SEMESTER 2: EXAM 5 final draft

The nurse is preparing a dose of naloxone for a newborn who weighs 6.9 pounds. How much naloxone does the nurse administer? ______ mg

0.31 mg The dose is 0.1 mg/kg for this 3.1-kg baby. REF: p. 642 | Drug Guide

Which of the following is a clinical manifestation of increased intracranial pressure in infants? A. Irritability B. Photophobia C. Pulsating anterior fontanel D. Vomiting and diarrhea

A. Irritability A. Irritability is one of the changes that may indicate increased intracranial pressure. B. Photophobia is not indicative of increased intracranial pressure in infants. C. Vomiting is one of the signs in children, but when present with diarrhea it is indicative of a gastrointestinal disturbance. D. Frequently, pulsations are visible in the anterior fontanel. It is not an indication of increased intracranial pressure.

A nurse is caring for a toddler status post surgery for a brain tumor. During an assessment the nurse notes that the toddler is becoming irritable and that the pupils are unequal and sluggish. What is the most appropriate nursing action? A. Notify the physician immediately. B. Assess for level of consciousness. C. Observe for signs of increased intracranial pressure (ICP). D. Administer pain medication and assess for response.

A. Notify the physician immediately. A. The worsening of symptoms may indicate that the ICP is increasing. The physician should be notified immediately. B. Assessing for level of consciousness should be done as part of the overall assessment. C. Pain medication should not be given. Consultation with the physician should occur first. D. The nurse is noting signs of potentially increased ICP.

A 6-year-old girl born with a myelomeningocele has a neurogenic bladder disorder. Her parents have been performing clean intermittent catheterization. Based on the knowledge of child development and chronic disability, what action should the nurse implement? A. Teach the child to do self-catheterization. B. Teach the child appropriate bladder control. C. Continue having the parents do the catheterization. D. Encourage the family to consider urinary diversion.

A. Teach the child to do self-catheterization. • At 6 ys age, child should be able to intermittent catheterization herself. This will give her more control and mastery over her disability. • Bladder control cannot be taught in a child with a neurogenic bladder. • This would be a good time to have the child begin caring for herself. • A urinary diversion is not necessary.

25. What should the nurse teach parents when the child is taking phenytoin (Dilantin) to control seizures? a. The child should use a soft toothbrush and floss the teeth after every meal. b. The child will require monitoring of renal function while taking this medication. c. Dilantin should be taken with food because it causes gastrointestinal distress. d. The medication can be stopped when the child has been seizure free for 1 month.

ANS: A A side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverse effect. The child should have liver function studies because this anticonvulsant may cause hepatic dysfunction, not renal dysfunction. Dilantin has not been found to cause gastrointestinal upset. The medication can be taken without food. Anticonvulsants should never be stopped suddenly or without consulting the physician. Such action could result in seizure activity.

14. A mother reports that her child has episodes where he appears to be staring into space. This behavior is characteristic of which type of seizure? a. Absence b. Atonic c. Tonic-clonic d. Simple partial

ANS: A Absence seizures are very brief episodes of altered awareness. The child has a blank expression. Atonic seizures cause an abrupt loss of postural tone, loss of consciousness, confusion, lethargy, and sleep. Tonic-clonic seizures involve sustained generalized muscle contractions followed by alternating contraction and relaxation of major muscle groups. There is no change in level of consciousness with simple partial seizures. Simple partial seizures consist of motor, autonomic, or sensory symptoms.

9. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which of the following? a. Avoiding using any latex product b. Using only non-allergenic latex products c. Administering medication for long-term desensitization d. Teaching family about long-term management of allergic manifestations

ANS: A Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. Latex allergy is estimated to occur in 75% of this patient population. There are no non-allergenic latex products. At this time, desensitization is not an option. There are no treatment options for long-term management of allergic symptoms for latex allergy.

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? a. Headache b. Bulging fontanel c. Tachypnea d. Increase in head circumference

ANS: A Headaches are a clinical manifestation of increased ICP in children. A change in the child's normal behavior pattern may be an important early sign of increased ICP. Bulging fontanel or increased head circumference is seen in infants. A change in respiratory pattern is a late sign of increased ICP. Cheyne-Stokes respiration may be evident. This refers to a pattern of increasing rate and depth of respirations followed by a decreasing rate and depth with a pause of variable length.

Which data should alert the nurse that the neonate is postmature? a. Cracked, peeling skin b. Short, chubby arms and legs c. Presence of vernix caseosa d. Presence of lanugo

ANS: A Loss of vernix caseosa, which protects the fetal skin in utero, may leave the skin macerated and appearing cracked and peeling. Postmature infants usually have long, thin arms and legs. Vernix caseosa decreases in the postmature infant. Absence of lanugo is common in postmature infants.

6. The most common problem of children born with a myelomeningocele is a. bladder incontinence. b. intellectual impairment. c. respiratory compromise. d. cranioschisis.

ANS: A Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children, leading to incontinence. Risk of intellectual impairment is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

10. When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with observable distended scalp veins, the nurse recognizes these signs as indicative of which disorder? a. Hydrocephalus b. Syndrome of inappropriate antidiuretic hormone (SIADH) c. Cerebral palsy d. Reye's syndrome

ANS: A The combination of signs is strongly suggestive of hydrocephalus. SIADH would not manifest in this way. The child would have decreased urination, hypertension, weight gain, fluid retention, hyponatremia, and increased urine specific gravity. The manifestations of cerebral palsy vary but may include persistence of primitive reflexes, delayed gross motor development, and lack of progression through developmental milestones. Reye's syndrome is associated with an antecedent viral infection with symptoms of malaise, nausea, and vomiting. Progressive neurologic deterioration occurs.

A nurse is caring for a preterm baby who weighs 4.8 pounds. What assessment finding indicates the baby is dehydrated? a. Urine output of 3.3 mL/hour b. Urine specific gravity of 1.001 c. Low serum sodium d. Weight gain of 43 g in one day

ANS: A This baby weighs 2.18 kg. Dehydration is noted with a urine output of <2 mL/kg/hour. A urine output of 3.3 mL is 1.5 mL/kg/hour and so indicates dehydration. The dilute urine specific gravity indicates overhydration as does the low serum sodium. The weight gain is normal (15 to 20 g/kg/day).

