4. Sodium and potassium are sufficient in EBM. TIP: Premature babies who are breastfed have fewer complications than bottlefed babies, especially necrotizing enterocolitis. Unfortunately, very low birth weight babies do not receive sufficient quantities of calcium and phosphorus from the EBM. The breast milk, then, is enriched with a milk fortifier that contains the needed elements.

30. A Roman Catholic couple has just delivered a baby with an Apgar of 1 at 1 minute, 2 at 5 minutes, and 2 at 10 minutes. Which of the following interventions is appropriate at this time? 1. Advise the parents that they should pray very hard so that everything turns out well. 2. Ask the parents whether they would like the nurse to baptize the baby. 3. Leave the parents alone to work through their thoughts and feelings. 4. Inform the parents that a priest will listen to their confessions whenever they are ready.

2 1. It is inappropriate to imply that, if a couple were to pray, that their sick child will be "all right." The baby may be seriously ill and even may die. 2. This baby's Apgar is very low. There is a chance that the baby will not survive. It is appropriate to ask the parents, since they are known to be Roman Catholic, if they would like their baby baptized. 3. Although it is often easier for the nurse to leave parents alone whose babies are doing poorly, it is rarely therapeutic. 4. It is inappropriate to assume that the parents wish to give confession, although it may be appropriate to offer to have the priest visit them. TIP: When a baby is doing very poorly during the first minutes after delivery, there is a possibility that the baby may not survive. Couples who are Roman Catholic often wish to have their babies baptized in such situations. Because a priest is not present, it is appropriate for a nurse, of any religious faith, to perform the baptism at that time.

80. A nurse is assisting a mother to feed a baby born with cleft lip and palate. Which of the following should the nurse teach the mother? 1. The baby is likely to cry from pain during the feeding. 2. The baby is likely to expel milk through the nose. 3. The baby will feed more quickly than other babies. 4. The baby will need milk with added calories.

2 1. It is not painful for a cleft lip and palate baby to feed. 2. It is likely that milk will be expelled from the baby's nose during feedings. 3. Babies with clefts often take much longer to feed than do other babies. 4. Babies with clefts usually consume the same milk, either breast milk or formula, that other babies consume. TIP: This question asks about the feeding of a baby with a cleft palate. Although the lip is intact, a cleft in the palate means that there is direct communication between the mouth and the sinuses. Because of the opening, milk is often expelled from the nose. Plus, the milk frequently enters the eustachian tubes. These babies, therefore, are at high risk for ear infections.

24. An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL. The nurse should monitor this baby carefully for which of the following? 1. Jaundice. 2. Jitters. 3. Erythema toxicum. 4. Subconjunctival hemorrhages.

2 1. Jaundice is not related to blood glucose levels. 2. Babies who are hypoglycemic will often develop jitters (tremors). 3. Erythema toxicum is the newborn rash. It is unrelated to blood glucose levels. 4. Subconjunctival hemorrhages are often evident in neonates. They are related to the trauma of delivery, not to blood glucose levels. TIP: The test taker should remember that the normal glucose level for neonates in the immediate postdelivery period—approximately 45 to 90 mg/dL—is less than that seen in older babies and children.

46. The birth of a baby, weight 4500 grams, was complicated by shoulder dystocia. Which of the following neonatal complications should the nursery nurse observe for? 1. Leg deformities. 2. Brachial palsy. 3. Fractured radius. 4. Buccal abrasions.

2 1. Limb deformities develop during pregnancy. They are not related to dystocia. 2. During a difficult delivery with shoulder dystocia, the brachial nerve can become stretched and may even be severed. The nurse should, therefore, observe the baby for signs of palsy. 3. A fracture of the radius is an unlikely injury to occur even during a shoulder dystocia. 4. Buccal surfaces lie inside the cheeks. Buccal abrasions are highly unlikely injuries for the baby to sustain during a shoulder dystocia. TIP: The key to answering this question is understanding the terminology. A shoulder dystocia is a difficult delivery when the shoulder fails to pass easily through the pelvis. Deformities are disfigurements or malformations. Although the arm and shoulder may be injured, the baby is not disfigured. A buccal abrasion would occur on the inside of the cheek.

55. A baby is born with caudal agenesis. Which of the following maternal complications is associated with this defect? 1. Poorly controlled myasthenia gravis. 2. Poorly controlled diabetes mellitus. 3. Poorly controlled splenic syndrome. 4. Poorly controlled hypothyroidism.

2 1. Myasthenia gravis is not associated with caudal agenesis in the fetus. 2. Poorly controlled maternal diabetes mellitus is one of the most important predisposing factors for caudal agenesis in the fetus. 3. Splenic syndrome is sometimes seen in patients with sickle cell anemia. It is not related to caudal agenesis in the fetus. 4. Hypothyroidism is not related to caudal agenesis in the fetus. TIP: Women with diabetes must be in excellent glucose control before becoming pregnant. Because fetal deformities develop during the organogenic period in the first trimester, it is too late to educate diabetic women to control their disease when they are already pregnant.

21. A baby born addicted to cocaine is being given paregoric. The nurse knows that which of the following is a rationale for its use? 1. Paregoric is nonaddictive. 2. Paregoric corrects diarrhea. 3. Paregoric is nonsedating. 4. Paregoric suppresses the cough reflex.

2 1. Paregoric contains morphine. It is addictive. 2. Paregoric does help to control the diarrhea seen in drug-addicted neonates. 3. Paregoric does cause drowsiness. 4. Sneezing is a symptom seen in drugaddicted neonates, not coughing. TIP: Paregoric, a liquid form of morphine, is an especially effective therapy for a baby who is experiencing severe neonatal abstinence syndrome. The narcotic relieves the cravings that the baby has for the addicted drug, while, in addition, paregoric is effective against the diarrhea that many addicted baby's experience.

100. The nurse assessed four newborns in the neonatal nursery. The nurse called the neonatalogist for a cardiology consult on the baby who exhibited which of the following signs/symptoms? 1. Setting sun sign. 2. Anasarca. 3. flaccid extremities. 4. Polydactyly.

