Complicated Newborn NCLEX Q's
Which of the following would be a priority nursing intervention for a newborn experiencing hypothermia? a. Administering oxygen b. Monitoring for hypoglycemia c. Rapidly rewarming the newborn d. Starting phototherapy
b. Monitoring for hypoglycemia Explanation: The newborn reacts to hypothermia by burning brown fat to produce body heat. This process requires oxygen and glucose. When an infant experiences hypothermia, glucose and oxygen needs increase, and hypoglycemia can result. Newborns should be rewarmed slowly to prevent hypotension. The newborn might require oxygen administration, but the need should always be assessed first. Phototherapy is not indicated.
While feeding an infant, the nurse notices white, adherent patches on the infant's gums and buccal cavity. Which action should the nurse should take at this time? a. Further evaluate for yeast infection. b. Verify that vitamin K was given at delivery. c. Document this normal finding. d. Assess for maternal history of herpes simplex.
a. Further evaluate for yeast infection. Explanation: The presence of white adherent patches in the mouth is not a normal finding. The primary sign of an oral yeast infection, or thrush, is the presence of white patches in the mouth that tend to bleed if they are touched. The presence of white patches is unrelated to whether vitamin K was given at delivery. Maternal history of herpes simplex is not relevant.
The parents of a preterm neonate ask why their baby gets cold so easily. The nurse responds with which explanation about preterm neonates? a. Preterm neonates have minimal body fat to retain body heat. b. Preterm neonates lose heat faster because they lie in a fetal position. c. Preterm neonates are able to shiver to produce body heat. d. Preterm neonates have blood vessels that are deep under the skin surface.
a. Preterm neonates have minimal body fat to retain body heat. Explanation: In general, infants are not able to shiver to produce body heat when they are cold. Preterm infants have minimal adipose tissue, so they lose heat more quickly through their skin. The skin of a neonate is thin, with blood vessels near the surface, which increases heat loss through the skin. Because they are weak and neurologically immature, they aren't able to lie in a tight fetal position, allowing greater exposure of the body to the air, which results in heat loss.
The nurse assesses a newborn and obtains the following information: Left arm limp and extended; left hand internally rotated; positive grasp reflex bilaterally; no response on left side to Moro reflex. What is the most appropriate nursing intervention for this infant? Select all that apply. a. Prepare supplies for a cast application. b. Avoid positioning infant on left side. c. Immobilize the arm by securing the infant's sleeve to the shirt d. Provide passive range of motion exercises after 24 hours e. Assess for congenital hip dysplasia.
b, c Explanation: Congenital hip dysplasia is characterized by a clicking sound with hip rotation, while this infant has Erb-Duchenne's paralysis (Erb's palsy) of the left arm. The infant should not be positioned on the affected side. Passive range of motion is delayed until the 10th day to prevent further damage. Occasionally a splint may be applied, but a cast is not indicated. The arm may be secured by securing the infant's sleeve to the shirt or using a brace or splint.
Which neonate requires the closest observation by the nurse? a. The neonate with enlarged breast tissue b. The baby who startles at loud sounds c. The neonate with irregular respirations at 30-40 breaths/minute d. The neonate whose color became cyanotic during the first feeding
d. The neonate whose color became cyanotic during the first feeding Explanation: Being startled at loud noises is normal for a neonate. Enlarged breast tissue in neonatesis normal for a neonate. Central cyanosis is always considered abnormal, and warrants further evaluation.
An infant with fetal alcohol spectrum disorder is about to be discharged home with foster parents. Place in order the priority of the nurse in teaching the following topics to the foster parents. Feeding methods Infection prevention Immunizations Toy safety
1. Feeding methods 2. Infection prevention 3. Immunizations 4. Toy safety Explanation: Infants with fetal alcohol syndrome have an increased risk of feeding difficulties related to hyperactivity. Nutrition is a key concern for this infant for proper growth and development. Infection prevention is the second priority concern, since this will help to maintain healthy physiological condition. The immunization schedule has third priority because it is also related to prevention of communicable diseases and infection. Although toy safety is important, it is the fourth priority because newborns are not developed sufficiently to play with toys.
The nurse realizes that a neonate born at 34 weeks' gestation might not have enough surfactant, so the nurse should observe closely for which of the following?Select all that apply. a. Tachypnea b. Abdominal distention c. Jaundice d. Sternal retractions e. Jitteriness
a, d Explanation: Abdominal distention is not directly related to RDS. Jaundice is not directly related to RDS. Jitteriness is not directly related to RDS. Preterm infants lack adequate surfactant to keep their alveoli open during expiration. This can lead to development of respiratory distress syndrome (RDS), which would be evidenced by signs of respiratory distress, including sternal retractions. Preterm infants lack adequate surfactant to keep their alveoli open during expiration. This can lead to development of respiratory distress syndrome (RDS), which would be evidenced by signs of respiratory distress, including tachypnea.
