OB High Risk Newborn
In the NICU you're caring for baby Jasmine, who was born at 26 weeks 4 days approximately 7 weeks ago. She's been doing well so far, but her first weeks of life were difficult and required significant interventions, including several weeks of mechanical ventilation, sepsis, intraventricular hemorrhage, and a blood transfusion. Her mom has type two diabetes, and baby Jasmine had a low birth weight at delivery. What neonatal complication is Jasmine at risk for developing?
Retinopathy of prematurity (Jasmine is at risk of developing retinopathy of prematurity due to her low birth weight and extreme prematurity. Combined with her other complications and her mother's diabetes, she'll need to be monitored closely for retinal changes.)
A nurse is caring for a 28-week gestation infant. What assessment finding would the nurse determine as being consistent with this gestational age? a. Abundant lanugo b. Hypertonia c. Flexed posture d. Descended testes
a. Abundant lanugo
Zika is an arbovirus that can infect the neonate in utero. What would the nurse explain as the method of transmission to the parents? a. Trans-placental transfer b. Ascending infection c. Intrapartum exposure d. Horizontal transmission
a. Trans-placental transfer
A mother states to the nurse, "I want to breastfeed, but my baby is too fragile to hold." What can the nurse recommend to support breastfeeding by the mother? a. Use donor breast milk to feed the infant. b. Begin using a breast pump and storing milk for the infant. c. Place cabbage on her breasts to prevent engorgement until the baby can nurse. d. Use ice packs if breasts become firm and sore.
b. Begin using a breast pump and storing milk for the infant.
During the cardiac assessment of a preterm neonate, the nurse is likely to identify what abnormality? a. Hypertension b. Heart murmur c. Capillary refill less than 3 seconds d. Increased hemoglobin and hematocrit
b. Heart murmur
The nurse is teaching the parents of a preterm infant about necrotizing enterocolitis (NEC). What statement indicates to the nurse that teaching has been successful? a. "This condition causes increased digestion and diarrhea." b. "Full term infants are at the highest risk for developing NEC." c. "The rotavirus vaccine will help protect my baby from NEC." d. "Breastfeeding will help protect my baby's gut from NEC."
d. "Breastfeeding will help protect my baby's gut from NEC."
A nurse is assessing a 28-week neonate who is on 25% oxygen at 0.5 L/m via nasal cannula. The infant is pale with O2 saturation of 75%. What is the first intervention to perform? a. Call the health care provider for orders. b. Increase the oxygen percentage. c. Increase the oxygen flow rate. d. Assess the infant's airway.
d. Assess the infant's airway
The nurse is administering oxygen to a 29-week gestation infant. To decrease the risk of retinopathy of prematurity (ROP), what safety measure does the nurse utilize? a. Use an oxygen blender to administer oxygen b. Never let the infant's oxygen saturation drop below 95%. c. Rotate the pulse oximetry site daily. d. Administer humidified oxygen via a nasal cannula.
a. Use an oxygen blender to administer oxygen
A neonate born at 28 weeks is 9 days old. During the nurse's assessment, symptoms of necrotizing enterocolitis (NEC) are noted. What is the highest priority symptom to address? a. Unstable temperature b. Bloody stool c. Increased gastric residual d. Abdominal distension
a. Unstable temperature
The nurse is teaching parents about home use of the fiberoptic bili blanket. Which statement by the mother indicates effective teaching? a. "I should dress my baby before wrapping him in the bili blanket." b. "I should wrap my baby from neck to toe in the bili blanket." c. "I can unwrap my baby for feedings." d. "I should keep the bili blanket on 24 hours a day."
d. "I should keep the bili blanket on 24 hours a day."
