Chapter 17: Nursing Care of the Newborn at Risk

Which physical characteristics should the nurse expect to find when assessing a post-term newborn? (Select all that apply.) A. Dry and peeling skin B. Excess vernix and lanugo C. Loose skin D. Meconium staining on the umbilical cord E. Decrease in alertness after birth

A. Dry and peeling skin Dry and peeling skin is a common finding in the post-term infant. C. Loose skin Loose skin is often noted in the post-term infant. D. Meconium staining on the umbilical cord Meconium staining on the umbilical cord is often noted in the post-term infant because the infant is more likely to have meconium in the amniotic fluid.

To assess the risk for birth asphyxia, which condition should the nurse monitor for during labor and delivery? A. Maternal anemia B. Maternal hypotension C. Precipitous childbirth D. Too much oxygen during childbirth

B. Maternal hypotension Maternal hypotension and hypertension are both risk factors for birth asphyxia.

Which nursing intervention is appropriate when caring for a newborn suffering from cold stress? A. Administering warm IV fluids B. Monitoring the infant's temperature every 15 minutes C. Leaving the infant's hat off to allow his or her hair to dry D. Monitoring for hyperglycemia

B. Monitoring the infant's temperature every 15 minutes The nurse should monitor the infant's temperature every 15 minutes until stable per unit protocol or provider order.

Which birth complication is more likely when an infant is large-for-gestational age (LGA)? A. Preterm labor B. Shoulder dystocia C. Hyperglycemia D. Neonatal sepsis

B. Shoulder dystocia Shoulder dystocia is more common in LGA infants due to large size. This is a birth complication.

Birth trauma can be caused by all of the following except ________. A. Rapid delivery B. Small fetal head C. Use of forceps or vacuum extraction D. Abnormal presentation

B. Small fetal head Small fetal head is not a cause of birth trauma.

Which data collected during the health history of a laboring patient may increase the risk of delivering an SGA newborn? A. Blood pressure level of 110/60 mm Hg B. Serum glucose level of 85 mg/dL C. Weight gain of 12 lb (5.5 kg) D. Pulse rate of 90 beats per minute

C. Weight gain of 12 lb (5.5 kg) Poor maternal nutrition, noted by inadequate weight gain during pregnancy, is a risk factor for delivering an SGA newborn.

Which term should the nurse use to document decreased fetal growth due to impaired perfusion of the placenta? A. Low birth weight B. Premature neonate C. Small-for-gestational age (SGA) D. Intrauterine growth restriction (IUGR)

D. Intrauterine growth restriction (IUGR) IUGR is the term that the nurse should use to document decreased fetal growth due to impaired perfusion of the placenta.

The nurse caring for the infant with brachial plexus injury demonstrates proper care of the newborn by ___________. A. Lifting the infant equally under both axillae B. Allowing the affected arm to move freely C. Ordering an x-ray of the infant's clavicle D. Monitoring the infant for signs of pain

D. Monitoring the infant for signs of pain Monitoring for signs of pain and reporting to the health-care provider is an appropriate nursing intervention.

Which of the following interventions would the nurse exclude from her plan of care for a hypoglycemic infant? A. Carefully managing the newborn's temperature B. Monitoring blood glucose after feedings C. Encouraging frequent feedings D. Obtaining arterial blood gases

D. Obtaining arterial blood gases Obtaining arterial blood gases is not part of the nursing plan of care for this infant.

Which intervention should be included in the nursing plan of care for a newborn diagnosed with sepsis? A. AIV fluids B. Placing a central line C. Cardiopulmonary support D. Promoting thermoregulation

D. Promoting thermoregulation Promoting thermoregulation is a nursing intervention implemented in the plan of care for a newborn diagnosed with sepsis.

Which term should the nurse use to describe gas exchange in which no oxygen is reaching the cells? A. Anoxia B. Hypoxia C. Asphyxia D. Hypercapnia

A. Anoxia Anoxia is the term that the nurse should use when communicating that no oxygen is reaching the cells during gas exchange.

Which complications should the nurse monitor for when providing care to a premature newborn suspected of having NEC? (Select all that apply.) A. Hematochezia B. Hypoglycemia C. Respiratory distress D. Palpable abdominal mass E. Hypoactive bowel sounds

A. Hematochezia Hematochezia, or bright red blood in the stool, is a clinical manifestation associated with NEC. D. Palpable abdominal mass A palpable abdominal mass is a clinical manifestation associated with NEC. E. Hypoactive bowel sounds Hypoactive bowel sounds are clinical manifestations associated with NEC.

Which clinical manifestations support the diagnosis of polycythemia for a neonate? (Select all that apply.) A. Hematuria B. Ruddy skin C. Poor feeding D. Hematochezia E. Hyperglycemia

A. Hematuria This is correct. Hematuria is a clinical manifestation associated with polycythemia. B. Ruddy skin This is correct. Ruddy skin is a clinical manifestation associated with polycythemia. C. Poor feeding This is correct. Poor feeding is a clinical manifestation associated with polycythemia.

