Ch 27: The Newborn at Risk: Birth-Related Stressors
18) The nurse is observing a student nurse who is caring for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? A) Urine specific gravity is assessed at each voiding. B) Eye coverings are left off to help keep the baby calm. C) Temperature is checked every 6 hours. The infant is taken out of the isolette for diaper changes
Answer: A Explanation: A) This action is correct. Specific gravity provides one measure of urine concentration. Highly concentrated urine is associated with a dehydrated state. Weight loss is also a sign of developing dehydration in the newborn. B) Eyes should be covered at all times. C) Six hours is too long. Vital signs should be monitored every 4 hours with axillary temperatures. D) The isolette helps the infant maintain his or her temperature while undressed. The diaper should be changed while the infant is under the lights in the isolette, as care activities should be clustered. Page Ref: 846
8) Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? A) Jitteriness B) Sucking on fingers C) Lusty cry D) Axillary temperature of 98°F
Answer: A Explanation: A) Jitteriness of the newborn is associated with hypoglycemia. Aggressive treatment is recommended after a single low blood glucose value if the infant shows this symptom. B) Sucking on the fingers is a normal finding. C) A lusty cry is a normal finding. D) An axillary temperature of 98°F is a normal finding. Page Ref: 828
19) The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? A) The newborn maintains a normal temperature B) An increase of serum bilirubin levels C) Weight loss D) Skin blanching yellow
Answer: A Explanation: A) Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy. The isolette helps the infant maintain his or her temperature while undressed. B) Phototherapy is a primary intervention that is used for the prevention of hyperbilirubinemia, to halt bilirubin levels from climbing dangerously high. C) Weight loss is a sign of developing dehydration in the newborn. The newborn should be weighed daily. D) Yellowing in the skin should disappear with effective phototherapy. Page Ref. 835
1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require which of the following? A) Initial resuscitation B) Vigorous stimulation at birth C) Phototherapy immediately D) An initial feeding of iron-enriched formula
Answer: A Explanation: A) The presence of meconium in the amniotic fluid indicates that the fetus may be suffering from asphyxia. Meconium-stained newborns or newborns who have aspirated particulate meconium often have respiratory depression at birth and require resuscitation to establish adequate respiratory effort. B) Stimulation at birth should be avoided to minimize respiratory movements. C) Phototherapy is not required immediately. D) Mild or chronic anemia in an infant may be treated adequately with iron supplements alone or with iron-fortified formulas. Page Ref: 822
9) A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. B) Use a previous puncture site. C) Cool the heel prior to obtaining blood. D) Use a sterile needle and aspirate.
Answer: A Explanation: A) The site should be cleaned by rubbing vigorously with a 70% isopropyl alcohol swab. The friction produces local heat, which aids vasodilation. B) A microlancet is used to make the puncture in an unpunctured site. C) The heel should not be cooled. D) A microlancet, not a needle, is used to make the puncture. Page Ref: 829
3) During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? A) The rise and fall of the chest B) Sudden wakefulness C) Urinary output D) Adequate thermoregulation
Answer: A Explanation: A) With proper resuscitation, chest movement is observed for proper ventilation. Pressure should be adequate to move the chest wall. B) Sudden wakefulness is not associated with effectiveness of bag-and-mask ventilations. C) Urinary output is not associated with effectiveness of bag-and-mask ventilations. D) Adequate thermoregulation is not associated with effectiveness of bag-and-mask ventilations. Page Ref: 808
11) The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Lights can stay on all the time. B) The eyes do not need to be covered. C) The lights will need to be removed for feedings. D) Newborns do not get overheated. E) Weight loss is not a complication of this system.
Answer: A, B, D, E Explanation: A) With the fiber-optic blanket, the light stays on at all times. B) The eyes do not have to be covered with a fiber optic blanket. C) With the fiber-optic blanket, the light stays on at all times, and the newborn is accessible for care, feeding, and diaper changes. D) With the fiber-optic blanket, greater surface area is exposed and there are no thermoregulation issues. E) Fluid and weight loss are not complications of fiber-optic blankets. Page Ref: 835
23) Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Obtain skin cultures. B) Restrict parental visits. C) Evaluate bilirubin levels. D) Administer oxygen as ordered. E) Observe for signs of hypoglycemia.