The nurse is admitting a neonate two hours after delivery. About which assessment data should the nurse be concerned?Select all that apply. a. Nasal flaring b. Hands and feet are blue c. Apical heart rate 156 d. Minimal response to verbal stimulation e. Retractions
a, e Explanation: Distal cyanosis This is a normal finding for a neonate at 2 hours of age. Nasal flaring could be a sign of respiratory distress, and requires immediate intervention. Retractions could be a sign of respiratory distress, and requires immediate intervention. Minimal response to verball stimuli and a apical heart rate are normal for 2 hours after delivery
The parents of a 28-weeks'-gestation neonate ask the nurse, "Why does he have to be fed through a tube in his mouth?" What is the best response by the nurse? a. "The baby's sucking, swallowing, and breathing are not coordinated yet." b. "The baby's stomach cannot digest formula at this time." c. "It helps to prevent thrush, an infection that could affect the baby's mouth." d. "It allows us to accurately determine the baby's intake."
a. "The baby's sucking, swallowing, and breathing are not coordinated yet." Explanation: Intake can be accurately assessed with gavage feedings but the concern is risk for aspiration. Neonates generally aren't able to effectively coordinate sucking, swallowing, and breathing until 34-36 weeks' gestation. If fed orally before that time, they are at greater risk of aspiration. Typically, they will be fed through a gavage tube until they are able to drink from a bottle or breastfeed. The stomach of a preterm infant can digest small amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused during passage through the birth canal, and gavage feedings will not prevent it from occurring.
A baby's mother is HIV-positive. Which intervention is most important for the nurse to include when planning care for this newborn? a. Administer zidovudine (ZDV) after delivery. b. Place the baby's crib in a quiet corner of the nursery. c. Cuddle the baby as much as possible. d. Encourage the mother to breastfeed.
a. Administer zidovudine (ZDV) after delivery. Explanation: Breastfeeding is contraindicated in an HIV-positive mother because the virus can be passed through breast milk. Administering zidovudine (ZDV, formerly AZT) to the mother prenatally and intrapartally, and to the infant immediately after delivery, decreases the prenatal risk of transmission of HIV by 60-70%. Cuddling the infant is important, but not the highest priority in this situation. Decreasing environmental stimulation is not indicated.
A nurse is caring for a 12-hour-old newborn. The nurse notes a yellow tint to the baby's skin and sclera. What laboratory test should the nurse anticipate being ordered? a. Direct Coombs' b. Blood culture c. Arterial blood gas (ABG) d. Blood glucose
a. Direct Coombs' xplanation: Blood glucose is not related to hyperbilirubinemia. Jaundice in an infant less than 24 hours old is often caused by Rh or ABO incompatibility. A direct Coombs' test determines the presence of maternal antibodies in the baby's blood. A blood culture is not related to hyperbilirubinemia. ABG's are not related to hyperbilirubinemia.
Which nursing intervention is appropriate in the care of an infant with respiratory distress syndrome (RDS)? a. Maintain a neutral thermal environment. b. Perform chest physiotherapy twice a day. c. Perform a complete gestational age assessment. d. Suction meconium from airway as needed.
a. Maintain a neutral thermal environment. Explanation: Infants use additional oxygen and glucose when faced with cold stress. Infants with RDS are already compromised, so it is important to keep environmental temperatures stable to minimize their oxygen and glucose requirements. A complete assessment could increase oxygenation requirements even further. Chest physiotherapy might or might not be needed. There is no specific evidence in the question that meconium is present.
The nurse is developing a plan of care for an infant born at 28 weeks' gestation. What would be a realistic goal for this infant to achieve within one week? a. Maintaining respiratory rate at 30-60 breaths/minute b. Maintaining body temperature in a bassinet c. Recognizing the parents d. Drinking from a bottle
a. Maintaining respiratory rate at 30-60 breaths/minute Explanation: Drinking from a bottle is not a timely goal for a 28-week-gestation infant at 1 week of age. Recognizing parents is not a timely goal for a 28-weeks-gestation infant at 1 week of age. A healthy respiratory rate for all newborns is 30-60 breaths/min. Maintaining body temperature in a bassinet is not a timely goal for a 28-week-gestation infant at 1 week of age.