2 1. Setting sun sign is a symptom of hydrocephalus. It is not a symptom of cardiac disease. 2. Anasarca refers to overall, systemic edema. It is seen is severe cardiovascular disease. A cardiac consult would be appropriate for this baby as would, perhaps, a renal consult. 3. A baby with flaccid extremities is exhibiting a neurological or musculoskeletal problem, not a cardiac problem. 4. A baby with polydactyly has more than 5 digits on the hands or feet. The finding has nothing to do with cardiac problems. TIP: Although each of the answer options is abnormal, there is only one option that describes a symptom of a cardiac disease. The test taker must carefully discern what is being asked in each question in order to choose the one answer that relates specifically to the stem.

71. A 1000-gram neonate is being admitted to the neonatal intensive care unit. The surfactant Survanta (beractant) has just been prescribed to prevent respiratory distress syndrome. Which of the following actions should the nurse take while administering this medication? 1. flush the intravenous line with normal saline solution. 2. Assist the neonatalogist during the intubation procedure. 3. Inject the medication deep into the vastus lateralis muscle. 4. Administer the reconstituted liquid via an oral syringe.

2 1. Surfactant is not administered intravenously. 2. Surfactant is administered intratracheally. The baby must first be intubated. The nurse would assist the doctor with the procedure. 3. Surfactant is not administered parenterally. 4. Surfactant is not administered orally. TIP: Surfactant is a slippery substance that is needed to prevent the alveoli from collapsing during expiration. It is prescribed for preterm babies who are so immature that they do not produce sufficient quantities of the substance in their lung fields. The medication is used to prevent and/or to treat respiratory distress syndrome (RDS).

72. A 30-week-gestation neonate, 2 hours old, has received Survanta (beractant). Which of the following would indicate a positive response to the medication? 1. Axillary temperature 98.0°F. 2. Oxygen saturation 96%. 3. Apical heart rate 154 bpm. 4. Serum potassium 4.0 mEq/L.

2 1. Temperature is not related to the action of the medication. 2. A normal oxygen saturation level would be considered a positive result of the medication. 3. Heart rate is not related to the action of the medication. 4. Electrolyte levels are not related to the action of the medication. TIP: The medication is given to provide the baby with lung surfactant. The drug is given to treat RDS. When preterm babies have RDS, they are having respiratory difficulty that leads to poor gas exchange. When there is poor gas exchange, the oxygen saturation drops. A normal O2 saturation level, which is >96%, therefore, indicates a positive outcome.

14. 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? 1. Maintain a warm ambient environment. 2. Have the mother feed the baby frequently. 3. Have the mother hold the baby skin to skin. 4. Place the baby naked by a closed sunlit window.

2 1. The ambient temperature will affect the baby's temperature, but it will not affect the bilirubin level. 2. Bilirubin is excreted through the bowel. The more the baby consumes, the more stools, and therefore the more bilirubin the baby will expel. 3. Holding the baby skin-to-skin has no direct affect on the bilirubin level. 4. The bilirubin levels of babies exposed to direct sunlight will drop. It is unsafe, however, to expose a baby's skin to direct sunlight. TIP: This is one example of a change in practice that has occurred because of updated knowledge. In the past, babies have been placed in sunlight in order to reduce their bilirubin levels, but that practice is no longer considered to be safe. It is important, therefore, for the test taker to have as current knowledge as possible.

92. A neonate has just been born with a meningomyelocele. Which of the following nursing diagnoses should the nurse identify as related to this medical diagnosis? 1. Deficient fluid volume. 2. High risk for infection. 3. Ineffective breathing pattern. 4. Imbalanced nutrition: less than body requirements.

2 1. The baby is not suffering from a fluid volume deficit. 2. If the fragile sac is injured, the baby is very high risk for infection. 3. The defect is below the respiratory nerves. The baby is not at high risk for respiratory difficulties. 4. Although babies with meningomyelocele must be fed in the prone position, they are able to eat without difficulty. TIP: Babies with meningomyelocele, a form of spina bifida, are at very high risk for infection in the central nervous system until the defect is corrected. In addition, the vast majority of babies with myelomeningocele also have hydrocephalus for which they will receive a VP shunt. Plus, the most common problem associated with VP shunts is infection. Nurses, therefore, must care for these affected babies using strict aseptic technique.

57. 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? 1. Hyperalbuminemia. 2. Polycythemia. 3. Hypercalcemia. 4. Hypoinsulinemia.

2 1. The baby's serum protein levels should be normal. 2. 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. 3. Rather than hypercalcemia, the nurse would expect to see hypocalcemia. 4. Rather than hypoinsulinemia, if the maternal glucose levels are higher than normal, the nurse would expect to see hyperinsulinemia in the neonate. TIP: The test taker must be familiar with the pathology of diabetes and its effect on pregnancy. Although infants of diabetic mothers (IDMs) are usually macrosomic as a result of increased plasma glucose levels, when mothers have vascular damage, the placenta functions poorly. The IDM consequently may be small-for-gestational age with intrauterine growth restriction and polycythemia from the poor nourishment and oxygenation.

85. The nurse administers Lanoxin (digoxin) to a baby in the NICU that has a cardiac defect. The baby vomits shortly after receiving the medication. Which of the following actions should the nurse perform next? 1. Give a repeat dose. 2. Notify the physician. 3. Assess the apical and brachial pulses concurrently. 4. Check the vomitus for streaks of blood.

2 1. The dose should not be readministered until it has been determined that the child's digoxin levels are within normal limits. 2. The nurse should notify the physician that the baby has vomited the digoxin. 3. This action is not needed. The apical pulse will have been assessed prior to the initial administration of the medication and assessing the two pulses together will provide no further information. 4. It is unlikely that the vomitus will be streaked with blood. TIP: Vomiting is a sign of digoxin toxicity. This baby needs to have a digoxin level drawn. Because the nurse needs an order for the test, the nurse must notify the doctor of the problem.

41. At 1 minute of life a baby, who appears preterm, has exhibited no effort to breathe even after being stimulated. Which of the following actions should the nurse perform first? 1. Perform a gestational age assessment. 2. Inflate the lungs with positive pressure. 3. Provide external chest compressions. 4. Palpate the base of the umbilical cord.