2. Which information should the nurse give to a child who is to have magnetic resonance imaging (MRI) of the brain? a. "You won't be able to move your head during the procedure." b. "You will have to drink a special fluid before the test." c. "You will have to lie flat after the test is finished." d. "You will have electrodes placed on your head with glue."

ANS: A To reduce fear and enhance cooperation during the MRI, the child should be made aware that head movement will be restricted to obtain accurate information. The child does not need to drink special liquids, lie on the back afterward, or have electrodes placed.

A nurse is caring for a late preterm infant. What action by the nurse is inconsistent with best practice to prevent cold stress? a. Wean the infant directly to an open crib. b. Check temperature every 3 to 4 hours. c. Encourage kangaroo care. d. Place infant on a radiant warmer.

ANS: A Weaning to an open crib takes many steps and is not done directly because of the risk of cold stress. The other actions help prevent cold stress.

While caring for the postterm infant, the nurse recognizes that the fetus may have passed meconium prior to birth as a result of a. hypoxia in utero. b. NEC. c. placental insufficiency. d. rapid use of glycogen stores.

ANS: A When labor begins, poor oxygen reserves may cause fetal compromise. The fetus may pass meconium as a result of hypoxia before or during labor, increasing the risk of meconium aspiration. Meconium is not passed as a result of NEC, placental insufficiency, or rapid use of glycogen stores.

The nurse tells the nursing student that late preterm infants are at increased risk for which of the following problems? (Select all that apply.) a. Problems with thermoregulation b. Cardiac distress c. Hyperbilirubinemia d. Sepsis e. Hyperglycemia

ANS: A, C, D Problems with thermoregulation, hyperbilirubinemia, and sepsis are common with late preterm infants. They typically have respiratory distress and hypoglycemia.

19. Which statement best describes a subdural hematoma? a. Bleeding occurs between the dura and the skull. b. Bleeding occurs between the dura and the cerebrum. c. Bleeding is generally arterial, and brain compression occurs rapidly. d. The hematoma commonly occurs in the parietotemporal region.

ANS: B A subdural hematoma is bleeding that occurs between the dura and the cerebrum as a result of a rupture of cortical veins that bridge the subdural space. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region. An epidural hemorrhage occurs between the dura and the skull, is usually arterial with rapid brain concussion, and occurs most often in the parietotemporal region.

To maintain optimal thermoregulation for the premature infant, what action by the nurse is most appropriate? a. Bathe the infant once a day. b. Put an undershirt on the infant in the incubator. c. Assess the infant's hydration status. d. Lightly clothe the infant under the radiant warmer.

ANS: B Air currents around an unclothed infant will result in heat loss. Bathing causes evaporative heat loss. Assessing hydration will not maintain thermoregulation. Clothing is not worn when the infant is under a radiant warmer.

Which preterm infant should receive gavage feedings instead of a bottle? a. Sometimes gags when a feeding tube is inserted b. Is unable to coordinate sucking and swallowing c. Sucks on a pacifier during gavage feedings d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: B An infant who cannot coordinate sucking, swallowing, and breathing should receive gavage feedings. The other infants are ready for bottle feedings.

33. What should be the nurse's first action when a child with a head injury complains of double vision and a headache, and then vomits? a. Immobilize the child's neck. b. Report this information to the physician. c. Darken the room and put a cool cloth on the child's forehead. d. Restrict the child's oral fluid intake.

ANS: B Any indication of ICP such as double vision, headache, or vomiting should be promptly reported to the physician. Stabilizing the child's neck does not address the child's symptoms. Darkening the room and giving a cool cloth are comfort measures. A fluid restriction is not needed.

24. After a tonic-clonic seizure, it would not be unusual for a child to display a. irritability and hunger. b. lethargy and confusion. c. nausea and vomiting. d. nervousness and excitability.

ANS: B In the period after a tonic-clonic seizure, the child may be confused and lethargic. Some children may sleep for a period of time. The other manifestations are not normally seen after a seizure.

8. How much folic acid does the nurse tell female patients is recommended for women of childbearing age? a. 1.0 mg b. 0.4 mg c. 1.5 mg d. 2.0 mg

ANS: B It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age has contributed to a reduction in the number of children with neural tube defects. The other doses are not the recommended dose.

17. A child with a head injury sleeps unless aroused, and when aroused responds briefly before falling back to sleep. What should the nurse chart for this child's level of consciousness? a. Disoriented b. Obtunded c. Lethargic d. Stuporous

ANS: B Obtunded describes an individual who sleeps unless aroused and once aroused has limited interaction with the environment. Disoriented refers to lack of ability to recognize place or person. An individual is lethargic when he or she awakens easily but exhibits limited responsiveness. Stupor refers to requiring considerable stimulation to arouse the individual.

23. What is the most appropriate nursing action when a child is in the tonic phase of a generalized tonic-clonic seizure? a. Guide the child to the floor if standing and go for help. b. Turn the child's body on the side. c. Place a padded tongue blade between the teeth. d. Quickly slip soft restraints on the child's wrists.

ANS: B Positioning the child on his side will prevent aspiration. It is inappropriate to leave the child during the seizure. Nothing should be inserted into the child's mouth during a seizure to prevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects and furniture should be moved out of the way to prevent injury.

What is most helpful in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Transitional Assistance to Needy Families d. Women, Infants, and Children nutritional program

ANS: B Prenatal care is vital in identifying possible problems. Women from higher economic status are more likely to seek adequate prenatal care, but it is the care that is most helpful. Government programs help with specific needs of the pregnant woman, but adequate care is more important.

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

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

11. What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy? a. Tremulous movements at rest and with activity b. Sudden jerking movement caused by stimuli c. Writhing, uncontrolled, involuntary movements d. Clumsy, uncoordinated movements

ANS: B Spastic cerebral palsy, the most common type of cerebral palsy, will manifest with hypertonicity and increased deep tendon reflexes. The child's muscles are very tight, and any stimuli may cause a sudden jerking movement. Tremulous movements, slow writhing movements, and loss of kinesthetic sense are not manifestations of spastic cerebral palsy.