A neonatal nurse is attending a high-risk delivery, and is told that the mother received morphine sulfate IV 30 minutes ago. The nurse should be prepared to give which medication to the infant immediately after delivery? a. Naloxone b. Regular insulin c. Magnesium sulfate d. Double dose of vitamin K
a. Naloxone Explanation: Opioid analgesics (narcotics) such as morphine cross the placenta, and can cause respiratory depression in a neonate when given shortly before delivery. Naloxone is the drug of choice to reverse respiratory depression in the neonate caused by narcotics. Insulin would be given to treat hyperglycemia. Double doses of vitamin K are not given. Magnesium sulfate is given to the mother to prevent eclampsia.
A newborn's temperature is 97.4°F. What is the priority nursing intervention? a. Wrap the newborn in two warm blankets, and place a cap on the head. b. Take the newborn to the nursery, and observe for two hours. c. Reassess the temperature in four hours. d. Notify the physician or nurse practitioner immediately.
a. Wrap the newborn in two warm blankets, and place a cap on the head. Explanation: The physician can be notified if needed once the infant has been attended to. Observing the infant is an assessment and not a protective intervention. Reassessing the temperature in four hours is not a protective intervention. This newborn has a low temperature, and the nurse must intervene quickly to prevent complications related to hypothermia. Wrapping the baby in warm blankets and covering the head will help prevent heat loss through conduction, convection, and radiation, and are the most important initial interventions. A baby can lose a large amount of heat from his head, so keeping it covered will help stabilize the temperature.
The nurse finds the mother of a 28-weeks'-gestation infant crying in her room. The mother states, "I just know my baby is going to die." What is the most therapeutic response by the nurse? a. "My baby was born at 27 weeks, and he is fine now." b. "You seem very worried about what will happen to your baby." c. "I know this seems overly optimistic, but it is likely that everything will be fine." d. "Why do you think that?"
b. "You seem very worried about what will happen to your baby." Explanation: It is not therapeutic to give false reassurance to the client. It is not therapeutic to ask clients "why" they feel the way they do. Reflecting on what the client said offers her an opportunity to share her feelings. A therapeutic response focuses on the client rather than the nurse.
A 26-week-gestation neonate has received 80-100% oxygen via mechanical ventilation for two weeks, and has received several blood transfusions for anemia. The nurse should plan for which intervention needed by the infant? a. Wean supplemental oxygen rapidly. b. Arrange for eye exam by ophthalmologist prior to discharge. c. Begin phototherapy. d. Administer surfactant via endotracheal tube.
b. Arrange for eye exam by ophthalmologist prior to discharge. Explanation: Phototherapy is indicated for treatment of high bilirubin levels. This infant has been receiving high levels of oxygen for two weeks, and is at risk for retinopathy of prematurity (ROP). All preterm infants who receive oxygen should have a thorough eye exam done by an ophthalmologist prior to discharge. It is important to administer the minimum amount of oxygen to infants to decrease the risk that this condition will develop. Oxygen should be weaned as tolerated but this may or may not be rapidly. Artificial surfactant may be administered within the first several days of life to decrease the risk of respiratory distress syndrome (RDS).
An infant of a diabetic mother (IDM) is admitted to the newborn nursery. Which nursing intervention has highest priority at this time? a. Complete a gestational age assessment. b. Assess the infant's blood glucose level. c. Administer vitamin K intramuscularly. d. Clean the umbilical cord.
b. Assess the infant's blood glucose level. Explanation: Cleaning the umbilical cord is important, but is not the highest priority for a newborn of a diabetic mother. Administering vitamin K is important, but is not the highest priority for a newborn of a diabetic mother. Completing a gestational age assessment is important, but is not the highest priority for a newborn of a diabetic mother. An infant of a diabetic mother is at risk for hypoglycemia, and blood glucose should be monitored closely after delivery and treated if necessary.
A nurse is assessing a neonate born 12 hours ago, and notes a yellow tint to the sclera. The nurse should read the medical record for what other assessment that is important to note at this time? a. Length of time prior to delivery that membranes ruptured b. Blood type and Rh factor of mother and newborn c. Most recent blood pressure d. Blood glucose
b. Blood type and Rh factor of mother and newborn Explanation: Blood glucose is not of concern with jaundice. This newborn has signs of jaundice, which include a yellow tint to the sclera and skin. Jaundice is considered pathologic if it occurs in the first 24 hours of life, when it is most often caused by Rh or ABO incompatibility. It would be important to assess both the mother's and newborn's blood type and Rh factor to determine if this could be causing the jaundice. A bilirubin level should also be obtained. Most recent blood pressure is not of concern with jaundice. Timing of membrane rupture is not of concern with jaundice.