2 1. The gestational age assessment should be performed only after resuscitation efforts have been performed. 2. The baby's airway should be established by inflating the lungs with an ambu bag. 3. Chest compressions are begun after an airway is established and the heart rate has been assessed. 4. Heart rate assessment should be performed after an airway has been established. TIP: Although the steps of a neonatal resuscitation are slightly different than those for an older baby, child, or adult, the basic principles of resuscitation still apply: ABC. A, the airway must first be established; B, artificial breathing is then begun, and after that, C, chest compressions are performed to establish an artificial circulation.

12. An 18-hour-old baby is placed under the bili-lights with an elevated bilirubin level. Which of the following is an expected nursing action in these circumstances? 1. Give the baby oral rehydration therapy after all feedings. 2. Rotate the baby from side to back to side to front every two hours. 3. Tightly swaddle in baby blankets to maintain normal temperature. 4. Administer intravenous fluids via pump per doctor orders.

2 1. The neonate needs nourishment with formula and/or breast milk. 2. Rotating the baby's position maximizes the therapeutic response because the more skin surface that is exposed to the light source, the better the results. 3. The skin surface must be exposed to the light source so swaddling is contraindicated. 4. Intravenous fluids would be administered only under extreme circumstances. TIP: Bilirubin levels decrease with exposure to a light source. The more skin surface that is exposed, the more efficient the therapy. Although fluids are needed to maintain hydration and to foster stooling, oral rehydration therapy is nutritionally insufficient.

37. A woman who received an intravenous analgesic 4 hours ago has had prolonged late decelerations in labor. She will deliver her baby shortly. Which of the following is the priority action for the delivery room nurse to take? 1. Preheat the overhead warmer. 2. Page the neonatalogist on call. 3. Draw up Narcan (naloxone) for injection. 4. Assemble the neonatal eye prophylaxis.

2 1. The warmer must be preheated, but that is not the priority at this time. 2. The neonatalogist must be called to the delivery room so that he or she arrives before the baby is delivered. 3. The woman did receive a narcotic analgesic 4 hours ago. Although Narcan may be needed, she has likely metabolized most of the medication by this time. The medication is not a priority at this time. 4. The eye prophylaxis can wait until this baby is at least 1 hour old. It is not a priority at this time. TIP: This is a prioritizing question. Although all of these actions may be performed by the nurse, only one is a priority. This baby is showing signs of fetal distress—prolonged late decelerations. The baby may need to be resuscitated. The nurse must, therefore, page the neonatalogist so that he or she is present for the birth of the baby.

23. 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: 96.6°F, 158, 62, jittery, pink body with bluish hands and feet, crying. Which of the following actions should the nurse perform first? 1. Swaddle the baby to provide warmth. 2. Assess the glucose level of the baby. 3. Take the baby to the mother for feeding. 4. Administer the neonatal medications.

2 1. This baby is hypothermic, but the best intervention would be to place the baby under a warmer rather than to swaddle the baby. Plus, the baby's glucose levels must be assessed in order to determine whether or not this baby is hypoglycemic. The glucose can be evaluated while the baby is under the warmer. 2. The glucose level should be assessed to determine whether or not this baby is hypoglycemic. 3. A feeding will elevate the glucose level if it is below normal. The nurse does need to assess the level, however, in order to make a clear determination of the problem. 4. The administration of the neonatal medicines is not a priority at this time. TIP: 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.

76. A baby is suspected of having esophageal atresia. The nurse would expect to see which of the following signs/symptoms? 1. Frequent vomiting. 2. Excessive mucus. 3. Ruddy complexion. 4. Abdominal distention.

2 1. Vomiting is literally impossible. 2. Babies with esophageal atresia would be expected to expel large amounts of mucus from the mouth. 3. A ruddy complexion is related to polycythemia, not esophageal atresia. 4. Abdominal distension is not related to esophageal atresia. TIP: With esophageal atresia, the esophagus ends in a blind pouch. In addition, there is usually a fistula connecting the stomach to the trachea. These babies are at high risk for respiratory compromise because they can aspirate the large quantity of oral mucus. The neonatalogist should be notified whenever esophageal atresia is suspected.

42. A neonatalogist requests Narcan (naloxone) during a neonatal resuscitation effort. Which of the following dosages would the nurse expect to prepare? 1. 1 microgram/kg. 2. 10 microgram/kg. 3. 0.1 milligrams/kg. 4. 1 milligram/kg.

3 1. 1 microgram/kg is too low (it is 1⁄100th the correct dosage) 2. 10 microgram/kg is too low (it is 1⁄10th the correct dosage) 3. 0.1 milligram/kg is the correct dosage. This dosage can also be expressed as 100 microgram/kg 4. 1 milligram/kg is too high (it is 10 times the correct dosage). TIP: The test taker must not confuse micrograms and milligrams. There are 1000 micrograms in 1 milligram. The correct answer, therefore, could have been stated as 0.1 milligram/kg or 100 microgram/kg. http://pediatrics.aappublications.org/cgi/content/full/117/5/e1029

101. A preterm infant has a patent ductus arteriosus (PDA). Which of the following explanations should the nurse give to the parents about the condition? 1. Hole has developed between the left and right ventricles. 2. Hypoxemia occurs as a result of the poor systemic circulation. 3. Oxygenated blood is reentering the pulmonary system. 4. Blood is shunting from the right side of the heart to the left.

3 1. A hole between the left and right ventricles is called a ventricular septal defect, or VSD. 2. Unless the baby is decompensating, this defect rarely results in cyanosis. The blood is being oxygenated and, although there is mixed blood, the baby is sufficiently oxygenated. 3. There is a left to right shunt of blood with a patent ductus arteriosus (PDA) resulting in oxygenated blood reentering the pulmonary system. 4. There is a left to right shunt rather than a right to left shunt. TIP: The ductus arteriosus is a fetal circulatory duct that connects the pulmonary artery with the aorta. In utero, the blood is being oxygenated through the placenta precluding the need for the blood to enter the lungs. In extrauterine life, however, the duct should close in order to create a one-way, intact system. When a ductus arteriosus stays open, a left to right shunt develops (because the left side of the heart is stronger than the right side of the heart) forcing the blood to reenter the lungs.

40. A 42-week gravida is delivering her baby. A nurse and pediatrician are present at the bith. The amniotic fluid is green and thick. The baby fails to breathe spontaneously. Which of the following actions should the nurse take next? 1. Stimulate the baby to breathe. 2. Assess neonatal heart rate. 3. Assist with intubation. 4. Place the baby in the prone position.

