CH 32 OB

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? Select all that apply. 1. Increased pulse 2. High blood pressure 3. Tachycardia 4. Bradycardia 5. Capillary filling time greater than 3 seconds

3, 5

Which nursing intervention is appropriate in the management of the preterm infant with hypothermia? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Warm the baby rapidly to reverse the hypothermia. 2. Monitor skin temperature every 2 hours to determine whether the infants temperature is increasing. 3. Keep IV fluids at room temperature. 4. Initiate efforts to maintain the newborn in a neutral thermal environment. 5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

4, 5

Which findings would the nurse expect when assessing a newborn infected with syphilis? Select all that apply. 1. Rhinitis 2. Fissures on mouth corners 3. Red rash around anus 4. Lethargy 5. Large for gestational age

1, 2, 3

The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment? Select all that apply. 1. Hemoglobin 2. Hematocrit 3. Reticulocyte count 4. Direct Coombs test 5. Cord serum OgM

1, 2, 3, 4

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? Select all that apply. 1. Lights can stay on all the time. 2. The eyes do not need to be covered. 3. The lights will need to be removed for feedings. 4. Newborns do not get overheated. 5. Weight loss is not a complication of this system.

1, 2, 4, 5

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Select all that apply. 1. Obtain skin cultures. 2. Restrict parental visits. 3. Evaluate bilirubin levels. 4. Administer oxygen as ordered. 5. Observe for signs of hypoglycemia.

1, 3, 4, 5

When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate? Select all that apply. 1. Hypoxia 2. Respiratory alkalosis 3. Metabolic acidosis 4. Massive atelectasis 5. Pulmonary edema

1, 3, 4, 5

Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn? Select all that apply. 1. Nonreassuring fetal heart rate pattern/sustained bradycardia 2. Fetal scalp/capillary blood sample pH greater than 7.25 3. History of meconium in amniotic fluid 4. Prematurity 5. Significant intrapartum bleeding

1, 3, 4, 5

The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Select all that apply. 1. Physiologic jaundice occurs after 24 hours of age. 2. Pathologic jaundice occurs after 24 hours of age. 3. Phototherapy increases serum bilirubin levels. 4. The need for phototherapy depends on the bilirubin level and age of the infant. 5. Kernicterus causes irreversible neurological damage.

1, 5

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? 1. Begin chest compressions. 2. Begin direct tracheal suctioning. 3. Begin bag-and-mask ventilation. 4. Obtain a blood pressure reading.

Begin bag-and-mask ventilation.

The nurse notes that a 36-hour-old newborns 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? 1. Continue to observe 2. Begin phototherapy 3. Begin blood exchange transfusion 4. Stop breastfeeding

Begin phototherapy

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? 1. A history of obsessive-compulsive disorder (OCD) 2. Chlamydia 3. Delivered six other children by cesarean section 4. A urinary tract infection (UTI)

Chlamydia

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? 1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions. 2. Direct tracheal suctioning by specially trained personnel. 3. Preparation for the immediate use of positive pressure to expand the lungs. 4. Suctioning of the oropharynx when the newborns head is delivered.

Direct tracheal suctioning by specially trained personnel.

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? 1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.

Intravenous acyclovir (Zovirax) and contact precautions.

Mild or chronic anemia in an infant may be treated adequately which of the following? 1. Transfusions with O-negative or typed and cross-matched packed red cells 2. Iron supplements or iron-fortified formulas 3. Steroid therapy 4. Antibiotics or antivirals

Iron supplements or iron-fortified formulas

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? 1. If I had taken better care of myself, this wouldnt have happened. 2. Ive been sleeping very well since I had the baby. 3. This is probably the doctors fault. 4. If I hadnt seen our babys birth, I wouldnt believe she is ours.

Ive been sleeping very well since I had the baby.