High-risk neonates that can be assisted by the use of a pacifier include which of the following? Select all that apply. a. An infant who is 1150 gm. b. An infant diagnosed with patent ductus arteriosus. c. An infant who is gavage fed. d. An infant withdrawing from intrauterine exposure to a narcotic. e. An infant diagnosed with necrotizing enterocolitis.
a. An infant who is 1150gm c. An infant who is gavage feed d. An infant withdrawing from intrauterine exposure to a narcotic
A 30-week gestation infant has been born at a small rural hospital with no neonatal intensive care unit (NICU). The health care team has decided that the infant will be transferred via ambulance to a regional care center 45 minutes away. Place the following nursing interventions in the correct order in which they will need to be performed. 1. Call and report pertinent information regarding maternal and neonatal histories to the regional care center 2. Dispatch the appropriate healthcare team and equipment needed for the transport 3. Inform the parents of the infant's status upon arrival at the regional care center 4. Provide developmental care to the infant, including light and sound protection during transport
1. Call and report pertinent information regarding maternal and neonatal histories to the regional care center 2. Dispatch the appropriate healthcare team and equipment needed for the transport 4. Provide developmental care to the infant, including light and sound protection during transport 3. Inform the parents of the infant's status upon arrival at the regional care center
The nurse is caring for a preterm infant who has recently started enteral feedings. What assessment findings would the nurse associate with the possible development of necrotizing enterocolitis (NEC)? Select all that apply. a. Blood in the stool b. Vomiting c. Distended abdomen d. Decreased gastric residuals e. Visible bowel loops
a. Blood in the stool b. Vomiting c. Distended abdomen e. Visible bowel loops
Baby Cheyenne was born 38 hours ago at 39 weeks 2 days. Her delivery was uneventful, but she does have a small cephalohematoma. As you assess her, you notice she has a pale yellow hue to her sclera. Her mother states she's been breastfeeding frequently. What neonatal complication is Cheyenne showing evidence of developing?
Hyperbilirubinemia (Breastfeeding and a cephalohematoma are both risk factors for developing hyperbilirubinemia. Other risk factors include blood incompatibility with her mother, delayed cord clamping, prematurity, infection, and a sibling who also had hyperbilirubinemia as a neonate. The yellow hue of her sclera indicates that she does have some jaundice occurring.)
Despite maintaining a neutral thermal environment, a premature infant continues to have hypothermia. What intervention should the nurse perform next? a. Check the infant's blood glucose. b. Order an IV infusion of warmed saline. c. Place the infant under double bili lights. d. Continue to monitor and document findings.
a. Check the infant's blood glucose.
You're at the bedside of the Chan family as the NICU nurse in the delivery room, assisting with caring for their infant son Ki, who was born at 41 weeks and five days minutes ago. His skin and umbilical cord have a greenish hue. As you continue to assess him, you note nasal flaring and chest retractions. His Apgar scores are 4 at one minute, and 6 at five minutes. You call the neonatologist to the bedside, who prepares to intubate Ki and begin surfactant therapy. What neonatal complication is Ki developing?
Meconium aspiration syndrome (Ki has several indicators that he is developing meconium aspiration syndrome. Meconium staining, low Apgar scores, and signs of respiratory distress all indicate this syndrome. His post-term delivery is a risk factor as well. The provider will intubate him, begin surfactant therapy, and order sedatives and antibiotics. Cooling therapy may also be started if Ki shows signs that he had an hypoxic event.)
In the NICU, you're providing care for baby Jordan, who was delivered at 28 weeks 5 days about 8 days ago. On assessment, you notice he seems lethargic and his abdomen is distended with visible bowel loops. His vital signs are blood pressure 52/35 mmHg, pulse 183, respirations 86, temperature 35.4°C, blood oxygenation 89%. What neonatal complication is Jordan experiencing?
Necrotizing enterocolitis (Jordan is showing indications of necrotizing enterocolitis (NEC), which is associated with decreased gastrointestinal blood flow, or ischemia caused by other complications such as asphyxia and polycythemia. Infants who are breastfed have lower risk of NEC. NEC is more common in preterm neonates and can be fatal in up to 30% of cases. Abnormal vital signs, abdominal distention, visible bowel loops, bloody stools, and emesis are indications of NEC.)
Baby Miguel was born at 38 weeks 6 days, around 7 hours ago. His mother's pregnancy was normal, but her delivery was difficult. Miguel had meconium staining at delivery, and his Apgar scores were 5 at one minute, and 7 at five minutes. You were also told in report that his temperature at delivery was 35.8°C, and the provider has ordered a complete blood count, blood cultures, and dopamine. He's currently on a mechanical ventilator and receiving nitric oxide therapy. While doing your assessment at the beginning of your shift, his vital signs are as follows: blood pressure 48/35 mmHg, pulse 148, respirations 28, temperature 36.6°C, and blood oxygenation 81%. What neonatal complication is Miguel experiencing?