3 1. Because meconium is present in the amniotic fluid, the baby should not be stimulated to breathe. 2. Although the heart rate is important, cardiac function is secondary to respiratory function. 3. Before breathing, the baby must be intubated so that the meconiumcontaminated fluid can be aspirated from the baby's airway. (http://pediatrics.aappublications.org/cgi/content/full/117/5/e1029) 4. The baby is kept in a head-down, supine position. TIP: It is actually a positive fact that the baby has not breathed immediately after delivery because the airway can then be aspirated to remove the meconium. The nurse, once the fluid was seen, should have paged the appropriate health care professional who would perform the intubation. The nurse would then assist with the procedure.

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 1. Blood urea nitrogen and serum creatinine tests are done to assess the renal system. Kernicterus does not affect the renal system. It results from an infiltration of bilirubin into the central nervous system. 2. Although alkaline phosphotase and bilirubin would be evaluated when a child is jaundiced, they are not appropriate as 340 assessment tests for the child who has developed kernicterus. 3. 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. 4. The respiratory system is unaffected by high bilirubin levels. TIP: The test taker must be aware that kernicterus is the syndrome that develops when a neonate is exposed to high levels of bilirubin over time. The bilirubin crosses the blood-brain barrier, often leading to toxic changes in the CNS.

47. During a health maintenance visit at the pediatrician's office, the nurse notes that a breastfeeding baby has thrush. Which of the following actions should the nurse take? 1. Nothing because thrush is a benign problem. 2. Advise the mother to bottlefeed until the thrush is cured. 3. Obtain an order for antifungals for both mother and baby. 4. Assess for other evidence of immunosuppression.

3 1. Candida will infect both mother and baby. 2. Only under very special circumstances should a mother be advised not to breastfeed. And it is safe to breastfeed when the baby has thrush. 3. Candida is a fungal infection, and it is important to treat both the mother's breasts and the baby's mouth to prevent the infection from being transmitted back and forth between the two. 4. Although immunosuppressed patients often do develop thrush, that is an unlikely cause of thrush in this situation. TIP: It is important to keep from confusing pathology with the normal processes of birth and growth and development. Thrush, which is often seen in the mouth of immunosuppressed patients, is also a normal flora in the vagina of women. The baby may have contracted the fungus in his or her mouth during delivery or from his or her mother's poorly washed hands.

89. The nurse is developing a teaching plan for parents of an infant with a tetralogy of Fallot. Which of the following positions should parents be taught to place the infant during a "blue," or "tet," spell? 1. Supine. 2. Prone. 3. Knee-chest. 4. Semi-Fowler's.

3 1. Healthy babies should always be placed in the supine position for sleep and during unsupervised periods. For therapeutic reasons, however, sick babies may need to be placed in other positions. 2. The prone position is not the appropriate position for a baby during a "tet" spell 3. Parents should place an infant during a "tet" spell into the knee-chest position. 4. The Semi-Fowler's position is ordinarily a safe position for a baby with tetralogy of Fallot, but during a "tet" spell, the baby should be moved to the knee-chest position. TIP: The four defects that are present in tetralogy of Fallot— ventricular septal defect, overriding aorta, pulmonary stenosis, and hypertrophied right ventricle—create a circulatory system in which much of the blood bypasses the lungs. As a result, a baby with tetralogy is predisposed to cyanotic, or "tet," spells. When a baby is placed in a squatting or knee-chest position, the femoral arteries are constricted, decreasing the amount of blood perfusing the lower body. This leads to improved perfusion to the upper body and the vital organs. With this action, the cyanotic spell will likely resolve.

99. The nurse caring for an infant with a congenital cardiac defect is monitoring the child for which of the following early signs of congestive heart failure? 1. Hypertension, cyanosis, bradycardia. 2. Irritability, hypotension, palpitations. 3. Tachypnea, tachycardia, diaphoresis. 4. Angina, oliguria, dysrhythmias.

3 1. Hypertension, cyanosis, and bradycardia are not early signs of congestive heart failure (CHF). 2. Irritability, hypotension, and palpitations are not early signs of CHF. 3. No matter whether a baby or an adult is developing CHF, the early signs that the nurse would note are tachypnea, tachycardia, and diaphoresis. 4. Angina, oliguria, and dysrhythmias are not early signs of CHF. TIP: The term that is most descriptive in the phrase congestive heart failure is the word failure. If the test taker remembers that, because of poor functioning, the heart is failing to oxygenate the body effectively, the test taker can remember the symptoms of the disease. When the body is being starved of oxygen, the body compensates by increasing respirations to take in more oxygen and the pulse rate speeds up to move the oxygenated blood more quickly through the body. Sweating is also a component of the early stages of the disease.

2. Which of the following neonates is at highest risk for cold stress syndrome? 1. Infant of diabetic mother. 2. Infant with Rh incompatibility. 3. Postdates neonate. 4. Down syndrome neonate.

3 1. Infants of diabetic mothers are often large-for-gestational age, but they are not especially at high risk for cold stress syndrome. 2. Infants born with Rh incompatibility are not especially at high risk for cold stress syndrome. 3. Postdates babies are at high risk for cold stress syndrome because while still in utero they often metabolize the brown adipose tissue for nourishment when the placental function deteriorates. 4. Down syndrome babies are hypotonic, but they are not especially at high risk for cold stress syndrome. TIP: The test taker must know that cold stress syndrome results from a neonate's inability to create heat through metabolic means. Brown adipose tissue (BAT) and glycogen stores in the liver are the primary substances used for thermogenesis. The test taker must then deduce that the infant most likely to have poor supplies of BAT and glycogen is the postdates infant.

3. Which of the following would lead the nurse to suspect cold stress syndrome in a newborn with a temperature of 96.5°F? 1. Blood glucose of 50 mg/dL. 2. Acrocyanosis. 3. Tachypnea. 4. Oxygen saturation of 96%.

3 1. Infants with cold stress exhibit hypoglycemia. A neonatal blood glucose of 50 mg/dL is normal. 2. Acrocyanosis—bluish hands and feet—is normal for the neonate during the first day or two. 3. Babies who have cold stress syndrome will develop respiratory distress. One symptom of the distress is tachypnea. 4. The oxygen saturation is within normal limits. TIP: It is important for the test taker to know the normal variations seen in the neonate—-for example, normal blood glucoses are lower in neonates than in the older child and adult and acrocyanosis is normal for a neonate's first day or two.