Which complications should the nurse monitor for when providing care to an LGA newborn? (Select all that apply.) A. Hypoglycemia B. Respiratory distress C. Meconium aspiration D. Palpable abdominal mass E. Hypoactive bowel sounds

A. Hypoglycemia Hypoglycemia is a complication that the nurse should monitor for when providing care to an LGA newborn. LGA newborns are often the result of a pregnancy complicated by DM. Hypoglycemia occurs because of the retention of maternal insulin transferred while in utero. B. Respiratory distress Respiratory distress is often a complication that the nurse should monitor for when providing care to an LGA newborn. These neonates tend to be large in size, but their New Ballard assessment score finds them neurologically immature. C. Meconium aspiration Meconium aspiration is often a complication that the nurse should monitor for when providing care to an LGA newborn. Meconium aspiration is a complication associated with post-term newborns, which is often associated with LGA status.

Which factor requires the nurse to most closely monitor the infant for the development of respiratory distress syndrome (RDS)? A. Preterm birth B. Precipitous delivery C. Hyperbilirubinemia D. Spina bifida

A. Preterm birth Preterm birth is a risk factor for RDS that necessitates close monitoring by the nurse.

Which parental actions indicate correct understanding of the care required for a newborn diagnosed with NAS? (Select all that apply.) A. Swaddling the neonate B. Avoiding strong fragrances C. Providing a calm environment D. Allowing the neonate to "cry it out" E. Handling the neonate as often as possible

A. Swaddling the neonate Swaddling the neonate is an appropriate action when caring for a newborn diagnosed with NAS. B. Avoiding strong fragrances Avoiding strong fragrances is an appropriate action when caring for a newborn diagnosed with NAS. C. Providing a calm environment Providing a calm environment is an appropriate action when caring for a newborn diagnosed with NAS.

Which intervention should be included by the nurse in the plan of care for a family whose newborn is admitted to the NICU? A. Referring to the baby using the last name B. Allowing the parents to participate in the baby's care C. Withholding the baby's true diagnosis until more family is present D. Explaining to the parents that their baby cannot be held if intubated

B. Allowing the parents to participate in the baby's care The family should be allowed to provide care, as appropriate, in order to promote family-centered care.

The nurse assessing an infant born to a diabetic mother knows that all but which of the following findings are signs of hypoglycemia? A. Lethargy B. Hyperthermia C. Weak cry D. Tremors

B. Hyperthermia Hyperthermia is not generally associated with hypoglycemia.

Which description regarding the pathophysiology of persistent pulmonary hypertension should the nurse include in the teaching session with a newborn's parents? A. "Gas exchange occurs in the alveoli." B. "Oxygen is picked up, and carbon dioxide is released." C. "Blood is shunted away from the lungs, affecting oxygenation." D. "Blood flows from the right ventricle into the pulmonary artery."

C. "Blood is shunted away from the lungs, affecting oxygenation." Blood is shunted away from the lungs, which affects oxygenation in persistent pulmonary hypertension of the newborn.

The nurse is providing education to the parents of an infant experiencing transient tachypnea of the newborn (TTN). Which of the following statements should be included in the teaching? A. "Your baby will need to be kept cool to reduce her respiratory rate." B. "It is important to give your baby extra stimulation during this time." C. "TTN usually resolves on its own within 3-5 days." D. "TTN could have been prevented if you had not had a cesarean delivery."

C. "TTN usually resolves on its own within 3-5 days." TTN is thought to be caused by incomplete reabsorption of fluid in the lungs and usually resolves within 3 to 5 days.

Which intervention should the nurse include in the plan of care for a jaundiced newborn who is to receive phototherapy? A. Keeping the baby fully clothed to avoid burns B. Encouraging breastfeeding four to six times per day C. Placing eye protection on the baby during therapy D. Reporting fewer than two stools per day to the provider

C. Placing eye protection on the baby during therapy To protect the retina from injury, eye protection should be placed on a newborn who is receiving phototherapy for the treatment of hyperbilirubinemia.

Which medication prescription should the nurse anticipate when providing care to a newborn exposed to HIV in utero? A. Caffeine B. Morphine C. Zidovudine D. Phenobarbital

C. Zidovudine Zidovudine is an antiretroviral medication that is often prescribed for newborns who are exposed to HIV in utero.

Which data collected during the newborn's physical assessment support the current diagnosis of meconium aspiration syndrome? A. Bradypnea B. Hypertension C. Increased breath sounds D. Decreased oxygen saturation Decreased oxygen saturation level is a clinical manifestation that supports the current diagnosis of meconium aspiration syndrome.

D. Decreased oxygen saturation Decreased oxygen saturation level is a clinical manifestation that supports the current diagnosis of meconium aspiration syndrome.

Which data would cause the licensed practical nurse (LPN) to notify the registered nurse (RN) when providing care for a newborn patient? A. Eupnea B. Acrocyanosis C. Crying with a blood draw D. Grunting with expirations

D. Grunting with expirations Grunting with expirations is a clinical manifestation associated with RDS; therefore, the LPN should notify the RN immediately.

Which term describes a state of elevated carbon dioxide? A. Hypocalcemia B. Hematochezia C. Hypoxic-ischemic encephalopathy D. Hypercapnia

D. Hypercapnia Hypercapnia is defined as elevated carbon dioxide in the bloodstream.