Of the following nursing diagnoses for a high-risk newborn, which requires the most immediate intervention by the nurse? a. Imbalanced Nutrition: Less than Body Requirements related to limited oral intake b. Ineffective Airway Clearance related to pulmonary secretions c. Deficient Knowledge related to infant care needs d. Acute Pain related to frequent heelsticks
b. Ineffective Airway Clearance related to pulmonary secretions Explanation: Pain has a lower priority than airway and breathing. Nutrition has a lower priority than airway and breathing. Maintaining a patent airway is the highest priority when providing care for a newborn. A newborn's condition will deteriorate rapidly without a patent airway. Learning needs have a lower priority than airway and breathing.
The nurse is observing a student practicing maintaining a patent airway on a newborn doll. The nurse must intervene if which of the following is observed? a. Positioning the infant in a "sniffing" position b. Inserting a nasogastric tube c. Squeezing the bulb syringe before insertion into mouth d. Suctioning the mouth, then the nose
b. Inserting a nasogastric tube Explanation: Suctioning the mouth, then the nose is a correct intervention for maintaining a patent airway. Squeezing the bulb syringe before inserting in the mouth correct intervention for maintaining a patent airway. Infants are obligate nose breathers. A gastric tube may be inserted to keep the stomach decompressed and allow for easier lung expansion. But if it is inserted nasally, it occludes one nare, and might make respiratory effort more difficult. Gastric tubes are placed as oral/gastric.
Which data would be most important for the nurse to note as part of an initial assessment of a newborn's history? a. Mother's age is 14. b. Mother received morphine sulfate 4 mg IV 20 minutes before delivery. c. Mother reports drinking a glass of wine with dinner each night. d. Mother's blood type is O negative.
b. Mother received morphine sulfate 4 mg IV 20 minutes before delivery. Explanation: Opioid analgesics cross the placenta and, if given close to delivery, can cause respiratory depression in the newborn, making this the priority item. Maternal drinking might warrant further investigation, but the priority at delivery is to establish and maintain an airway. Young maternal age has possible implications that might warrant further investigation, but the priority at delivery is to establish and maintain an airway. Maternal blood type O negative warrants follow-up, but the priority at delivery is to establish and maintain an airway.
A newborn male is admitted to the nursery 15 minutes after delivery. His skin is mottled, and mucous membranes are blue; he is active, and is wrapped in a blanket. The nurse should make which assessment as a priority? a. Umbilical cord for bleeding b. Patent airway c. Visible deformities d. Infant's temperature
b. Patent airway Explanation: Once airway and breathing are assessed, the nurse may check the umbilical cord for bleeding, measure temperature, and, finally, check for visible deformities. Once airway and breathing are assessed, the nurse may check the umbilical cord for bleeding, measure temperature, and, finally, check for visible deformities. Once airway and breathing are assessed, the nurse may check the umbilical cord for bleeding, measure temperature, and, finally, check for visible deformities. The highest priority after delivery is to maintain and support respiratory function. This infant is demonstrating initial signs of respiratory deficiency.
A nurse is admitting a baby to the nursery 30 minutes after delivery. Which information from the mother's history should be of greatest concern? a. Membranes ruptured 10 hours prior to delivery. b. Preexisting insulin-dependent diabetes mellitus. c. Received meperidine (Demerol) IV three hours prior to delivery. d. Marginal placenta previa.
b. Preexisting insulin-dependent diabetes mellitus. Explanation: If the woman received meperidine (Demerol), most of the drug would be metabolized within three hours, and should not cause respiratory depression in the infant at delivery. A marginal placenta previa increases the mother's risk of bleeding during pregnancy, but should not cause significant complications in the newborn after delivery. Membranes ruptured greater than 24 hours prior to delivery increase the risk of infection for mother and infant. A maternal history of diabetes increases the risk of hypoglycemia in the newborn, and this infant should be monitored closely.
The nurse is assigned to a baby receiving phototherapy. Which assessment warrants further investigation by the nurse? a. Loose green stools b. Temperature 97.2°F c. Fine, red rash on trunk d. Yellow tint to the skin
b. Temperature 97.2°F Explanation: Loose green stools are expected findings with hyperbilirubinemia. A yellow tint to the skin is an expected finding with hyperbilirubinemia. Any temperature below 97.6°F is considered hypothermia, and requires immediate attention. A fine, raised red rash might appear on the infant's skin as a side effect of the phototherapy, and does not require intervention.