Answer: A, C, D, E Explanation: A) The nurse will assist in obtaining skin cultures. Skin cultures are taken of any lesions or drainage from lesions or reddened areas. B) Restricting parental visits has not been shown to have any effect on the rate of infection and may be harmful to the newborn's psychologic development. C) The nurse will observe for hyperbilirubinemia, anemia, and hemorrhagic symptoms. D) The nurse will administer oxygen as ordered. E) ) The nurse will observe for signs of hypoglycemia. Page Ref: 846
13) The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Physiologic jaundice occurs after 24 hours of age. B) Pathologic jaundice occurs after 24 hours of age. C) Phototherapy increases serum bilirubin levels. D) The need for phototherapy depends on the bilirubin level and age of the infant. E) Kernicterus causes irreversible neurological damage.
Answer: A, E Explanation: A) Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life, and appears after 24 hours of life. B) Diagnosis of pathologic jaundice is given to newborns who exhibit jaundice within the first 24 hours of life. C) Phototherapy decreases serum bilirubin levels. D) The decision to start phototherapy is based on two factors: gestational age and age in hours. E) Kernicterus refers to the deposition of unconjugated bilirubin in the basal ganglia of the brain and to permanent neurologic sequelae of untreated hyperbilirubinemia. Page Ref: 831
26) One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? A) Meticulous hand washing and antibiotic eye ointment administration. B) Intravenous acyclovir (Zovirax) and contact precautions. C) Cultures of blood and CSF and serial chest x-rays every 12 hours. D) Parental rooming-in and four intramuscular injections of penicillin.
Answer: B Explanation: A) Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or chlamydia. B) Administering intravenous acyclovir (Zovirax) and contact precautions are appropriate measures for an infant at risk for developing herpes simplex 2 infection. C) Cultures of blood and CSF cultures are appropriate, but chest X-rays are not indicated. Chest X-rays are obtained if the neonate is thought to have group B strep pneumonia. D) Parental rooming-in is encouraged, but penicillin does not treat viral illness. Page Ref: 842
15) The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? A) "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells." C) "The red blood cells of your baby are breaking down because you both have type O blood." D) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."
Answer: B Explanation: A) Although this statement is true, the term "alloimmunization" is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology. B) This explanation is accurate and easy for the client to understand. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin. C) Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if mother is O and baby is A or B. D) The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice. Page Ref: 831
14) The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? A) Continue to observe B) Begin phototherapy C) Begin blood exchange transfusion D) Stop breastfeeding
Answer: B Explanation: A) Continued observation is only appropriate with normal findings. B) Neonatal hyperbilirubinemia must be considered pathologic if the serum bilirubin concentration is rising by more than 0.2 mg/dL per hour. If the newborn is over 24 hours old, which is past the time where an increase in bilirubin would result from pathologic causes, phototherapy may be the treatment of choice to prevent the possible complications of kernicterus. C) If a newborn has hemolysis with an unconjugated bilirubin level of 14 mg/dL, weighs less than 2500 g (birth weight), and is 24 hours old or less, an exchange transfusion may be the best management. This newborn is 36-hours-old. D) The newborn may continue to breastfeed. Page Ref: 832
12) The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? A) Eyes are covered, no clothing on, diaper in place B) Axillary temperature 99.7°F C) Infant removed from the isolette for breastfeeding D) Loose bowel movement
Answer: B Explanation: A) Eye coverings are used because it is not known if phototherapy injures delicate eye structures, particularly the retina. Because the tissue absorbs the light, best results are obtained when there is maximum skin surface exposure. B) Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7°F-98.6°F. Vital signs should be monitored every 4 hours with axillary temperatures. C) Breastfeeding should continue during phototherapy; removing the infant for feedings repositions the infant to prevent pressure areas. D) Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. Page Ref: 835
25) The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? A) A history of obsessive-compulsive disorder (OCD) B) Chlamydia C) Delivered six other children by cesarean section D) A urinary tract infection (UTI)
Answer: B Explanation: A) Obsessive-compulsive disorder (OCD) is not a risk factor for the infant. B) Infants born to mothers with chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and require close observation of the respiratory status and eyes. C) Having multiple siblings, regardless of how they were delivered, is not a risk factor for the infant. D) An infant whose mother has an untreated urinary tract infection might have been exposed to pathogens, but it is not known whether the mother in this question is on antibiotics. Page Ref: 843
21) Mild or chronic anemia in an infant may be treated adequately by which of the following? A) Transfusions with O-negative or typed and cross-matched packed red cells B) Iron supplements or iron-fortified formulas C) Steroid therapy D) Antibiotics or antivirals
Answer: B Explanation: A) Severe cases of anemia are treated with transfusions with O-negative or typed and cross-matched packed red cells. B) Mild or chronic anemia in an infant may be treated adequately with iron supplements or iron-fortified formulas. C) Management of anemia of prematurity includes treating the causative factor (e.g., antibiotics or antivirals used for infection or steroid therapy for disorders of erythrocyte production). D) Management of anemia of prematurity includes treating the causative factor (e.g., antibiotics or antivirals used for infection or steroid therapy for disorders of erythrocyte production). Page Ref: 840
28) The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? A) "If I had taken better care of myself, this wouldn't have happened." B) "I've been sleeping very well since I had the baby." C) "This is probably the doctor's fault." D) "If I hadn't seen our baby's birth, I wouldn't believe she is ours."