3. Which term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation? a. Coma b. Stupor c. Obtundation d. Persistent vegetative state

ANS: B Stupor exists when the child remains in a deep sleep, responsive only to vigorous and repeated stimulation. Coma is the state in which no motor or verbal response occurs to noxious (painful) stimuli. Obtundation describes a level of consciousness in which the child is arousable with stimulation. Persistent vegetative state describes the permanent loss of function of the cerebral cortex.

The Glasgow Coma Scale consists of an assessment of a. pupil reactivity and motor response. b. eye opening and verbal and motor responses. c. level of consciousness and verbal response. d. ICP and level of consciousness.

ANS: B The Glasgow Coma Scale assesses eye opening, and verbal and motor responses. Pupil reactivity is not a part of the Glasgow Coma Scale but is included in the pediatric coma scale. Level of consciousness is not a part of the Glasgow Coma Scale. Intracranial pressure and level of consciousness are not part of the Glasgow Coma Scale.

A nurse is caring for a preterm infant who has a weak cry and is irritable. What action by the nurse is best? a. Assess the infant for pain. b. Take the infant's temperature. c. Obtain a bedside glucose reading. d. Reduce stimulation in the environment.

ANS: B These are signs of inadequate thermoregulation. The nurse should assess the infant's temperature first. The other actions do not address thermoregulation.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping related to a. severe immaturity. b. environmental stress. c. physiologic distress. d. behavioral responses.

ANS: B This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation. The other diagnoses do not recognize that fact.

16. The nurse teaches parents to alert their health care provider about which adverse effect when a child receives valproic acid (Depakene) to control generalized seizures? a. Weight loss b. Bruising c. Anorexia d. Drowsiness

ANS: B Thrombocytopenia is an adverse effect of valproic acid. Parents should be alert for any unusual bruising or bleeding. Weight gain, not loss, is a side effect of valproic acid. Drowsiness is not a side effect of valproic acid, although it is associated with other anticonvulsant medications. Anorexia is not a side effect of valproic acid.

An important nursing factor during the care of the infant in the NICU is assessment for signs of adequate parental attachment. The nurse must observe for signs that bonding is not occurring as expected. These include (Select all that apply.) a. using positive terms to describe the infant. b. showing interest in other infants equal to that of their own. c. naming the infant. d. decreasing the number and length of visits. e. refusing offers to hold and care for the infant.

ANS: B, D, E Bonding is not progressing as expected when parents show interest in other babies equal to that of their own, decreasing the number and length of visits, and refusing to hold and help care for the infant. Using positive terms to describe the baby and naming the infant are signs that bonding is occurring.

22. Which type of seizure involves both hemispheres of the brain? a. Focal b. Partial c. Generalized d. Acquired

ANS: C Clinical observations of generalized seizures indicate that the initial involvement is from both hemispheres. Focal seizures may arise from any area of the cerebral cortex, but the frontal, temporal, and parietal lobes are most commonly affected. Partial seizures are caused by abnormal electric discharges from epileptogenic foci limited to a circumscribed region of the cerebral cortex. A seizure disorder that is acquired is a result of a brain injury from a variety of factors; it does not specify the type of seizure.

18. Which type of fracture describes traumatic separation of cranial sutures? a. Basilar b. Linear c. Comminuted d. Depressed

ANS: C Comminuted skull fractures include fragmentation of the bone or a multiple fracture line. A basilar fracture involves the basilar portion of the frontal, ethmoid, sphenoid, temporal, or occipital bone. A linear fracture includes a straight-line fracture without dural involvement. A depressed fracture has the bone pushed inward, causing pressure on the brain.

Of all the signs seen in infants with respiratory distress syndrome, which sign is especially indicative of the syndrome? a. Pulse more than 160 beats/min b. Circumoral cyanosis c. Grunting d. Substernal retractions

ANS: C Grunting increases the pressure inside the alveoli to keep them open when surfactant is insufficient. This is a characteristic and often early sign of RDS. The other assessments are not specific to RDS.

5. Nursing care of the infant who has had a myelomeningocele repair should include a. securely fastening the diaper. b. measurement of pupil size. c. measurement of head circumference. d. administration of seizure medications.

ANS: C Head circumference measurement is essential because hydrocephalus can develop in these infants. A diaper should be placed under the infant but not fastened. Keeping the diaper open facilitates frequent cleaning and decreases the risk for skin breakdown. Pupil size measurement is usually not necessary. Seizure medications are not routinely given to infants who do not have seizures.

With regard to eventual discharge of the high-risk newborn or transfer to a different facility, nurses and families should be aware that a. infants will stay in the NICU until they are ready to go home. b. once discharged to home, the high-risk infant should be treated like any healthy term newborn. c. parents of high-risk infants need special support and detailed contact information. d. if a high-risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

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

Which statement is true about large for gestational age (LGA) infants? a. They weigh more than 3500 g. b. They are above the 80th percentile on gestational growth charts. c. They are prone to hypoglycemia, polycythemia, and birth injuries. d. Postmaturity syndrome and fractured clavicles are the most common complications.

ANS: C Hypoglycemia, polycythemia, and birth injuries are common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on the gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

A nurse is assessing an SGA infant with asymmetric intrauterine growth restriction. What assessment finding correlates with this condition? a. One side of the body appears slightly smaller than the other. b. All body parts appear proportionate. c. The head seems large compared with the rest of the body. d. The extremities are disproportionate to the trunk.

ANS: C In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infant's body is long and thin due to lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected due to the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared to the head.

Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem? a. Group all care activities together to provide long periods of rest. b. While giving your report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. c. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers. d. Keep charts on top of the incubator so the nurses can write on them there.

ANS: C Parents should be taught these signs of overstimulation so they will learn to adapt their care to the needs of their infant. This may understimulate the infant during those long periods and overtire the infant during the procedures. Talking in front of the incubator could overstimulate the baby. Placing objects on top of the incubator or using it as a writing surface increases the noise inside.