17. There is a baby in the neonatal intensive care unit (NICU) who is exhibiting signs of neonatal abstinence syndrome. Which of the following medications is contraindicated for this neonate? 1. Morphine. 2. Opium. 3. Narcan. 4. Phenobarbital.

3 1. Morphine is an opiate narcotic. It may be administered to an addicted baby to control diarrhea associated with neonatal abstinence syndrome. 2. Opium is administered to neonates who are exhibiting signs of severe neonatal abstinence syndrome. 3. Narcan is an opiate. If it were to be given to the neonate with neonatal abstinence syndrome, the baby would go into a traumatic withdrawal. 4. Phenobarbital is sometimes administered to drug-exposed neonates to control seizures. TIP: Neonatal abstinence syndrome is the term used to describe the many behaviors exhibited by neonates who are born drug addicted. The behaviors range from hyperreflexia to excessive sneezing and yawning to loose diarrheal stools. Medications may or may not be administered to control the many signs/symptoms of the syndrome.

68. A mother of a preterm baby is performing kangaroo care in the neonatal nursery. Which of the following responses would the nurse evaluate as a positive neonatal outcome? 1. Respiratory rate of 70. 2. Temperature of 97.0°F. 3. Licking the mother's nipples. 4. flaring of the baby's nares.

3 1. Respiratory rate of 70 is above normal. The rate should be between 30 and 60 breaths per minute. 2. Temperature of 97.0ºF is below normal. The temperature should be between 97.6ºF and 99ºF. 3. The baby is showing signs of interest in breastfeeding. This is a positive sign. 4. Nasal flaring is an indication of respiratory distress, which is abnormal. TIP: Kangaroo care, when mothers hold their babies skin-to-skin, is a technique that has been shown to benefit preterm infants. The vital signs of babies who kangaroo with their mothers have been shown to stabilize more quickly. The babies also have been shown to nipple feed earlier and to have shorter lengths of stay in the NICUs.

27. 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? 1. Xiphoid process. 2. Forehead. 3. Abdominal wall. 4. Great toe.

3 1. The appropriate placement for the skin thermal sensor is the abdominal wall, not the xiphoid process. 2. The appropriate placement for the skin thermal sensor is the abdominal wall, not the forehead. 3. The abdominal wall is the appropriate placement for the skin thermal sensor. 4. The appropriate placement for the skin thermal sensor is the abdominal wall, not the great toe. TIP: 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.

48. 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? 1. Monitor daily viral load laboratory reports. 2. Check the baby's viral antibody status. 3. Obtain an order for antiviral medication. 4. Place the baby on strict precautions.

3 1. The baby will have a positive antibody titer, as a result of passive immunity through the placenta, but there will be no evidence of active viral production that early in the newborn's life. 2. There is no need to assess the antibody titer. It will definitely be positive because the mother has HIV/AIDS. 3. 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. 4. There is no need to place the baby on strict precautions. The institution of standard precautions in the well-baby nursery is sufficient. TIP: The test taker should be aware that neonates must be followed after delivery because of the viral exposure in utero. The best way to prevent vertical transmission from the mother to the newborn is to administer antiviral medications to the mother during pregnancy and delivery and for 6 weeks to the newborn following delivery.

61. A neonate has intrauterine growth restriction secondary to placental insufficiency. Which of the following signs/symptoms should the nurse expect to observe at delivery? 1. Thrombocytopenia. 2. Neutropenia. 3. Polycythemia. 4. Hyperglycemia.

3 1. The baby will likely be born with a normal platelet count. 2. The baby will likely be born with a normal white blood cell count. 3. Babies who have lived in utero with an aging placenta usually are born with polycythemia. 4. Rather than hyperglycemia, babies who have lived in utero with an aging placenta usually are born with hypoglycemia. TIP: 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.

13. A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? 1. Cover the foot with an iced wrap for one minute prior to the procedure. 2. Avoid puncturing the lateral heel to prevent damaging sensitive structures. 3. Blot the site with a dry gauze after rubbing it with an alcohol swab. 4. Grasp the calf of the baby during the procedure to prevent injury.

3 1. The foot should be covered with a warm wrap to draw blood to the area for the heel stick. 2. The lateral heel is the site of choice because it contains no major nerves or blood vessels. 3. Alcohol can irritate the punctured skin and can cause hemolysis. 4. The ankle and foot should be firmly grasped during the procedure. TIP: The test taker must be aware of the physiological structures in the body. In the case of a heel stick, if the posterior surface of the heel is punctured, the posterior tibial nerve and artery could be injured.

1. A 1-day-old neonate, 32 weeks' gestation, is in an overhead warmer. The nurse assesses the morning axillary temperature as 96.9°F. Which of the following could explain this assessment finding? 1. This is a normal temperature for a preterm neonate. 2. Axillary temperatures are not valid for preterm babies. 3. The supply of brown adipose tissue is incomplete. 4. Conduction heat loss is pronounced in the baby.

3 1. The normal temperature of a premature baby is the same as a full-term baby. 2. Axillary temperatures, when performed correctly, provide accurate information. 3. Preterm babies are born with an insufficient supply of brown adipose tissue that is needed for thermogenesis, or heat generation. 4. There is nothing in the question that would explain conduction heat loss. TIP: It is important for the test taker not to read into questions. Even though conduction can be a means of heat loss in the neonate and, more particularly, in the premature, there are three other means by which neonates lose heat—-radiation, convection, and evaporation. Conduction could only be singled out as a cause of the hypothermia if it were clear from the question that that were the cause of the problem.

86. A baby is born with a meningomyelocele at L2. In assessing the baby, which of the following would the nurse expect to see? 1. Sensory loss in all four extremities. 2. Tuft of hair over the lumbosacral region. 3. flaccid paralysis of the legs. 4. Positive Moro reflex.

3 1. There should not be sensory loss in all four quadrants. 2. With a myelomeningocele, there will be a sac at the base of the spine, not a tuft of hair. 3. With a defect at L2, the nurse would expect to see paralysis of the legs. 4. The Moro reflex will be asymmetrical because the enervation to the lower extremities is impaired. TIP: If the test taker remembers that a sac with cerebral spinal fluid and nerves is seen at the base of the spine in a baby with myelomeningocele and that L2 innervates the motor nerves of the legs, the answer becomes obvious. This is an example of the importance of carefully studying normal anatomy and physiology and the pathophysiology of important diseases.