Persistent pulmonary hypertension of the newborn (Miguel has all the indications of persistent pulmonary hypertension of the newborn. His meconium staining, low Apgar scores, and hypothermia are all indications of this complication. The provider will order a full laboratory work up to rule out infection, as well as vasopressors to decrease the right to left shunting taking place in his heart.)
Baby Alysa was just delivered at 25 weeks 3 days. You're the NICU nurse who is assisting with stabilization and transfer to the NICU. Your initial assessment at one minute of life finds substernal retractions, expiratory grunting, and cyanosis. Her vital signs are as follows: pulse 194, respirations 74, temperature 37.1°C, blood oxygenation 96%. At five minutes, as you prepare to place her in the isolette for transport, you note her expiratory grunting has become more pronounced and she is now having intercostal and subcostal retractions. What neonatal complication is Alysa showing signs of developing?
Respiratory distress syndrome (Due to Alysa's extreme prematurity, she will not be producing surfactant for a few more weeks. Your assessment findings indicate she is beginning to have significant respiratory distress because of her lack of surfactant. This syndrome is a very common occurrence in infants less than 28 weeks gestation. Alysa will receive continuous support on a ventilator once she's in the NICU.)
A mother comes to visit her infant in the neonatal intensive care unit (NICU). She verbalizes anxiety regarding caring for the infant after discharge. What is the best response by the nurse? a. "Being hands-on in your baby's care now will increase your confidence to handle things at home." b. "Could you hire a home health nurse?" c. "I understand your concern. You have a fragile newborn." d. "We will write down all of your discharge instructions for you.
a. "Being hands-on in your baby's care now will increase your confidence to handle things at home."
After birth, an infant received surfactant replacement therapy. The father questioned the nurse regarding the purpose of this therapy. What is the correct response by the nurse? a. "It allows the infant to expand his lungs more easily." b. "It prevents a lung infection." c. "It causes bronchodilation so he can breathe better." d. "It thins the mucus in the respiratory tract."
a. "It allows the infant to expand his lungs more easily."
The nurse is teaching parents to administer gavage feedings. Which statement made by the parents indicates to the nurse that further teaching is required? a. "We should lay infant flat for feedings." b. "We should use nonnutritive sucking during feeding." c. "We should waken our infant for feeding tolerance." d. "We should check the placement of the tube before each feeding."
a. "We should lay infant flat for feedings."
Bronchopulmonary dysplasia (BPD) is a chronic lung problem associated w/ neonates who have been treated with mechanical ventilation. Which assessment is consistent with BPD? Select all that apply. a. Chest x-ray shows lung hyperinflation b. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 c. Intake matches output for at least 24 hours d. Lung sounds clear throughout all fields e. Increased pressure needed for ventilation
a. Chest x-ray shows lung hyperinflation b. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 e. Increased pressure needed for ventilation
Bronchopulmonary dysplasia (BPD) is a chronic lung problem associated w/neonates who have been treated with mechanical ventilation. Which assessment is consistent with BPD? Select all that apply. a. Chest x-ray shows lung hyperinflation b. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 c. Intake matches output for at least 24 hours d. Lung sounds clear throughout all fields e. Increased pressure needed for ventilation
a. Chest x-ray shows lung hyperinflation b. ABG's pH 7.30, PCO2-60, HCO3 19, PO2-55 e. Increased pressure needed for ventilation
A neonate with respiratory distress syndrome is being prepared for intubation and surfactant administration. The mother refuses any animal products. What should the nurse anticipate the healthcare provider (HCP) will order? a. Colfosceril (Exosurf) b. Poractant (Curosurf ) c. Beractant (Survanta) d. Calfactant (Infasurf)
a. Colfosceril (Exosurf)
The nurse encourages parents of a stable neonate to start kangaroo care. The mother is hesitant. What should the nurse include when explaining the benefits of kangaroo care? Select all that apply a. Decreases illness and infection b. Prevents unstable temperature c. Decreases excessive weight gain d. Increases length of hospital stay e. Decreases feeding intolerance