The nurse is observing a graduate nurse administering a gavage feeding to a newborn. The nurse must intervene if which of the following is observed? a. The infant is offered a pacifier during the feeding. b. The feeding is administered within 15 seconds. c. The stomach contents are aspirated prior to administering the feeding. d. The gavage tube is measured from the tip of nose to the earlobe to the xiphoid process.
b. The feeding is administered within 15 seconds. Explanation: Measuring from the tip of the nose to the earlobe to the xiphoid process is the correct action when administering a gavage feeding. Aspirating stomach contents a correct action to confirm placement of the tube. Offering the baby a pacifier during the feed is a correct action. Gavage feedings should be administered over 5-10 minutes to decrease the risk of GI distress.
A newborn is receiving phototherapy for the treatment of hyperbilirubinemia. The nurse evaluates that teaching has been effective when the parents demonstrate which behaviors?Select all that apply. a. Limit the infant's intake due to loose green stools. b. Cover the infant with a loose blanket while under the bililights. c. Continue breastfeeding during the jaundice. d. Cover the infant's eyes before placing him under the bililight. e. Keep the genitalia covered to prevent soiling.
c, d, e Explanation: The infant should be unclothed to allow as much skin exposure to the bililight as possible. Breastfeeding is not contraindicated with hyperbilirubinemia. Increased fluid intake will aid excretion of bilirubin and loose green stools are an indication that bilirubin is being excreted. It is important to protect the infant's eyes from the bililight to prevent permanent damage. It is acceptable practice to keep the genitalia covered to prevent soiling from urine or feces.
Which assessment data would alert the nurse that a newborn infant is experiencing dehydration? Select all that apply. a. Urine volume 2 mL/kg/hr b. Low serum sodium c. Poor skin turgor d. Urine-specific gravity 1.006 e. Sunken anterior fontanel
c, e Explanation: A urine specific gravity of 1.006 is an expected finding in a newborn infant. A urine volume of 2 mL/kg/hr is an expected finding in a newborn infant. A low serum sodium is an expected finding in a newborn infant. Signs of dehydration in an infant include sunken fontanels. Signs of dehydration in an infant include poor skin turgor and dry mucous membranes.
A father asks how the bilirubin lights make the newborn's bilirubin level go down. What is the best reply by the nurse? a. "Exposing the skin to the air helps get rid of the jaundice. The bililights really just keep the baby warm while this occurs." b. "The bililights release a substance in the body that attacks the bilirubin and destroys it." c. "The bililights help convert the bilirubin to a form the baby can get rid of." d. "The lights prevent more bilirubin from being released into your baby's body."
c. "The bililights help convert the bilirubin to a form the baby can get rid of." Explanation: Phototherapy assists the body in converting unconjugated bilirubin to conjugated bilirubin, which is water-soluble and easier for the body to eliminate.
A mother is crying while sitting by the isolette of her premature newborn, who was born at 25 weeks' gestation. What is the most therapeutic communication by the nurse? a. "It's important to try not to worry. Let's hope that everything will work out." b. "Can you tell me some specific things that have gotten you upset?" c. "This must be hard for you. Can you share with me what has you most concerned at this time?" d. "Would you like me to call the hospital chaplain? This has helped many others."
c. "This must be hard for you. Can you share with me what has you most concerned at this time?" Explanation: The nurse should not give the client false hope. Clients often do not know why they feel the way they do, and it is not helpful to ask them. Some clients might find comfort in a religious leader, but care should be taken not to stereotype the client's religious beliefs. Reflection allows the client to verbalize her feelings.
The maternal-newborn nurse determines that which infant is at greatest risk for infection? a. 39 weeks' gestation, diagnosed with caput succedaneum b. 38 weeks' gestation, cesarean birth for breech presentation c. 38 weeks' gestation, small for gestational age (SGA) d. 41 weeks' gestation, infant of a diabetic mother (IDM)
c. 38 weeks' gestation, small for gestational age (SGA) Explanation: SGA infants often experience intrauterine growth restriction related to decreased blood flow to the placenta, which increases their risk for infection. In comparison, the infants in the other options are at less risk for infection. An infant born at 39 weeks' gestation, and diagnosed with caput succedaneum does not have an especially high risk for infection. An infant born at 38 weeks' gestation, by cesarean for breech presentation does not have an especially high risk for infection. An infant born at 41 weeks' gestation, from a diabetic mother (IDM) does not have an especially high risk for infection.
The following neonates are admitted to the nursery. The nurse should withhold the scheduled initial feeding on which newborn? a. A neonate with an axillary temperature of 36.4°C (97.5°F) b. A neonate who is small for gestational age (SGA) c. A neonate with a sustained respiratory rate of 68 breaths/min d. A neonate with a sustained heart rate of 118 beats/min
c. A neonate with a sustained respiratory rate of 68 breaths/min Explanation: A heart rate of 118 is slightly below the normal range of 120-160 beats/min, but it is not a contraindication to feeding the infant. A hypothermic infant is at risk for hypoglycemia, and requires a consistent source of glucose. Feeding a baby with a respiratory rate greater than 60 breaths/min orally increases the risk of aspiration. An infant who is SGA is at risk for hypoglycemia, and requires a consistent source of glucose.