A preterm infant is on a respirator with intravenous lines and much equipment around her when her parents come to visit for the first time. What action by the nurse is most important? a. Suggest that the parents visit for only a short time to reduce their anxieties. b. Reassure the parents that the baby is progressing well. c. Encourage the parents to touch her. d. Discuss the care they will give her when she goes home.

ANS: C Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the care giving responsive to the needs of both the parents and the infant. The nurse should encourage the parents to touch their baby and show them how to do so safely. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant. It is important to keep the parents informed about the infant's progression, but the nurse needs to be honest with the explanations. Discussing home care needs to wait until the parents are ready and discharge is closer with known needs.

Decreased surfactant production in the preterm lung is a problem because surfactant a. causes increased permeability of the alveoli. b. provides transportation for oxygen to enter the blood supply. c. keeps the alveoli open during expiration. d. dilates the bronchioles, decreasing airway resistance.

ANS: C Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not cause increased permeability, provide transportation of oxygen or dilate the bronchioles.

15. What is the best response to a father who tells the nurse that his son "daydreams" at home and that his teacher has observed this behavior at school? a. "Your son must have an active imagination." b. "Can you tell me exactly how many times this occurs in one day?" c. "Tell me about your son's activity when you notice the daydreams." d. "He is probably overtired and needs more rest."

ANS: C The daydream episodes are suggestive of absence seizures, and data about activity associated with the daydreams should be obtained. Describing an active imagination or an overtired child does not address the symptoms of the father's concern. Determining the number of times the behavior occurs is not as helpful as information about the behavior.

21. A 5-year-old sustained a concussion after falling out of a tree. In preparation for discharge, the nurse is discussing home care with the parents. Which statement made by the parents indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."

ANS: C The parents are advised of probable posttraumatic symptoms. These include behavioral changes and sleep disturbances. Vomiting and diplopia should be reported immediately. Sleep disturbances may occur with postconcussive syndrome, but difficulty waking the child up should be reported.

7. A recommendation to prevent neural tube defects is the supplementation of a. vitamin A throughout pregnancy. b. multivitamin preparations as soon as pregnancy is suspected. c. folic acid for all women of childbearing age. d. folic acid during the first and second trimesters of pregnancy.

ANS: C The widespread use of folic acid among women of childbearing age is expected to decrease the incidence of spina bifida significantly. Vitamin A, multivitamins, and folic acid only during specific points during the pregnancy have not been shown to prevent neural tube defects.

The nurse is observing a parent holding a preterm infant. The infant is sneezing, yawning, and extending the arms and legs. What action by the nurse is best? a. Cover the infant with a warmed blanket. b. Encourage the parent to do kangaroo care. c. Encourage the parent to place the infant back in the warmer d. Have the parent fold the infant's arms across the chest.

ANS: C These are signs that the preterm infant is overstimulated. The parent should place the infant back in her warmer, and the nurse can turn down the lights and limit noise. The other suggestions will not help decrease stimulation.

Which combination of expressing pain could be demonstrated in a neonate? a. Low-pitched crying, tachycardia, eyelids open wide b. Cry face, flaccid limbs, closed mouth c. High-pitched, shrill cry, withdrawal, change in heart rate d. Cry face, eye squeeze, increase in blood pressure

ANS: D Cry face, eye squeeze, and an increase in blood pressure indicate pain. The other manifestations are not those of pain in the neonate.

32. A child is brought to the emergency department in status epilepticus. Which medication should the nurse expect to be given initially in this situation? a. Clorazepate dipotassium (Tranxene) b. Fosphenytoin (Cerebyx) c. Phenobarbital d. Lorazepam (Ativan)

ANS: D Lorazepam (Ativan) or diazepam (Valium) is given intravenously to control generalized tonic-clonic status epilepticus and may also be used for seizures lasting more than 5 minutes. The other drugs are used for seizures but are not the first-line treatment for status.

34. A nurse is explaining to parents how the central nervous system of a child differs from that of an adult. Which statement accurately describes these differences? a. The infant has 150 mL of CSF compared with 50 mL in the adult. b. Papilledema is a common manifestation of ICP in the very young child. c. The brain of a term infant weighs less than half of the weight of the adult brain. d. Coordination and fine motor skills develop as myelinization of peripheral nerves progresses.

ANS: D Peripheral nerves are not completely myelinated at birth. As myelinization progresses, so does the child's coordination and fine muscle movements. An infant has about 50 mL of CSF compared with 150 mL in an adult. Papilledema rarely occurs in infancy because open fontanels and sutures can expand in the presence of ICP. The brain of the term infant is two thirds the weight of an adult's brain.

Compared to the term infant, the preterm infant has a. few blood vessels visible though the skin. b. more subcutaneous fat. c. well-developed flexor muscles. d. greater surface area in proportion to weight.

ANS: D Preterm infants have greater surface area in proportion to their weight. They often have visible blood vessels because their skin is thin and they have less fat. More fat and well- developed flexor muscles are characteristic of a more mature infant.

Which is true about newborns classified as small for gestational age (SGA)? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. Placental malfunction is the only recognized cause of this condition. d. They are below the 10th percentile on gestational growth charts.

ANS: D SGA infants are defined as below the 10th percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA babies.

A nurse is caring for an SGA newborn. What nursing action is most important? a. Observe for respiratory distress syndrome. b. Observe for and prevent dehydration. c. Promote bonding. d. Prevent hypoglycemia by early and frequent feedings.

ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Respiratory distress syndrome is seen in preterm infants. Dehydration is a concern for all infants and is not specific for SGA infants. Promoting bonding is a concern for all infants and is not specific for SGA infants.

13. How should the nurse explain positioning for a lumbar puncture to a 5-year-old child? a. "You will be on your knees with your head down on the table." b. "You will be able to sit up with your chin against your chest." c. "You will be on your side with the head of your bed slightly raised." d. "You will lie on your side and bend your knees so that they touch your chin."

ANS: D The child should lie on her side with knees bent and chin tucked in to the knees. This position exposes the area of the back for the lumbar puncture. The other positions are not used for a lumbar puncture.

27. Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? a. Rapid, shallow breathing b. Irregular, rapid heart rate c. Increased diastolic pressure with narrowing pulse pressure d. Confusion and altered mental status

ANS: D The child with a head injury may have confusion and altered mental status, a change in vital signs, retinal hemorrhaging, hemiparesis, and papilledema. Respiratory changes occur with ICP. One pattern that may be evident is Cheyne-Stokes respiration. This pattern of breathing is characterized by increasing rate and depth, then decreasing rate and depth, with a pause of variable length. Temperature elevation may occur in children with ICP. Changes in blood pressure occur, but the diastolic pressure does not increase, nor is there a narrowing of pulse pressure.

26. The father of a newborn infant with myelomeningocele asks about the cause of this condition. What response by the nurse is most appropriate? a. "One of the parents carries a defective gene that causes myelomeningocele." b. "A deficiency in folic acid in the father is the most likely cause." c. "Offspring of parents who have a spinal abnormality are at greater risk for myelomeningocele." d. "There may be no definitive cause identified."

ANS: D The etiology of most neural tube defects is unknown in most cases. There may be a genetic predisposition or a viral origin, and the disorder has been linked to maternal folic acid deficiency; however, the actual cause has not been determined. There may be a genetic predisposition, but no pattern has been identified. Folic acid deficiency in the mother has been linked to neural tube defect. There is no evidence that children who have parents with spinal problems are at greater risk for neural tube defects.

20. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What is the most essential part of nursing assessment to detect early signs of a worsening condition? a. Posturing b. Vital signs c. Focal neurologic signs d. Level of consciousness

ANS: D The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.

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

ANS: D The nurse needs to know that decreased immune functioning increases the risk for infection. The other diagnoses are appropriate for the premature infant but not related directly to immune function.

The temperature of an adolescent who is unconscious is 105º F(ax). What is the priority nursing action? A. Initiate a pain assessment. B. Apply a hypothermia blanket. C. Continue to monitor temperature. D. Administer acetaminophen or ibuprofen.

B. Apply a hypothermia blanket. A. Pain assessment should be continuous; lowering the body temperature is the priority action. B. Brain damage can occur at temperatures this high. It is extremely important to institute temperature-lowering interventions, such as hypothermia blankets and tepid water baths. C. The temperature needs to be monitored, but it also needs to be lowered. D. Antipyretics are not useful in cases of hyperthermia.

A child with spina bifida has a latex allergy from exposure to numerous bladder catheterizations and surgeries. What is a priority nursing intervention in this child's care? A. Recommend allergy testing. B. Provide a latex-free environment. C. Use only powder-free latex gloves. D. Limit use of latex products as much as possible.

B. Provide a latex-free environment. A. Allergy testing may expose the child to the allergen; it is not recommended. B. Providing a latex-free environment is the most important nursing intervention. From birth on, the limitation of exposure to latex is essential in an attempt to minimize sensitization. C. The gloves contain latex and will contribute to sensitization. D. Latex products must be avoided.

The nurse is discussing long-term care with the parents of child with a ventriculoperitoneal shunt to correct hydrocephalus. What should the teaching plan include? A. Parental protection is essential until the child reaches adulthood. B. Shunt malfunction or infection requires immediate treatment. C. Intellectual impairment is to be expected with hydrocephalus. D. Most usual childhood activities must be restricted.

B. Shunt malfunction or infection requires immediate treatment. A. Cerebral palsy is not genetic and neonatal disease is not a common cause. B. Birth-related brain anoxia at times has caused cerebral palsy but prematurity, not post-maturity, is the problem. C. Cerebral palsy results from faulty development (brain anomalies) during the prenatal period or from damage during the perinatal period, including brain anoxia and cerebral trauma during delivery and prematurity. D. Mother-infant bonding has nothing to do with the development of cerebral palsy, and meningitis in the newborn is very rare.

A young child is having a seizure that has lasted 35 minutes with loss of consciousness. What type of seizure would the nurse document? A. An absence seizure. B. Status epilepticus. C. A generalized seizure. D. A simple partial seizure.

B. Status epilepticus. A. Absence seizures are brief losses of consciousness. B. Status epilepticus is a generalized seizure that lasts more than 30 minutes. C. Generalized seizures are the most common of seizures. They have a tonic phase of approximately 10 to 20 seconds. They involve both hemispheres of the brain. D. Simple partial seizures are characterized by varying sensations.

A school-age child begins to have a tonic-clonic seizure as the nurse walks into her room. What actions should she take? (Select all that apply.) A. Gently place an oral airway in the child's mouth. B. Turn the child on her side. C. Hold the child's head so it doesn't hit the headboard. D. Get additional pillows to pad the siderails. E. Note how long the seizure lasts. F. Note whether any incontinence occurs during or after the seizure.

B. Turn the child on her side. E. Note how long the seizure lasts. F. Note whether any incontinence occurs during or after the seizure. • Nothing should be placed in a patient's mouth during a seizure. • The side should be placed on her side • The child should not be restrained during the seizure • The nurse should stay with the child during a seizure • The nurse should note how long the seizure lasts, what body parts are involved, any vocalizations made during the seizure, presence or absence of incontinence, and level of consciousness after the seizure ends • Presence or absence of incontinence should be noted, and if it occurs when, whether during the seizure or afterward.

What are two of the most common causes of cerebral palsy? A. A sex-linked recessive inheritance pattern & neonatal dz B. Birth-related brain anoxia and post-maturity status C. Prematurity and brain fragility/anomalies D. Faulty mother-infant bonding and neonatal meningitis

C. Prematurity and brain fragility/anomalies • Cerebral palsy is not genetic and neonatal disease is not a common cause. • Birth-related brain anoxia at times has caused cerebral palsy but prematurity, not post-maturity, is the problem. • Cerebral palsy results from faulty development (brain anomalies) during the prenatal period or from damage during the perinatal period, including brain anoxia and cerebral trauma during delivery and prematurity. • Mother-infant bonding has nothing to do with the development of cerebral palsy, and meningitis in the newborn is very rare.