a. Decreases illness and infection b. Prevents unstable temperature e. Decreases feeding intolerance
A nursing diagnosis for a very preterm neonate is ineffective thermos-regulation related to prematurity, lack of subcutaneous fat tissue, and environmental temperature. Which interventions would be the most important to perform immediately? Select all that apply. a. Dry infant and discard wet linen b. Place on pre-heated warmer c. Keep head covered d. Encourage kangaroo care e. Place on mother's abdomen
a. Dry infant and discard wet linen b. Place on pre-heated warmer c. Keep head covered
Fetal alcohol syndrome (FAS) can cause physical anomalies. What assessment would the nurse identify as consistent with FAS? a. Heart defects b. Increased cranial size c. Amniotic bands d. Congenital hip dysplasia
a. Heart defects
The nurse is seeing a neonate for an immediate cardiac assessment. What will the nurse be looking for? Select all that apply. a. Heart sounds b. Peripheral pulses c. Blood glucose level d. Capillary refill e. Body temperature
a. Heart sounds b. Peripheral pulses d. Capillary refill
Which of the following neonates is at increased risk for hyperbilirubinemia? Select all that apply. a. Infant George, whose mother has gestational diabetes. b. Infant Anna, born at 37 weeks 2 days. c. Infant Juan, who has caput succedaneum. d. Infant Tricia, whose mother's blood type is B+. e. Infant Rohan, whose mother was induced for labor at 39 weeks 5 days.
a. Infant George, whose mother has gestational diabetes b. Infant Anna, born at 37 weeks 2 days e. Infant Rohan, whose mother was induced for labor at 39 weeks 5 days
Changes in cerebral blood flow can increase the risk of intraventricular hemorrhage (IVH). What nursing interventions help maintain steady cerebral blood flow? Select all that apply. a. Keep the head of the bed flat. b. Avoid lifting hips with diaper changes. c. Provide developmental stimulation, such as lights and sounds. d. Minimize crying. e. Avoid having the infant become too hot or cold.
a. Keep the head of bed flat b. Avoid lifting hips with diaper changes d. Minimize crying. e. Avoid having the infant become too hot or cold.
The nurse is caring for a neonate with a grade II Intraventricular Hemorrhage (IVH). Routine nursing care can cause fluctuations in cerebral blood flow. What nursing strategies will decrease the worsening of this condition? Select all that apply. a. Minimize crying b. Minimize stimulation c. Keep head of at 45 degrees d. Keep temperature normal e. Position infant prone
a. Minimize crying b. Minimize stimulation d. Keep temperature normal
When an infant is experiencing neonatal abstinence syndrome, what nursing action can help to minimize symptoms and complications? a. Minimize stimulation to promote rest b. Lay the infant on their abdomen to soothe gas pains c. Make sure they are only wearing a diaper to prevent diaphoresis d. Play music or the tv loudly to soothe them
a. Minimize stimulation to promote rest
The nurse is teaching a father how to bottle feed his premature infant. What instructions should the nurse include in the teaching? a. Pace the feeding to allow for breathing breaks. b. Hold the baby in a supine position to prevent fatigue. c. Use a high-flow nipple to make suckling easier. d. A decrease in heart rate is expected and feeding can continue.
a. Pace the feeding to allow for breathing breaks.
The nurse is assessing a client during a prenatal visit. The client is at 30 weeks gestation. What assessment identifies a non-modifiable risk for preterm labor? a. Placenta previa b. Domestic violence c. Periodontal disease d. Incompetent cervix
a. Placenta previa
During labor, the nurse notes the presence of meconium stained fluid. What does the nurse prepare for at the time of delivery? a. Suctioning of the infant's mouth and trachea b. Administration of antibiotics to the mother c. Vigorous tactile stimulation of the infant d. Culturing of the placenta for pathology
a. Suctioning of the infant's mouth and trachea
The nurse is caring for a client with diabetes mellitus. She asks the nurse why strict blood glucose control is important. What is the correct response by the nurse? Select all that apply. a. "High maternal blood glucose can cause hyperglycemia in the infant, as well." b. "High maternal blood glucose can cause hypoglycemia in the infant." c. "Congenital anomalies are more likely with uncontrolled diabetes." d. "Precipitous births are more likely when blood glucose is uncontrolled." e. "Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high."
b. "High maternal blood glucose can cause hypoglycemia in the infant." c. "Congenital anomalies are more likely with uncontrolled diabetes." e. "Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high."