78. An infant in the neonatal nursery has low set ears, Simian creases, and slanted eyes. The nurse should monitor this infant carefully for which of the following signs/symptoms? 1. Blood-tinged urine. 2. Hemispheric paralysis. 3. Cardiac murmur. 4. Hemolytic jaundice.

3 1. This baby has Down syndrome. The genetic disease is not associated with bloodtinged urine. 2. Down babies are not at high risk for hemispheric paralysis. 3. Cardiac anomalies occur much more frequently in Down babies than in other babies. 4. Down babies are no more at risk for hemolytic jaundice than are other babies. TIP: Babies with Down syndrome have the following characteristic anomalies: low set ears, simian creases, and slanted eyes. Because they are at high risk for internal anomalies as well, in particular cardiac defects, the nurse should carefully evaluate the baby for a heart murmur.

51. A baby has been admitted to the neonatal nursery whose mother is hepatitis B-surface antigen positive. Which of the following actions by the nurse should be taken at this time? 1. Monitor the baby for signs of hepatitis B. 2. Place the baby on contact isolation. 3. Obtain an order for the hepatitis B vaccine and the immune globulin. 4. Advise the mother that breastfeeding is absolutely contraindicated.

3 1. Vertical transmission of hepatitis B does occur. Symptoms of the disease would not be evident during the neonatal period, however. 2. Standard precautions are sufficient for the care of the baby exposed to hepatitis B in utero. 3. Babies exposed to hepatitis B in utero should receive the first dose of hepatitis B vaccine as well as hepatitis B immune globulin (HBIG) within 12 hours of delivery to reduce transmission of the virus. See http://www.cdc.gov/breastfeeding/disease/hepatitis.htm 4. Breastfeeding is not contraindicated when the mother is hepatitis B positive. TIP: Although breastfeeding is contraindicated when a mother is HIV positive, hepatitis B transmission rates do not change significantly when a mother breastfeeds. The mother should, however, take care to prevent any cracking and bleeding from her breasts since the virus is bloodborne.

96. A baby has been diagnosed with developmental dysplasia of the hip. Which of the following findings would the nurse expect to see? 1. Pronounced hip abduction. 2. Swelling at the site. 3. Asymmetrical leg folds. 4. Weak femoral pulses.

3 1. With DDH there is reduced hip abduction. 2. DDH is not associated with swelling at the site. 3. The leg folds of the baby, both anteriorally and posteriorly, are frequently asymmetrical. 4. Femoral pulses are unaffected by DDH. TIP: Because of the subluxation of the hip, the gluteal and thigh folds of the baby usually appear asymmetrical. In addition to this finding, the nurse would expect to see reduced abduction of the hip and/or asymmetrical knee heights when the legs are flexed.

59. 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. 1. Hyperopia. 2. Gestational diabetes. 3. Substance abuse. 4. Chronic hypertension. 5. Advanced maternal age.

3, 4, and 5 are correct. 1. Hyperopia, another name for farsightedness, is unrelated to placental function. 2. If the mother had gestational diabetes, the nurse would expect the baby to be macrosomic, not to have IUGR. 3. Placental function is affected by the vasoconstrictive properties of many illicit drugs, as well as by cigarette smoke. 4. Placental function is diminished in women who have chronic hypertension. 5. Placental function has been found to be diminished in women of advanced maternal age. TIP: The test taker should be reminded that 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.

67. A preterm baby is to receive 4 mg Garamycin (gentamicin) IV every 24 hours. The medication is being injected into an IV soluset. A total of 5 cc is to be administered via IV pump over 90 minutes. The pump should be set at what rate? __________ mL/hr.

3.33 mL/hr 5 mL/90 min = 5 mL/1.5 hours = 3.33 mL/hr TIP: Whenever a pump is used to deliver intravenous fluids, the rate should be set in mL/hr units. Pumps should always be used to deliver IV fluids to preterm neonates since, because of their small size, they can so easily become fluid overloaded.

38. A baby has been admitted to the neonatal intensive care unit with a diagnosis of postmaturity. The nurse expects to find which of the following during the initial newborn assessment? 1. Abundant lanugo. 2. Flat breast tissue. 3. Prominent clitoris. 4. Wrinkled skin.

4 1. Abundant lanugo is seen in the preterm baby, not the postterm baby. 2. Absence of breast tissue is seen in the preterm baby, not the postterm baby. 3. Prominent clitoris is seen in the preterm baby, not the postterm baby. 4. The postterm baby does have dry, wrinkled, and often desquamating skin. The baby's dehydration is secondary to a placenta that progressively deteriorates after 40 weeks' gestation. TIP: The test taker should be familiar with the characteristic presentations of preterm and postmature neonates. Studying the items on the New Ballard Scale and the corresponding gestational ages when the items are seen are excellent ways to associate certain characteristics with dysmature babies.

39. A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At delivery, thick green amniotic fluid was noted. Which of the following actions by the nurse is critical at this time? 1. Bath to remove meconium-contaminated fluid from the skin. 2. Ophthalmic assessment to check for conjunctival irritation. 3. Rectal temperature to assess for septic hyperthermia. 4. Respiratory evaluation to monitor for respiratory distress.

4 1. Although the fluid is green tinged because the baby expelled meconium in utero, the baby's skin is not at high risk for injury. 2. The conjunctiva are not at high risk for irritation from the meconium-stained fluid. 3. There is nothing in the scenario that suggests that this baby is currently septic. 4. Meconium aspiration syndrome (MAS) is a serious complication seen in postterm neonates who are exposed to meconium-stained fluid. Respiratory distress would indicate that the baby has likely developed MAS. TIP: Although meconium appears black in a newborn's diaper, it is actually a very dark green color. When diluted in the amniotic fluid, therefore, the fluid takes on a greenish tinge. Because meconium is a foreign substance, when aspirated by the baby, a chemical and, secondarily, a bacterial pneumonia often develop.