A nurse is caring for a comatose child with multiple injuries. The nurse should recognize that pain A. Cannot occur if the child is comatose B. May occur if child regains consciousness C. Requires astute nursing assessment and management D. Is best assessed by family members familiar with the child

C. Requires astute nursing assessment & management A. Pain can occur in the comatose child. B. The child can be in pain while comatose. C. Because the child cannot communicate pain through one of the standard pain rating scales, the nurse must be focused on physiologic and behavioral manifestations. D. The family can provide insight into different responses, but the nurse should be monitoring physiologic and behavioral manifestations.

A child has a myelomeningocele at the L2 level. What degree of bowel control would be anticipated when toilet training is complete? A. Periodic incontinence B. Moderate control using enemas and laxatives C. Total fecal continence D. The need for a colostomy

C. Total fecal continence A. At the L2 level, the lower extremities, not the bowel, are affected. B. Enemas and laxatives should not be needed, because the bowel is not affected at this level. C. Total fecal continence should be present with the defect at the L2 level. D. A colostomy is not required.

What is a major goal of therapy for children with cerebral palsy? A. Reverse the degenerative processes that have occurred. B. Cure the underlying defect causing the disorder. C. Prevent spread to individuals in close contact with child. D. Promote optimal development by identifying the condition early.

D. A. The underlying defect cannot be cured. B. It may not be possible to reverse degenerative processes. C. Cerebral palsy is not contagious. D. Because cerebral palsy is, so far as is known, a permanent disorder, the goal of therapy is to promote optimal development. This is done through early recognition and beginning of therapy.

A woman 6 weeks pregnant tells the nurse that she is worried the baby might have spina bifida because of a family history. What response would be most helpful to the patient? A. "There is no definite genetic basis for the defect." B. "Low levels of folic acid at the time of conception has been strongly linked to neural tube defects." C. "Chromosomal studies done on amniotic fluid can diagnose the defect prenatally." D. "The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally."

D. "The concentration of alpha-fetoprotein in amniotic fluid can indicate the presence of the defect prenatally." A. The origin of neural tube defects has several factors, including deficient maternal levels of folic acid at the time of conception and a possible, but unproven genetic predisposition. B. This is true, but the woman is already 6 weeks pregnant and the neural tube is developing. C. There is one chromosomal study for spina bifida at this time. D. Fetal ultrasonography and elevated concentrations of alpha-fetoprotein in amniotic fluid may indicate the presence of neural tube defects.

A nursing intervention to prevent increased intracranial pressure (ICP) in an unconscious child includes A. Suctioning any secretions frequently. B. Providing environmental stimulation. C. Turning the head side to side every hour. D. Avoiding activities that cause pain.

D. Avoiding activities that cause pain. A. Suctioning is a distressing procedure. In addition, the resultant decrease in carbon dioxide can increase ICP. B. Environmental stimulation should be minimized. C. The child's head should not be turned side to side. If the jugular vein is compressed, ICP can rise. D. Nursing interventions should focus on assessments and interventions that minimize pain. The activities in the other options can cause the intracranial pressure to increase.

Which nursing intervention is important when caring for an infant with myelomeningocele in the preoperative stage? A. Place the child in the sidelying position to decrease pressure on the spinal cord. B. Apply a heat lamp to facilitate drying and toughening of the sac. C. Keep skin clean and dry to prevent irritation from diarrheal stools. D. Measure head circumference & examine fontanels for signs that might indicate developing hydrocephalus.

D. Measure head circumference & examine fontanels for signs that might indicate developing hydrocephalus. A. Preoperatively, the child is kept in a prone position to decrease tension on the sac and reduce risk of trauma. B. The sac must be kept moist, so sterile, moist, non-adherent dressings are placed over the sac to prevent any leaks or tears from occurring. C. Most newborns do not have diarrheal stools. They are still expelling meconium. D. Hydrocephalus is frequently associated with myelomeningocele. Assessment of the fontanels and daily measurements of head circumference will aid in early detection.

What is a neural tube defect that may not be visible externally in the lumbosacral area called? A. A meningocele B. A myelomeningocele C. Spina bifida cystica D. Spina bifida occulta

D. Spina bifida occulta A. A meningocele contains meninges and spinal fluid but no neural tissue. Unless there are associated cutaneous findings, it is often not identified until later. B. A myelomeningocele is a neural tube defect that contains meninges, spinal fluid, and nerves. C. Spina bifida cystica is a cystic formation with an external saclike protrusion. D. Spina bifida occulta is completely enclosed. Often this defect will not be noticed.

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

a. Extracorporeal membrane oxygenation Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infant's lungs to rest and recover. The infant is most likely intubated and on a ventilator already. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath. REF: p. 644

What action by the nurse is the most important action in preventing neonatal infection? a. Good hand hygiene b. Isolation of infected infants c. Separate gown technique d. Standard Precautions

a. Good hand hygiene Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. The other actions do reduce risk but not nearly to the degree that good hand hygiene does. REF: p. 651

The nurse is teaching the parents of a newborn who is going to receive phototherapy. What other measure does the nurse teach to help reduce the bilirubin? a. Increase the frequency of feedings. b. Increase oral intake of water between feedings. c. How to prepare the newborn for an exchange transfusion d. Wrap the infant in triple blankets to prevent cold stress during phototherapy.

a. Increase the frequency of feedings. Frequent feedings prevent hypoglycemia, provide protein to maintain albumin levels in the blood and promote gastrointestinal motility and removal of bilirubin in the stools. More frequent breastfeeding should be encouraged. Avoid offering water between feedings, because the infant may decrease his or her milk intake. Breast milk or formula is more effective at removing bilirubin from the intestines. Exchange transfusions are seldom necessary but may be performed when phototherapy cannot reduce high bilirubin levels quickly enough. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed. REF: p. 647

The nurse is caring for a neonate undergoing phototherapy. What action does the nurse include on the infant's care plan? a. Keep the infant's eyes covered under the light. b. Keep the infant supine at all times. c. Restrict parenteral and oral fluids. d. Dress the infant in only a T-shirt and diaper.

a. Keep the infant's eyes covered under the light. Retinal damage from phototherapy should be prevented by using eye shields on the infant under the light. To ensure total skin exposure, the infant's position is changed frequently. Special attention to increasing fluid intake ensures that the infant is well hydrated. To ensure total skin exposure, the infant is not dressed. REF: p. 647