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? 1. Jitteriness 2. Sucking on fingers 3. Lusty cry 4. Axillary temperature of 98F

Jitteriness

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? 1. Grunting respirations 2. Nasal flaring 3. Respiratory rate of 40 during sleep 4. Chest retractions

Respiratory rate of 40 during sleep

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? 1. Increased skin temperature and respirations 2. Blood glucose level of 45 3. Room-temperature IV running 4. Positioned under radiant warmer

Room-temperature IV running

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? 1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. 2. Use a previous puncture site. 3. Cool the heel prior to obtaining blood. 4. Use a sterile needle and aspirate.

Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood.

What indications would lead the nurse to suspect sepsis in a newborn? 1. Respiratory distress syndrome developing 48 hours after birth 2. Temperature of 97.0F 2 hours after warming the infant from 97.4F 3. Irritability and flushing of the skin at 8 hours of age 4. Bradycardia and tachypnea developing when the infant is 36 hours old

Temperature of 97.0F 2 hours after warming the infant from 97.4F

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? 1. The newborn maintains a normal temperature 2. An increase of serum bilirubin levels 3. Weight loss 4. Skin blanching yellow

The newborn maintains a normal temperature

During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? 1. The rise and fall of the chest 2. Sudden wakefulness 3. Urinary output 4. Adequate thermoregulation

The rise and fall of the chest

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 infants condition? 1. Meconium aspiration syndrome 2. Transient tachypnea of the newborn 3. Respiratory distress syndrome 4. Prematurity of the neonate

Transient tachypnea of the newborn

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? 1. Urine specific gravity is assessed each voiding. 2. Eye coverings are left off to help keep the baby calm. 3. Temperature is checked every 6 hours. 4. The infant is taken out of the isolette for diaper changes.

Urine specific gravity is assessed each voiding.

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? 1. Your newborn likes to be touched. 2. Stroking the newborn will help with stimulation. 3. Visits must be scheduled between feedings. 4. Your baby loves her pink blanket.

Visits must be scheduled between feedings.

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? 1. Ill bring you to your baby and then leave so you can have some privacy. 2. Your baby is on a ventilator with 50% oxygen, and has an umbilical line. 3. I am so sorry this has all happened. I know how stressful this can be. 4. Your baby is working hard to breathe and lying quite still, and has an IV.

Your baby is working hard to breathe and lying quite still, and has an IV.

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? 1. The RhoGAM you received at 28 weeks gestation did not prevent alloimmunization. 2. Your body has made antibodies against the babys blood that are destroying her red blood cells. 3. The red blood cells of your baby are breaking down because you both have type O blood. 4. Your babys liver is too immature to eliminate the red blood cells that are no longer needed.

Your body has made antibodies against the babys blood that are destroying her red blood cells

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? 1. Initial resuscitation 2. Vigorous stimulation at birth 3. Phototherapy immediately 4. An initial feeding of iron-enriched formula

Initial resuscitation

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Select all that apply. 1. Jaundice present within the first 24 hours of life 2. Appearance of jaundice symptoms after 24 hours of life 3. Yellowish coloration of the sclera of the eyes 4. Cephalohematoma or excessive bruising 5. Cyanosis

2, 3

Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Cover the newborns eyes at all times, even when not under the lights. 2. Close the newborns eyelids before applying eye patches. 3. Inspect the eyes each shift for conjunctivitis. 4. Keep the baby swaddled in a blanket to prevent heat loss. 5. Reposition the baby every 2 hours.

2, 3, 5

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. 1. Northern European descent 2. Previous sibling received phototherapy 3. Gestational age 27 to 30 weeks 4. Exclusive breastfeeding 5. Infection

2, 4, 5

A newborn is receiving phototherapy. Which intervention by the nurse would be most important? 1. Measurement of head circumference 2. Encouraging the mother to stop breastfeeding 3. Stool blood testing 4. Assessment of hydration status

Assessment of hydration status

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? 1. Eyes are covered, no clothing on, diaper in place 2. Axillary temperature 99.7F 3. Infant removed from the isolette for breastfeeding 4. Loose bowel movement

Axillary temperature 99.7F

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 nurses assessment? 1. Decreased urine output 2. Pulmonary vascular resistance increases 3. Increased PCO2 4. Increased urination

Increased urination