87. When examining a nenonate in the well-baby nursery, the nurse notes that the sclerae of both of the baby's eyes is visible above the iris of the eyes. Which of the following assessments is highest priority for the nurse to make next? 1. Babinski and tonic neck reflexes. 2. Evaluation of bilateral eye coordination. 3. Blood type and Coombs' test results. 4. Circumferences of the head and chest.

4 1. Babinski and tonic neck reflexes are unrelated to the eye. 2. Pseudostrabismus is normally seen in the neonate. 3. Blood typing and Coombs' testing are unrelated to the eye. 4. The baby should be assessed for signs of hydrocephalus, especially a disparity between the circumferences of the neonatal head and the neonatal chest. TIP: Setting sun sign—-when the sclera of the eye is visible above the iris of the eye-—is one sign of hydrocephalus. An additional indication of hydrocephalus would be if the head circumference of the baby were found to be greater than 2 cm larger than the baby's chest circumference.

84. The nurse caring for a neonate with congestive heart failure identifies which of the following nursing diagnoses as highest priority? 1. Fatigue. 2. Activity intolerance. 3. Sleep pattern disturbance. 4. Altered tissue perfusion.

4 1. Fatigue is an important nursing diagnosis for the baby with congestive heart failure, but it is not the priority diagnosis. 2. Activity intolerance is an important nursing diagnosis for the baby with congestive heart failure, but it is not the priority diagnosis. 3. Sleep pattern disturbance is an important nursing diagnosis for the baby with congestive heart failure, but it is not the priority diagnosis. 4. Altered tissue perfusion is the priority diagnosis. TIP: Whenever the test taker is asked to identify the priority response, it is important to remember the hierarchy of needs. Respiratory issues almost always take precedence. Although the answer to this question does not refer to the respiratory system, it does relate to the oxygenation of the tissues. None of the other responses relates to critical physiological processes.

5. A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is appropriate? 1. Place a pacifier in the baby's mouth. 2. Check the baby's diaper. 3. Have the mother feed the baby. 4. Assess the respiratory rate.

4 1. Grunting is a sign of respiratory distress. Offering a pacifier is an inappropriate intervention. 2. Diapering is an inappropriate intervention. 3. The baby is not hungry. Rather the baby is in respiratory distress. 4. Grunting is often accompanied by tachypnea, another sign of respiratory distress. TIP: If the test taker were to attempt to grunt, he or she would feel the respiratory effort that the baby is creating. Essentially, the baby is producing his or her own positive end-expiratory pressure (PEEP) in order to maximize his or her respiratory function.

56. A macrosomic infant of a non-insulin dependent diabetic mother has been admitted to the neonatal nursery. The baby's glucose level on admission to the nursery is 25 mg/dL and after a feeding of mother's expressed breast milk is 35 mg/dL. Which of the following actions should the nurse take at this time? 1. Nothing because the glucose level is normal for an infant of a diabetic mother. 2. Administer intravenous glucagon slowly over five minutes. 3. Feed the baby a bottle of dextrose and water and reassess the glucose level. 4. Notify the neonatalogist of the abnormal glucose levels.

4 1. Hypoglycemia in the neonate is defined as a glucose level <40 mg/dL. A level of 35 mg/dL, therefore, is not normal. 2. Glucagon may be ordered as a remedy for severe hypoglycemia. Although the glucose level is low, it is unlikely that glucagon is indicated. Plus, the nurse would not administer the medication without an order. 3. Both breast milk and formula contain lactose. If the glucose level has not risen to normal as a result of the feeding, the nurse must notify the physician. 4. If the glucose level has not risen to normal as a result of the feeding, the nurse should notify the physician and anticipate that the doctor will order an intravenous of dextrose and water. TIP: The test taker should be aware that the normal glucose level of a neonate after delivery—40 mg/dL to 90 mg/L—is much lower than the adult normal of 60 to 110 mg/dL. Hypoglycemia is a common problem seen in infants, especially macrosomic infants and infants of diabetic mothers. Protocols to monitor for hypoglycemia in infants of diabetic mothers exist in all well-baby nurseries and NICUs.

75. The nurse is providing discharge teaching to the parents of a baby born with a cleft lip and palate. Which of the following should be included in the teaching? 1. Correct technique for the administration of a gastrostomy feeding. 2. Need to watch for the appearance of blood-stained mucus from the nose. 3. Optimal position for burping after nasogastric feedings. 4. Need to give the baby sufficient time to rest during each feeding.

4 1. It is not necessary to feed these babies via gastrostomy tubes. 2. Blood-stained mucus is not associated with cleft lip or palate. 3. It is not necessary to feed these babies via nasogastric tubes. 4. Cleft lip and palate babies require additional time to rest as well as to suck and swallow when being fed. TIP: Although cleft lips and palates do impact feeding, virtually all of the affected babies are able to feed orally and some are even able to breastfeed. But, feeding from a standard bottle and/or breastfeeding may prove to be impossible for some babies with clefts and/or palates. In those cases, there are a number of bottles that have been designed to facilitate their feeding so that neither gastrostomy tubes nor nasogastric tubes are needed. The Haberman feeder is one example. Either expressed breast milk or formula can be put in the feeder.

11. A newborn admitted to the nursery has a positive direct Coombs' test. Which of the following is an appropriate action by the nurse? 1. Monitor the baby for jitters. 2. Assess the blood glucose level. 3. Assess the rectal temperature. 4. Monitor the baby for jaundice.

4 1. The Coombs' test assesses for the presence of antibodies in the blood. The test will not predict or explain jitters in the neonate. 2. The Coombs' test will not predict or explain hypoglycemia in the neonate. 3. The Coombs' test will not predict or explain a change in temperature in the neonate. 4. When the neonatal bloodstream contains antibodies, hemolysis of the red blood cells occurs and jaundice develops. TIP: The indirect Coombs' test is performed on the pregnant woman to detect whether or not she carries antibodies against her fetus' red blood cells. The direct Coombs' test is performed on the newborn to detect whether or not he or she carries maternal antibodies in his or her blood.

15. A neonate is under phototherapy for elevated bilirubin levels. The baby's stools are now loose and green. Which of the following actions should the nurse take at this time? 1. Discontinue the phototherapy. 2. Notify the health care practitioner. 3. Take the baby's temperature. 4. Assess the baby's skin integrity.