Answer: B Explanation: A) Some parents may feel guilty about their baby's condition and think they have caused the problem. B) A sick infant is a source of great anxiety for parents. This response is from the mother would be unexpected. C) Parents express grief as shock and disbelief, denial of reality, anger toward self and others, guilt, blame, and concern for the future. D) Parents express grief as shock and disbelief, denial of reality, anger toward self and others, guilt, blame, and concern for the future. Page Ref: 835
22) What indications would lead the nurse to suspect sepsis in a newborn? A) Respiratory distress syndrome developing 48 hours after birth B) Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming. C) Irritability and flushing of the skin at 8 hours of age D) Bradycardia and tachypnea developing when the infant is 36 hours old
Answer: B Explanation: A) The infant may deteriorate rapidly in the first 12 to 24 hours after birth if β-hemolytic streptococcal infection is present. B) Temperature instability is often seen with sepsis. Fever is rare in a newborn. C) Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, and the skin is cool and clammy. D) Tachycardia and periods of apnea are seen with sepsis. Page Ref: 845
5) A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of 80. What does the nurse anticipate? A) Delivery of the neonate on its side with head up, to facilitate drainage of secretions. B) Direct tracheal suctioning by specially trained personnel. C) Preparation for the immediate use of positive pressure to expand the lungs. D) Suctioning of the oropharynx when the newborn's head is delivered.
Answer: B Explanation: A) The newborn is not delivered on its side. B) If the infant has absent or depressed respirations, heart rate less than 100 beats/min, or poor muscle tone, direct tracheal suctioning by specially trained personnel is recommended. C) Positive pressure is not used to expand the lungs. D) Current evidence does not support intrapartum oropharyngeal and nasopharyngeal suctioning as they do not prevent or alter the course of MAS. Page Ref: 808
6) The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition? A) Meconium aspiration syndrome B) Transient tachypnea of the newborn C) Respiratory distress syndrome D) Prematurity of the neonate
Answer: B Explanation: A) There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome. B) The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn. C) The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome. D) The infant is not premature. Page Ref: 816
16) Which of the following are considered risk factors for development of severe hyperbilirubinemia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Northern European descent B) Previous sibling received phototherapy C) Gestational age 27 to 30 weeks D) Exclusive breastfeeding E) Infection
Answer: B, D, E Explanation: A) East Asian or Mediterranean descent is considered a risk factor for development of severe hyperbilirubinemia. B) Previous sibling received phototherapy is considered a risk factor for development of severe hyperbilirubinemia. C) Gestational age 35 to 36 weeks (late preterm gestational age) is considered a risk factor for development of severe hyperbilirubinemia. D) Exclusive breastfeeding, particularly if nursing is not going well and excessive weight loss is experienced, is considered a risk factor for development of severe hyperbilirubinemia. E) Infection is considered a risk factor for development of severe hyperbilirubinemia. Page Ref: 832
2) A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best? A) Begin chest compressions. B) Begin direct tracheal suctioning. C) Begin bag-and-mask ventilation. D) Obtain a blood pressure reading.