A baby's mother is hepatitis B-positive. Which nursing interventions is most important when planning care for this newborn? a. Prepare for exchange transfusion. b. Isolate the newborn. c. Administer hepatitis B vaccine within 12 hours after delivery. d. Assess for HIV risk factors.
c. Administer hepatitis B vaccine within 12 hours after delivery. Explanation: Infants born to mothers who are hepatitis B-positive should receive a hepatitis B vaccine within 12 hours of birth to decrease their risk of acquiring the infection from maternal exposure. It is appropriate to assess for HIV risk factors in all infants, not just those at risk for hepatitis B. An exchange transfusion is not appropriate in this situation. Isolating the infant is not appropriate in this situation.
A nurse is admitting the infant of a diabetic mother (IDM). At 1 hour of age, the nurse notices that the newborn is very jittery. Which action by the nurse is most appropriate? a. Begin oxygen by nasal cannula. b. Initiate use of a cardiac/apnea monitor. c. Assess the newborn's blood sugar. d. Place the newborn under a radiant warmer.
c. Assess the newborn's blood sugar. Explanation: The newborn is not showing any signs of hypoxia, so oxygen would not be appropriate. Infants of diabetic mothers are at risk for hypoglycemia after delivery. A primary sign of hypoglycemia is jitteriness. Putting the newborn under a warmer would not harm the infant, but is not the priority intervention at this time. Putting the newborn on a monitor would not harm the infant, but is not the priority intervention at this time.
While observing parents whose newborn is in the neonatal intensive care unit, the nurse interprets that parental bonding is occurring when the parents perform which activity? a. Bring a 2-year-old sibling to visit. b. Wear gloves every time they touch their baby. c. Attach family pictures to the side of the isolette. d. Turn off the cardiac monitor when at the newborn's bedside.
c. Attach family pictures to the side of the isolette. Explanation: Parents should wash their hands when they enter the unit, but do not need to wear gloves when in contact with their infant. The act of taping family pictures to the sides of the isolette promotes bonding and infant stimulation. Young children often harbor organisms that could be transmitted to vulnerable newborns, and should not have contact until the infant is moved out of the neonatal intensive care unit. The cardiac monitor should not be turned off unless specifically allowed by staff.
A nurse observes that a preterm infant's urine output is less than 1 mL/kg/hr with a specific gravity greater than 1.020. The nurse draws which conclusion about the infant's status? a. Electrolyte imbalance b. Metabolic acidosis c. Dehydration d. Adequate hydration
c. Dehydration Explanation: Adequate hydration is evidenced by urine output of 1-3 mL/kg/hr and specific gravity <1.013. This newborn shows signs of dehydration because of low urine output and high specific gravity of the urine. Metabolic acidosis would be determined by blood sample, not by urine analysis. Electrolyte imbalance would be determined by drawing a sample of blood for electrolyte analysis.
A newborn is admitted with a diagnosis of transient tachypnea of the newborn (TTN). When planning nursing care for this baby, what should be the nurse's goal? a. Promote adequate quantity of surfactant. b. Assist in the removal of meconium from the airway. c. Promote absorption of fetal lung fluid. d. Stimulate respirations.
c. Promote absorption of fetal lung fluid. Explanation: Inadequate surfactant is related to prematurity and respiratory distress syndrome. Transient tachypnea of the newborn (TTN) is caused by delayed absorption of fetal lung fluid. Nursing care is focused on supporting oxygenation needs to allow the newborn's body to reabsorb the fluid. Meconium in the airway results in meconium aspiration syndrome, and is usually associated with fetal asphyxia. TTN causes tachypnea, so stimulating respirations is not appropriate.
A full-term newborn weighed 10 pounds, 5 ounces at birth. The nurse should formulate which priority nursing diagnosis for this infant? a. Impaired Gas Exchange related to lack of surfactant. b. Deficient Knowledge related to newborn care. c. Risk for Injury related to macrosomia. d. Ineffective Thermoregulation related to lack of subcutaneous fat.
c. Risk for Injury related to macrosomia. Explanation: Newborns experiencing macrosomia (large infant) are more likely to experience birth injuries during delivery. Nursing care after delivery should focus on assessing for signs of birth injuries and intervening, if appropriate. Lack of surfactant would be a problem for premature infants rather than large infants.Physiological needs take priority before teaching.