Meconium aspiration syndrome is most likely to occur at which gestational age in the newborn? a. 29 weeks 4 days b. 42 weeks 2 days c. 38 weeks 3 days d. 32 weeks 6 days
b. 42 weeks 2 days
Abrupt discontinuation of intrauterine exposure to various substances, including heroin, nicotine, alcohol, cannabis, opiates, cocaine, and methamphetamines puts the neonate at risk for signs and symptoms of neonatal abstinence syndrome (NAS). The withdrawal of what substance can cause symptoms of NAS to start within 4 hours? a. Cannabis b. Alcohol c. Narcotics d. Barbiturates
b. Alcohol
Which of the following would be expected findings and complications for a neonate who is considered to be very preterm? Select all that apply. a. Creases on the anterior of the foot b. Atelectasis c. Macrosomia d. Full flexion of extremities e. Fused eyelids
b. Atelectasis e. Fused eyelids
Which risk factor for hyperbilirubinemia is modifiable? Select all that apply. a. Mother is Native American b. Delayed cord clamping c. Infrequent feedings in first 24 hours d. Bacterial infection at birth e. Breast feeding only in first 24 hours
b. Delayed cord clamping c. Infrequent feedings in first 24 hours d. Bacterial infection at birth e. Breast feeding only in first 24 hours
The nurse receives an order to begin trophic feeding at 2 ml/hour via nasogastric tube. The nurse recognizes what about trophic feedings? a. Provides adequate nutrition b. Enhances gastrointestinal functioning c. Nasogastric feeding helps prevent choking d. Allows continuous hydration
b. Enhances gastrointestinal functioning
An infant has been diagnosed with bronchopulmonary dysplasia (BPD) following long term mechanical ventilation. What interventions should be included in the nursing care plan? Select all that apply. a. Keep oxygen level at 100% at all times. b. Gradually wean from mechanical ventilation per order. c. Provide chest physiotherapy. d. Restrict fluid intake. e. Administer corticosteroids per order.
b. Gradually wean from mechanical ventilation per order. c. Provide chest physiotherapy. e. Administer corticosteroids per order.
The nurse is caring for an infant with a nasogastric tube. Before starting a feeding, what does the nurse do to check for proper placement? a. Obtain an abdominal x-ray. b. Inject air into the tube while listening to the abdomen. c.Inject air into the tube while listening to the lungs. d. Measure the tubing length remaining outside the nares.
b. Inject air into the tube while listening to the abdomen.
Post-term pregnancy is a risk factor for which of the following neonatal complications? Select all that apply. a. Intrauterine growth restriction b. Meconium aspiration syndrome c. Persistent pulmonary hypertension d. Neonatal infection e. Polycythemia
b. Meconium aspiration syndrome e. Polycythemia
The nurse is caring for an infant born at 42 weeks gestation. What assessment findings by the nurse are consistent with post-term infants? Select all that apply. a. Abundant lanugo b. Meconium staining c. Vernix over back and face d. Smooth skin with visible veins e. Long fingernails
b. Meconium staining e. Long fingernails
The nurse is concerned that a newborn may be suffering from neonatal methamphetamine withdrawal. Which assessment finding is indicative of neonatal methamphetamine withdrawal? a. Tachypnea and increased wakefulness b. Poor weight gain and excoriated skin c. Skin mottling and apnea d. Hypotonia and high-pitched cry
b. Poor weight gain and excoriated skin
One of the most commonly occurring complications in infants under 28 weeks gestations is __________________. a. hyperbilirubinemia b. sudden infant death syndrome c. respiratory distress syndrome d. meconium aspiration syndrome
c. respiratory distress syndrome
To prevent damage to the premature infant's skin, what interventions should the nurse perform? Select all that apply. a. Bathe the infant with a mild, alkaline solution. b. Use the minimum amount of tape needed to secure tubes or IV lines. c. Avoid changing position and skin sheering. d. Use water, air, or gel mattresses. e. Assess skin at least once a shift for breakdown or infection.
b. Use the minimum amount of tape needed to secure tubes or IV lines. d. Use water, air, or gel mattresses e. Assess skin at least once a shift for breakdown or infection.