4 1. The stools are green from the increase in excreted bilirubin. 2. There is no need to inform the health care practitioner. Green stools are an expected finding. 3. Although green stools can be seen with diarrheal illnesses, in this situation, the green stools are expected and not related to an infectious state. 4. The stools can be very caustic to the baby's delicate skin. The nurse should cleanse the area well and inspect the skin for any sign that the skin is breaking down. TIP: The test taker must know the difference between signs that are normal and those that reflect a possible illness. Although green stools can be seen with diarrheal illnesses, in this situation, the green stools are expected. The green stools are due to the increased bilirubin excreted and not related to an infectious state.

77. The nurse is teaching a couple about the special health care needs of their newborn child with Down syndrome. The nurse knows that the teaching was successful when the parents state that the child will need which of the following? 1. Yearly three-hour glucose tolerance testing. 2. Immediate intervention during bleeding episodes. 3. A formula that is low in lactose and phenylalanine. 4. Prompt treatment of upper respiratory infections.

4 1. There is no need for Down syndrome children to undergo yearly glucose tolerance testing. 2. Down syndrome babies are not at high risk for bleeding episodes. 3. Down babies do not require special formulas. And although it can be a difficult beginning, many Down babies are successful breastfeeders. 4. Because of the hypotonia of the respiratory accessory muscles, Down babies often need medical intervention when they have respiratory infections. TIP: Down syndrome babies not only have a characteristic appearance but also have physiological characteristics that the nurse must be familiar with. One of those characteristics is hypotonia. Because of this problem, Down babies are often difficult to feed during the neonatal period, have delayed growth and development, and have difficulty fighting upper respiratory illnesses.

102. A nurse hears a heart murmur on a full-term neonate in the well baby nursery. The baby's color is pink while at rest and while feeding. The baby most likely has which of the following cardiac defects? 1. Transposition of the great vessels. 2. Tetralogy of Fallot. 3. Pulmonic stenosis. 4. Patent ductus arteriosus.

4 1. Transposition of the great vessels is a cyanotic defect that, if it stands alone, is incompatible with life. 2. Tetralogy of Fallot is a cyanotic defect characterized by four defects: VSD, pulmonic stenosis, overriding aorta, and right ventricular hypertrophy. 3. Pulmonic stenosis is characterized by a narrowed pulmonic valve. The blood, therefore, is restricted from entering the pulmonary artery and the lungs in order to be oxygenated. 4. Patent ductus arteriosus (PDA) is a very common cardiac defect in preterm babies. It is an acyanotic defect with a left to right shunt. Already oxygenated blood reenters the pulmonary system. TIP: The names of cardiac defects are very descriptive. Once the test taker remembers the pathophysiology of each of the defects, it becomes clear how the blood flow is affected. Of the choices in this question, the only defect that is an acyanotic defect, i.e., a defect that allows blood to enter the lungs to be oxygenated, is the PDA.

28. The nurse must perform nasopharyngeal suctioning of a newborn with profuse secretions. Place the following nursing actions for nasopharyngeal suctioning in chronological order. 1. Slowly rotate and remove the suction catheter. 2. Place thumb over the suction control on the catheter. 3. Assess type and amount of secretions. 4. Insert free end of the tubing through the nose.

4, 2, 1, and 3 is the correct order. 1. Rotation and removal of the suction catheter should be done after the tubing has been inserted through the nose and a thumb placed over the suction control on the catheter. 2. The nurse should place a thumb over the suction control on the catheter after inserting the free end of the tubing through the nose—and before the other two steps are taken. 3. Assessing the type and amount of secretions in the last step in the process. 4. Inserting the free end of the tubing through the nose is the first step in nasopharyngeal suctioning process. TIP: It is important for the test taker to remember that once the suction control is covered, the baby is unable to take in air. It is important, therefore, not to cover the suction control until the catheter is being removed.

64. A neonatalogist prescribes Garamycin (gentamicin) for a 2-day-old, septic preterm infant who weighs 1653 grams and is 38 centimeters long. The drug reference states: Neonatal dosage of Garamycin for babies less than 1 week of age is 2.5 mg/kg q 12-24 hours. Calculate the safe daily dosage of this medication. __________ mg q 24 hours.

4.13 mg q 24 hours The formula for calculating the safe dosage (per weight) is: Known dosage = Needed dosage 1 kg Weight of the child in kg 2.5 mg = x mg 1 kg 1.653 kg x = 4.13 mg q 24 hours TIP: When calculating the safe dosage of a medication for a child, the test taker must first note whether the recommended dosage for the medication is written per kg or per meters squared. If the dosage is written per kg, then the denominator of the ratio and proportion equation is in kg. If the dosage is written per m², the denominator of the ratio and proportion equation is in m².

82. In the delivery room, which of the following infant care interventions must a nurse perform when a neonate with a meningomyelocele is born? 1. Perform nasogastric suctioning. 2. Place baby in the prone position. 3. Administer oxygen via face mask. 4. Swaddle the baby in warm blankets.

5 1. It is not routinely necessary to perform nasogastric suctioning on a baby born with a meningomyelocele. 2. The baby should be lain prone to prevent injury to the sac. 3. It is not routinely necessary to administer oxygen to a baby born with a meningomyelocele. 4. A baby born with a meningomyelocele should not be swaddled. TIP: The baby with meningomyelocele is born with an opening at the base of the spine through which a sac protrudes. The sac contains cerebral spinal fluid and nerve endings from the spinal cord. It is essential that the nurse not injure the sac; therefore, the baby should be placed in a prone position immediately after birth.

31. The nurse assesses a newborn as follows: heart rate: 70 respirations: weak and irregular tone: flaccid color: pale baby grimaces when a pediatrician attempts to insert an endotracheal tube What should the nurse calculate the baby's Apgar score to be?

The baby's Apgar score is 3. TIP: Assessing the Apgar score is often a nursing function. The test taker, therefore, should know the criteria for the Apgar score. The score is traditionally performed at 1 and 5 minutes after birth. A total score of 7 to 10 means that the baby is having little to no difficulty transitioning to extrauterine life. With a total score of 4 to 6, the baby is having moderate difficulty transitioning to extrauterine life. Resuscitative measures may need to be instituted. With a total score of 0 to 3, the baby is in severe distress. Resuscitative measures must be instituted.