A newborn has meconium aspiration at birth. The nurse notes increasing respiratory distress. What action takes priority? a. Obtain an oxygen saturation. b. Notify the provider at once. c. Stimulate the baby to increase respirations. d. Prepare to initiate ECMO.

a. Obtain an oxygen saturation. This baby has a risk for, and signs of, persistent pulmonary hypertension. The nurse first checks an oxygen saturation then notifies the provider, or alternatively, gets the reading (and other assessments) while another nurse does the notification. This baby most likely has tachypnea so stimulation to increase respirations is not needed. ECMO may or may not be needed depending on whether or not other treatments work. REF: p. 645

A woman who has had no prenatal care enters the labor and delivery unit in advanced labor. She has chickenpox. What action by the nurse is best? a. Place the woman in isolation. b. Give the woman immune globulin before delivery. c. Treat the woman with acyclovir. d. Administer antibiotics to the infant after birth.

a. Place the woman in isolation. Women with varicella infections (chickenpox or shingles) need to be in isolation (airborne and contact per the CDC). There might not be enough time to administer immune globulin to the mother before delivery, but it could be given to the baby. Acyclovir is the drug of choice for treatment, but the staff needs to be protected from this infection through isolation precautions. Antibiotics are not used for this disease. REF: p. 649 | Table 30.1

Nursing care of the infant with neonatal abstinence syndrome should include a. Positioning the infant's crib in a quiet corner of the nursery b. Feeding the infant on a 2-hour schedule c. Placing stuffed animals and mobiles in the crib to provide visual stimulation d. Spending extra time holding and rocking the infant

a. Positioning the infant's crib in a quiet corner of the nursery Placing the crib in a quiet corner helps avoid excessive stimulation of the infant. These infants have an increase calorie needs but poor suck and swallow coordination. Feeding should occur to meet these needs. Stimulation should be kept to a minimum. REF: p. 655

Parents of a newborn with phenylketonuria are anxious to learn about the appropriate treatment for their infant. What topic does the nurse include in the teaching plan? a. Fluid and sodium restrictions b. A phenylalanine-free diet c. Progressive mobility and splinting d. A protein-rich diet

b. A phenylalanine-free diet Phenylketonuria is treated with a special diet that restricts phenylalanine intake. Fluid and sodium restrictions are not included in this plan. Mobility and splinting are not included in the plan. A protein-rich diet is not in the plan. REF: p. 655

A neonate has white patches in her mouth that bled when the mother tried wiping them away. What action by the nurse is best? a. Tell the mother to leave the patches alone. b. Assess the mother for a perineal rash. c. Give the infant medicated pacifiers. d. Test the infant for toxoplasmosis.

b. Assess the mother for a perineal rash. These patches are characteristic of maternal infection with candidiasis or yeast. The nurse assesses the mother's perineal area for a rash. Telling the mother to leave the rash alone may be appropriate information but does not get to the bottom of the issue. The nurse should not provide medication without knowing what is being treated. The baby does not have toxoplasmosis. REF: p. 650 | Table 30.1

Newborns whose mothers are substance abusers frequently have what behaviors? (Select all that apply.) a. Circumoral cyanosis b. Decreased amounts of sleep c. Hyperactive Moro (startle) reflex d. Difficulty feeding e. Weak cry

b. Decreased amounts of sleep c. Hyperactive Moro (startle) reflex d. Difficulty feeding The infant exposed to drugs in utero often has poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behavior. They do not have circumoral cyanosis and will have a high-pitched cry. REF: p. 654

A woman who has a history of frequent substance abuse is close to delivering. What action by the nurse is best? a. Notify social services of the situation prior to the birth. b. Draw up and label a syringe of naloxone. c. Administer naloxone if the baby shows signs of withdrawal. d. Prepare to administer naloxone to the mother.

b. Draw up and label a syringe of naloxone. When anticipating the delivery of a baby whose mother is addicted to opioids, the nurse prepares to give the newborn naloxone for respiratory depression. To administer the drug in the fastest way possible, the nurse prepares a syringe with the medication. Then when the baby's weight is known, the nurse discards the excess drug and administers the correct dose to the baby. Social services will need to be involved but not at this point; the medication is the priority. The naloxone may cause signs of withdrawal in the infant. The baby gets the naloxone, not the mother REF: p. 641 | p. 642 | Drug Guide

Some infants develop hypoxic-ischemic encephalopathy after asphyxia. Therapeutic hypothermia has been used to improve neurologic outcomes for these infants. Criteria for the use of this modality include (Select all that apply.) a. The infant must be 28 weeks gestation or greater. b. Have evidence of an acute hypoxic event. c. Be in a facility they can initiate treatment within 6 hours. d. The infant must be 36 or more weeks' gestation. e. The treatment must be initiated within the first 12 hours of life.

b. Have evidence of an acute hypoxic event. c. Be in a facility they can initiate treatment within 6 hours. d. The infant must be 36 or more weeks' gestation. The infant must be at least 36 weeks of gestation to meet the criteria for therapeutic hypothermia. Treatment should be initiated within the first 6 hours of life, ideally at a tertiary care center. The infant must have evidence of perinatal hypoxic-ischemic episodes. REF: p. 642

The nurse learns that the most common cause of pathologic hyperbilirubinemia is which of the following? a. Hepatic disease b. Hemolytic disorders in the newborn c. Postmaturity d. Congenital heart defect

b. Hemolytic disorders in the newborn Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage and prematurity may be causes of pathologic hyperbilirubinemia, but they are not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates. REF: p. 645

An infant with hypocalcemia is receiving an intravenous bolus of calcium. The infant's heart rate changes from 144 beats/minute to 62 beats/minute. What action by the nurse is best? a. Call for a stat EGG. b. Stop the infusion. c. Stimulate the infant. d. Administer magnesium.

b. Stop the infusion. IV calcium can lead to bradycardia. When this infant's heart rate drops to 60 beats/minute, the nurse stops the infusion. A stat ECG is not necessary unless policy requires it or the bradycardia does not resolve. Stimulating the infant will not increase the heart rate. Magnesium infusion will also not increase the heart rate. REF: p. 653