Answer: C Explanation: A) Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established. B) Direct tracheal suctioning would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid in the question. C) Most newborns can be effectively resuscitated by bag-and-mask ventilation. D) Blood pressure is insignificant during resuscitation efforts. This infant needs respirations established. Page Ref: 809
10) The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? A) Increased skin temperature and respirations B) Blood glucose level of 45 C) Room-temperature IV running D) Positioned under radiant warmer
Answer: C Explanation: A) Decreased skin temperature and decreased respirations are signs and symptoms of cold stress. B) A blood glucose level of 45 is an adequate blood sugar in a neonate. A level lower than 40 indicates the infant is hypoglycemic. C) IV fluids should be warmed prior to administration and the newborn can be wrapped in a chemically activated warming mattress immediately following birth to decrease the postnatal fall in temperature that normally occurs. D) Radiant warmers are used to gradually increase the neonate's temperature. Page Ref: 827
4) A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). Which of the following signs and symptoms would not be characteristic of RDS? A) Grunting respirations B) Nasal flaring C) Respiratory rate of 40 during sleep D) Chest retractions
Answer: C Explanation: A) Grunting with respirations is a characteristic of RDS. B) Nasal flaring is a characteristic of RDS. C) A respiratory rate of 40 during sleep is normal. D) Significant chest retractions are characteristic of RDS. Page Ref: 815
27) The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? A) "Your newborn likes to be touched." B) "Stroking the newborn will help with stimulation." C) "Visits must be scheduled between feedings." D) "Your baby loves her pink blanket."
Answer: C Explanation: A) Statements that encourage the parents to touch the newborn will help them bond with their child. B) Statements that encourage the parents to stroke the newborn will help them bond with their child and provide stimulation. C) The nurse should always encourage parents to visit and get to know their newborn, even in the NICU. Nurses foster the development of a safe, trusting environment by viewing the parents as essential caregivers, not as visitors or nuisances in the unit. D) Comments that personalize the baby will tell the parents their baby is unique and special. Page Ref: 849
20) The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Increased pulse B) High blood pressure C) Tachycardia D) Bradycardia E) Capillary filling time greater than 3 seconds
Answer: C, E Explanation: A) Decreased pulse would be a sign of shock. B) Low blood pressure would be a sign of shock. C) Tachycardia would be a sign of shock. D) Tachycardia, not bradycardia, would be a sign of shock. E) Capillary filling time greater than 3 seconds would be a sign of shock. Page Ref: 840
7) A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment? A) Decreased urine output B) Pulmonary vascular resistance increases C) Increased PCO2 D) Increased urination
Answer: D Explanation: A) Increased urination, not decreased urine output, could be an indication that the newborn's condition is improving. B) Pulmonary vascular resistance increases with hypoxia. C) Increased PCO2 results from alveolar hypoventilation. D) In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination/diuresis may be an early clue that the baby's condition is improving. Page Ref: 815
17) A newborn is receiving phototherapy. Which intervention by the nurse would be most important? A) Measurement of head circumference B) Encouraging the mother to stop breastfeeding C) Stool blood testing D) Assessment of hydration status
Answer: D Explanation: A) Phototherapy does not affect head circumference. B) Breastfeeding most likely can be continued. C) The stools do not need to be tested for blood. D) Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. This increases their risk of dehydration. Page Ref: 835
24) The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? A) "I'll bring you to your baby and then leave so you can have some privacy." B) "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." C) "I am so sorry this has all happened. I know how stressful this can be." D) "Your baby is working hard to breathe and lying quite still, and has an I V."
Answer: D Explanation: A) When bringing parents to see their ill newborn for the first time, it is important to prepare them for what they will see. Bringing parents without preparation is inappropriate. B) Although this statement describes the treatment the baby is receiving, it is worded in medical jargon that will not be understood by most parents. The nurse should describe the equipment being used for the at-risk newborn and its purpose before entering the unit. C) This response focuses on the nurse. Avoid saying "I know how you feel," because it is impossible for the nurse to actually know how clients feel. D) This answer is best because it explains what the parents will see in terminology that they will understand. A trusting relationship is essential for collaborative efforts in caring for the infant. The nurse should respond therapeutically to relate to the parents on a one-to-one basis. Page Ref: 849