A newborn's mother has a history of prenatal narcotic abuse. Which nursing interventions would be most appropriate for this infant?Select all that apply. a. Place a mobile on crib. b. Encourage family members to stroke and talk to the infant. c. Hold and rock the infant as much as possible. d. Offer the infant a pacifier. e. Position the infant on the right side or in semi-Fowler's position.
d, e Explanation: Holding and rocking involves increasing environmental stimulation. This is contraindicated in these infants because they are already hyperstimulated from the drug withdrawal process. Infants experiencing neonatal abstinence syndrome (NAS) often have an increased need for non-nutritive sucking, and offering a pacifier would help meet this need. A mobile increases environmental stimulation. This is contraindicated in these infants because they are already hyperstimulated from the drug withdrawal process. Talking and stroking the infant involve increasing environmental stimulation. This is contraindicated in these infants because they are already hyperstimulated from the drug withdrawal process. It is good to place the infant on the right side or in semi-Fowler's position to avoid possible aspiration of vomitus or secretions.
The nurse hears the parents of a 26-week gestation newborn tell family members, "We'll be ready to bring the baby home in a few weeks." What is the most therapeutic response by the nurse? a. "A therapist could help you resolve your feelings of denial." b. "I'm glad he's doing so well." c. "Do you have the nursery ready yet?" d. "He probably won't be ready to come home for a few months."
d. "He probably won't be ready to come home for a few months." Explanation: Agreeing with the parent's statement (by being glad the infant is doing well) prolongs the state of denial and makes it more difficult for the parents to see the situation realistically. Families are often in a state of denial with the birth of a sick newborn. It is important for nurses to gently encourage the parents to be realistic by sharing truthful information. Some parents do benefit from professional counseling, but nurses still need to provide support when working with families. It is not important if the nursery is ready yet, and this question distracts from the real issues this family is facing at this time.
The nurse is making client assignments for the shift. Which baby could be appropriately assigned to an LPN/LVN? a. An infant with rising bilirubin levels b. An infant scheduled to receive blood this shift c. An infant being admitted with hypoglycemia d. A stable premature infant being fed every two hours
d. A stable premature infant being fed every two hours Explanation: An LPN/LVN is not qualified to admit a client. This infant requires assessment and care by a registered nurse. An LPN/LVN is not qualified to administer blood. This infant requires assessment and care by a registered nurse. An LPN/LVN is qualified to perform certain procedures and care for stable clients, such as a premature infant who is able to take feedings every two hours. An LPN/LVN is not qualified to make nursing decisions for clients whose status is changing (such as rising bilirubin levels).
The nurse is caring for a 30-weeks'-gestation infant at risk for necrotizing enterocolitis (NEC). The nurse should observe for which of the following? a. Discolored feet b. A decrease in respiratory rate c. A bulging fontanelle d. Abdominal distention
d. Abdominal distention Explanation: A decreased respiratory rate should be reported to the health care provider, but is not related to NEC. Changes in the gastrointestinal assessment, including abdominal distention, occur with NEC. Discolored feet should be reported to the health care provider, but are not related to NEC. A bulging fontanelle should be reported to the health care provider, but is not related to NEC.
On admission to the nursery, it is noted that the mother's membranes were ruptured for 48 hours before delivery, and her temperature is 102°F. What information from this newborn's assessment should the nurse evaluate further? a. Excessive bruising of presenting part b. Jitteriness c. Irregular respiratory rate d. Axillary temperature 97.2°F
d. Axillary temperature 97.2°F Explanation: This newborn is at risk for sepsis caused by prolonged rupture of membranes and maternal fever. A primary sign of sepsis in the newborn is temperature instability, particularly hypothermia. An irregular respiratory pattern is normal. Jitteriness could be a sign of hypoglycemia. Excessive bruising is often related to a difficult delivery with an increased risk of hyperbilirubinemia.
The nurse is caring for a neonate born to a mother who is HIV-positive. Which sign in the newborn should be evaluated further? a. Absence of tears b. Fine, red rash over trunk c. White bumps on nose d. Enlarged liver
d. Enlarged liver Explanation: Absence of tears is assessment data thatis within normal limits for a neonate. The presence of milia is assessment data that is within normal limits for a neonate. Hepatosplenomegaly (enlarged liver and spleen) can be an early sign of HIV infection in an infant. A fine, red rash over trunk is assessment data that is within normal limits for a neonate .