The difference between physiologic and nonphysiologic jaundice is that nonphysiologic jaundice a. usually results in kernicterus. b. appears during the first 24 hours of life. c. results from breakdown of excessive erythrocytes not needed after birth. d. begins on the head and progresses down the body.

b. appears during the first 24 hours of life. Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is due to a pathologic condition, such as Rh incompatibility. REF: p. 645

The goal of treatment of the infant with phenylketonuria (PKU) is to a. cure cognitive delays. b. prevent central nervous system (CNS) damage. c. prevent gastrointestinal symptoms. d. prevent the renal system damage.

b. prevent central nervous system (CNS) damage. CNS damage can occur as a result of toxic levels of phenylalanine. No cure exists for cognitive delays should they occur. Digestive problems are a clinical manifestation of PKU, but it is more important to prevent the CNS damage. PKU does not involve renal dysfunction. REF: p. 655

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

c. "Erythromycin is given to prevent a gonorrheal infection." With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision and is not used for herpes infections or lubrication REF: p. 649 | Table 30.1

The nurse present at the delivery is reporting to the nurse who will be caring for the neonate after birth. What information might be included for an infant who had thick meconium in the amniotic fluid? a. The infant had Apgar scores of 6 and 8. b. An IV was started immediately after birth to treat dehydration. c. No meconium was found below the vocal cords when they were examined. d. The parents spent an hour bonding with the baby after birth.

c. No meconium was found below the vocal cords when they were examined. A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Apgar scores are important but not directly related to meconium. There is no relationship between dehydration and meconium fluid. Bonding is an expected occurrence. REF: p. 643

What action does the nurse add to the plan of care for an infant experiencing symptoms of drug withdrawal? a. Keeping the newborn sedated b. Feeding every 4 to 6 hours to allow extra rest c. Swaddling the infant snugly d. Playing soft music during feeding

c. Swaddling the infant snugly The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. The baby is not kept sedated. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability. REF: p. 655

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

c. congenital syphilis. This rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. This is not characteristic of gonorrhea, herpes, or HIV. REF: p. 650 | Table 30.1 | p. 654

Transient tachypnea of the newborn (TTN) is thought to occur as a result of a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal delivery associated with meconium-stained fluid.

c. delayed absorption of fetal lung fluid. Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant and hypoinflation of the lungs are not related to TTN. A slow vaginal delivery will help prevent TTN. REF: p. 642

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

c. neonatal abstinence syndrome scoring. Various scoring systems exist to determine the number, frequency, and severity of behaviors that indicate neonatal abstinence syndrome. The score is helpful in determining the necessity of drug therapy to alleviate withdrawal. Pharmacologic treatment is based on the severity of withdrawal symptoms. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. However, the scoring helps provide definitive care. Fluids and electrolyte balance are appropriate for any infant. REF: p. 654

A mother with diabetes has done some reading about the effects of the condition on her newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be." b. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c. "The red appearance of my baby's skin is due to an excessive number of red blood cells." d. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy."

d. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy." Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. The other statements are correct and show good understanding. REF: p. 652

The infant of a mother with diabetes is hypoglycemic. What type of feeding should be instituted first? a. Glucose water in a bottle b. D5W intravenously c. Formula via nasogastric tube d. Breast milk

d. Breast milk Breast milk is metabolized more slowly and provides longer normal glucose levels. Breast milk is best for nearly all babies. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines should be a later choice if the hypoglycemia continues. Formula does provide longer normal glucose levels but would be administered via bottle, not by tube feeding unless the baby is unable to take oral feedings. REF: p. 652

A macrosomic infant is born after a difficult, forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). What action by the nurse is most appropriate? a. Leave the infant in the room with the mother. b. Take the infant immediately to the nursery. c. Perform a gestational age assessment. d. Monitor blood glucose levels frequently.

d. Monitor blood glucose levels frequently. This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. The infant can stay with the mother, but this is not the best answer since it does not include the close monitoring needed. Regardless of gestational age, this infant is macrosomic. REF: p. 652

A nurse is participating in a neonatal resuscitation. What action by the nurse takes priority? a. Suction the mouth and nose. b. Stimulate the infant by rubbing the back. c. Perform the Apgar test. d. Place the infant in a preheated warmer.

d. Place the infant in a preheated warmer. In a resuscitation situation, the nurse places the newborn in a preheated warmer immediately to reduce cold stress. Next position the infant in a "sniffing" position. Suctioning is the third step. Drying the infant is fourth, although if more than one health care provider is present, drying can occur simultaneously with the other actions. REF: p. 643

Four hours after delivery of a healthy neonate of an insulin-dependent diabetic woman, the baby appears jittery, irritable, and has a high-pitched cry. Which nursing action has top priority? a. Start an intravenous line with D5W. b. Notify the clinician stat. c. Document the event in the nurses' notes. d. Test for blood glucose level.

d. Test for blood glucose level. These are signs of hypoglycemia in the newborn. The nurse should test the infant's blood glucose level and then feed the infant if it is low. It is not common practice to give intravenous glucose to a newborn prior to feeding. Feeding the infant is preferable because the formula or breast milk will last longer. The provider needs to be notified after corrective action has been taken. Documentation should occur but is not the priority. REF: p. 652

The nursing student learns that transmission of HIV from mother to baby occurs in which fashion? a. From the maternal circulation only in the third trimester b. From the use of unsterile instruments c. Only through the ingestion of amniotic fluid d. Through the ingestion of breast milk from an infected mother

d. Through the ingestion of breast milk from an infected mother Postnatal transmission of HIV through breastfeeding may occur. Transplacental transmission can occur at any time during pregnancy. Unsterile instruments are possible sources of transmission but highly unlikely. Transmission of HIV may also occur during birth from blood or secretions. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. This is highly unlikely as most health care facilities must meet sterility standards for all instrumentation. REF: p. 649 | Table 30.1

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

d. sepsis. The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. There is no evidence of phrenic nerve damage or respiratory distress syndrome. Early signs of sepsis may be difficult to distinguish from other problems such as hypoglycemia, but the prolonged rupture of membranes puts this baby at high risk of sepsis. REF: p. 650