Nursing actions for a neonate experiencing neonatal abstinence syndrome include __________________. Select all that apply. a. insure the room is brightly lit b. swaddle the infant c. inform the mother that the infant's symptoms are her fault d. allowing for rest during feedings e. assess feedings and daily weights
b. swaddle the infant d. allowing for rest during feedings e. assess feddings and daily weights
The nurse is preparing a woman to have a lecithin/sphingomyelin (L/S) ratio performed. What education should the nurse provide to the client about the procedure? a. "This blood sample will be taken from the baby's umbilical cord." b. "Do not eat or drink anything 12 hours prior to the procedure." c. "After the test, report any leaking of amniotic fluid to your provider." d. "The results will let us know if there are any chromosomal abnormalities with your baby."
c. "After the test, report any leaking of amniotic fluid to your provider."
The student nurse asks about the use of surfactant. Which statement indicates to the nurse that the student understands the teaching? a. "Surfactant increases surface tension of alveoli." b. "Adverse effects include hypertension and hypotonia." c. "Surfactant decreases risk of bronchopulmonary dysplasia." d. "Surfactant reduces lung compliance and work of breathing."
c. "Surfactant decreases risk of bronchopulmonary dysplasia."
The parents of an infant diagnosed with patent ductus arteriosus (PDA) met with the cardiologist. What statement by the mother indicates to the nurse that she understands the teaching? a. "My baby will need a heart transplant." b. "There was an abnormal shunt that formed during pregnancy." c. "The open shunt can be closed with a clip or suture." d. "He will need extra fluids because his blood pressure will be lower."
c. "The open shunt can be closed with a clip or suture."
The nurse knows that maternal alcohol, tobacco, cannabis, and cocaine abuse can all cause many long-term adverse effects. Which assessment findings can be attributed to all of these substances? a. Lower IQ and language problems b. Congenital infections and congenital anomalies c. Low birth weight and attention deficit disorder d. Mental retardation and aggressiveness
c. Low birth weight and attention deficit disorder
A nasogastric tube has been ordered for an infant who is not tolerating oral feedings. How does the nurse measure the correct length to insert the tube? a. Take the infant's length in centimeters and divide by 3 b. Measure from mouth, to ear, to lower sternum c. Measure from nose, to ear, to lower sternum d. Measure the distance from mouth to umbilicus
c. Measure from nose, to ear, to lower sternum
When caring for parents who are grieving after losing an infant, which of the following is the best action? a. Remind them they can have another child. b. Ensure that the hospital clergy comes to the room and prays for them. c. Sit quietly with them and listen. d. Take the baby to the morgue as soon as possible.
c. Sit quietly with them and listen.
The registered nurse (RN) is educating a mother whose infant is receiving phototherapy for hyperbilirubinemia. What statement by the mother does the RN identify as correct? a. "I cannot hold my infant for feedings." b. "My infant should wear a light shirt while under the lights." c. "I should leave my infant in the same position under the lights." d. "I will feed my baby frequently while on phototherapy."
d. "I will feed my baby frequently while on phototherapy."
The nurse is teaching parents of a preterm neonate about feedings in the newborn intensive care unit (NICU). What statement about nutrition indicates an understanding of the teaching? a. "My baby can breastfeed right away." b. "My baby can only have special formula." c. "My baby will need breast milk only." d. "My baby will need fortified breastmilk."
d. "My baby will need fortified breastmilk."
The nurse is caring for an infant with respiratory distress syndrome (RDS) who is intubated. What assessment does the nurse perform to ensure proper placement of the endotracheal tube (ET)? a. Check arterial blood gas values (ABG). b. Visually inspect the oropharynx. c. Obtain a chest x-ray. d. Auscultate bilateral breath sounds.