The nurse can best promote parental bonding with a high-risk newborn being transferred to the neonatal intensive care unit (NICU) by doing which of the following? a. Encouraging the parents to call the NICU daily. b. Allowing parents to see the newborn for 15 minutes three times each day. c. Not discussing how sick the infant is. d. Giving the parents a picture of the baby prior to transport to the NICU.
d. Giving the parents a picture of the baby prior to transport to the NICU. Explanation: Parents should be given a picture of the infant before the baby is transported. Calling the unit to check on their baby might help bonding, but seeing the baby is more effective. Parents are typically allowed to visit as often and for as long as they want. It is important to be honest with parents, even if the prognosis is poor.
A client who received no prenatal care delivers a 9-pound, 4-ounce baby boy who exhibits signs of respiratory distress. The nurse obtains a blood sample from the infant per protocol to assess for which potential problem? a. Hyperbilirubinemia b. Sepsis c. Hemolysis d. Hypoglycemia
d. Hypoglycemia Explanation: The blood sample is not being drawn to assess for hemolysis. The blood sample is not being drawn to assess for hyperbilirubinemia. A 9-pound, 4-ounce infant is large for gestational age (LGA). An LGA infant who demonstrates respiratory distress could have a diabetic mother. The infant produces his own insulin during pregnancy, and stores the excess glucose as fat to compensate for high maternal glucose loads. After delivery the infant is at high risk for hypoglycemia because excess maternal glucose is now absent from the infant's circulation. The blood sample is not being drawn to assess for sepsis.
Which nursing diagnosis should be the highest priority of the nurse who is caring for a preterm newborn? a. Anticipatory Grieving related to loss of "perfect delivery" b. Risk for Injury related to thin epidermis c. Imbalanced Nutrition: Less than Body Requirements related to immature digestive system d. Ineffective Thermoregulation related to lack of subcutaneous fat
d. Ineffective Thermoregulation related to lack of subcutaneous fat Explanation: Newborns compensate for hypothermia by metabolizing brown fat. This process requires glucose and oxygen. Preterm newborns are at risk for hypoglycemia and respiratory distress, so hypoglycemia can further increase their needs for oxygen and glucose, and can cause serious complications. This nursing diagnosis is appropriate, but is not the highest priority because it relates to psychosocial needs. This nursing diagnosis is appropriate, but is not the highest priority.
The nurse is caring for a preterm infant who is at risk for an intraventricular hemorrhage (IVH). Which daily assessment is most critical for this infant? a. Moro reflex b. Intake and output c. Blood pressure d. Occipital frontal circumference (OFC)
d. Occipital frontal circumference (OFC) Explanation: Changes in blood pressure might occur, but the changes might not be as noticeable, and can be caused by many other problems. Increasing occipital frontal circumference (OFC) is an indication of increasing intracranial pressure, which could result from an intraventricular hemorrhage (IVH). It should be assessed in infants at risk for an IVH every 8-12 hours. Intake and output are routine measurements that are not directly helpful in this situation. Changes in Moro reflex are not an indication of an IVH.
The nurse would take which action as part of nursing care of the baby experiencing neonatal abstinence syndrome? a. Spend extra time holding and rocking the baby. b. Place stuffed animals and mobiles in the crib to provide visual stimulation. c. Avoid the use of pacifiers. d. Position the baby's crib in a quiet corner of the nursery.
d. Position the baby's crib in a quiet corner of the nursery. Explanation: Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period.
A mother was diagnosed with gonorrhea immediately after delivery. When providing nursing care for the infant, what would be an important goal of the nurse? a. Prevent the development of thrush. b. Teach the danger of breastfeeding with gonorrhea. c. Lubricate the eyes. d. Prevent the development of ophthalmia neonatorum.
d. Prevent the development of ophthalmia neonatorum. Explanation: A newborn can become infected with gonorrhea as it passes through the birth canal. Gonorrhea can cause permanent blindness in the newborn, called ophthalmia neonatorum. All babies' eyes are treated with an antibiotic prophylactically after birth. The eyes require an antibiotic rather than a lubricant. Oral thrush is not a concern although eye care is a priority. Teaching does not take priority over physiological needs of the newborn or mother.
The nurse is preparing to initiate bottle feeding in a preterm infant. In which situation would the nurse withhold the feeding and notify the health care provider? a. Yellow tint to skin and sclera b. Apical heart rate 120 c. Axillary temperature 97.2°F d. Respiratory rate 72
d. Respiratory rate 72 Explanation: An apical heart rate of 120 is a normal finding. Although an infant temperature of 97.2°F is considered hypothermia, it would not be a contraindication to oral feedings. Jaundice can be considered abnormal, but it alone would not be an indication to withhold an oral feeding. Any sustained respiratory rate higher than 60 breaths/minute increases the risk of aspiration in the infant. Oral feedings should be withheld on infants experiencing tachypnea to decrease the risk of aspiration.