d. Auscultate bilateral breath sounds
A client calls the nurse to her room and states, "The baby is really sleepy and hasn't been feeding well." The nurse notes the infant is jittery. What additional assessment should the nurse perform? a. LATCH score b. Urine output c. Weight d. Blood glucose
d. Blood glucose
A premature neonate with severe hyperbilirubinemia is starting phototherapy. What nursing intervention is the most important? a. Bank of lights covered with plexiglass b. Only diaper in place for maximum exposure c. Feed neonate every 2 to 3 hours d. Eye patches in place while under lights
d. Eye patches in place while under lights
One of the best ways to prevent necrotizing enterocolitis is _____________. a. high flow oxygen therapy b. nitric oxide therapy c. delaying cord clamping d. breastfeeding
d. breastfeeding
Place the steps for neonatal gavage feedings in the correct order. 1. Check for residuals before starting feeding 2. Assess the neonate for feeding intolerance 3. Check for placement prior to feeding 4. Measure the tube accurately
4. Measure the tube accurately 3. Check for placement prior to feeding 1. Check for residuals before starting feeding 2. Assess the neonate for feeding intolerance
Baby Molly was born 52 hours ago at 37 weeks 4 days. An hour into your shift, her parents push the emergency button to report something wrong while they tried to feed her. Upon entering the room, you notice she has tremors, a high pitched cry, and is diaphoretic. Her parents say she was acting frantic while trying to eat and wouldn't stop crying. As you begin to assess her, she has a seizure. What neonatal complication is Molly experiencing?
Neonatal abstinence syndrome (Tremors, high pitched cry, diaphoresis, and seizure after 48 hours of life are all indications of neonatal abstinence syndrome. Molly may also be tachypenic, not feeding well, be congested and sneezing, along with many other symptoms. She should be assessed regularly using a scoring tool to determine her need for care. Molly should have minimal stimulation and be allowed to rest during feedings.)
The nurse is planning to assess a neonate born at 25 weeks. Which would be an expected assessment finding? Select all that apply. a. Hypotonic muscles b. Creases on feet c. Skin is pale d. Lack of lanugo e. Fused eyelids
a. Hypotonic muscles e. Fused eyelids
The nurse evaluates the gastric residual on an infant with a nasogastric tube and finds the volume to be high. In what position should the nurse place the infant to promote gastric emptying? a. Supine b. Prone c. Head of bed elevated 30 degrees d. Knees flexed to chest
b. Prone
A mother asks the nurse when her infant's nasogastric tube may be removed. What is the correct response by the nurse? a. "Once he is eating at least 60 mL per feeding." b. "When he reaches an adjusted gestational age of 34 weeks." c. "When he demonstrates a coordinated suck, swallow, breathe pattern." d. "Once he can maintain a blood glucose level above 50 mg/dL."
c. "When he demonstrates a coordinated suck, swallow, breathe pattern."
Which bilirubin level in a healthy term or near-term neonate would the nurse determine is concerning, but not critical, at 36 hours after birth? a. 1 to 3 mg/dL b. 4 to 5 mg/dL c. 10 to 14 mg/dL d. 15 to 20 mg/dL
c. 10 to 14 mg/dL
The nurse is caring for an infant born to a woman with diabetes. The nurse notes that the infant moves the left arm, but the right arm remains flaccid. What order does the nurse anticipate? a. Head CT b. Electroencephalogram c. Chest X-ray d. Electromyography
c. Chest X-ray
To prevent heat loss from evaporation immediately after delivery, what is the most important nursing intervention? a. Place the neonate on a chemical mattress. b. Keep the neonate's head covered with a hat. c. Dry the neonate gently and replace the wet linen. d. Place the neonate in a double-walled incubator.
c. Dry the neonate gently and replace the wet linen.
The nurse is assessing a preterm neonate immediately after delivery. Which assessment finding indicates respiratory distress? Select all that apply a. Cyanosis of hands and feet b. Low body temperature c. Grunting on exhalation d. Intercostal retractions e. Slow capillary refill
c. Grunting on exhalation d. Intercostal retractions
The nurse is admitting a 28-week neonate to the NICU. Which assessment would indicate an intraventricular hemorrhage (IVH)? a. Tachycardia b. Hypoglycemia c. Hypotonia d. Hypertension
c. Hypotonia
What assessment does the nurse know indicates a high risk of retinopathy of prematurity (ROP)? a. Advanced maternal age b. Oxygenation of 87 to 94% c. Intraventricular hemorrhage d. Use of oxygen blenders
c. Intraventricular hemorrhage