MCN
8. After therapeutic interventions, a newborn demonstrates adequate lung expansion. The amount of pressure that would enable her to continue to re-inflate the alveoli of her lungs would be:
ANSWER: 15-20 CM H20
3. Which of the following manifestations in a six month old infant who was born prematurely would lead a nurse to suspect that the infant has apnea?
ANSWER: A BASE OF SPONTANEOUS BREATHING FOR 20 SECONDS OR MORE
7. Which of the following nursing diagnoses would be given priority in the care of a newborn one hour of age?
ANSWER: ACTIVE THERMOREGULATION
11. The most common adaptation of a child with Tetralogy of Fallot
ANSWER: CLUBBING FINGERS
13. During assessment of a newborn diagnosed with a cardiac anomaly, you detected that the infant's femoral pulses are absent. Which of the following diseases is most likely presented by the symptom?
ANSWER: COARACTATION OF THE AORTA
12. Usually PDA closes as the oxygen level increases and the prostaglandin levels fall. If it does not close, which of the following drugs given?
ANSWER: INDOMETHACIN
9. A nurse in the nursery is caring for a neonate. On assessment, the infant is exhibiting grunting, tachypnea, nasal flaring and grunting. Respiratory distress syndrome is diagnosed and the physician prescribed surfactant replacement therapy by:
ANSWER: INSTILLATION OF THE PREPARATION INTO THE LUNGS THROUGH AN ENDOTREACHEAL TUBE
2. Andrea has no spontaneous respiration at birth. Suppose her amniotic fluid is heavily stained with meconium. Which would be your best action?
ANSWER: KEEP HER WARM UNTIL A LARYNGOSCOPE CAN BE PASSED
19. A 10-year old boy who is suspected of having coarctation of the aorta is hospitalized. It is essential that the nurse performs which of the following during the initial physical examination?
ANSWER: MONITORING BP IN ALL FOUR EXTREMITIES
10. The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, the neonate requires:
ANSWER: MORE OXYGEN, AND THE NEWBORN'S METABOLIC RATE INCREASES
15. A parent of an infant who has a small atrial septal defect makes all of the following comments. Which one indicates an accurate understanding of the infant's condition?
ANSWER: MY BABY NEEDS TO HAVE A HEART SURGERY IMMEDIATELY
4. Heat regulation is the most critical factor for a newborn's survival next to establishing respiration. Which of the following characteristics of newborns predispose them to poor heat regulation?
ANSWER: NEWBORNS CANNOT SHIVER YET
A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity?
ANSWER: PARTIAL PRESSURE OF OXYGEN (Pao2) LEVELS
5. Hypothermia is common in newborn because of their inability to control heat. The following would be an appropriate nursing intervention to prevent heat loss EXCEPT:
ANSWER: PLACE THE CRIB BESIDE THE WALL
20. When assessing a newly delivered neonate, the nurse notes the following findings: Arms and legs slightly flexed; skin smooth and transparent; abundant lanugo on the back; slow recoil of pinna; and few sole creases. In light of these findings, the care plan for this neonate should include nursing orders to monitor for:
ANSWER: RESPIRATORY DISTRESS SYNDROME
17. Meconium aspiration syndrome (MAS) can be prevented by
ANSWER: SUNCTIONING MOUTH, NOSE AND POSTERIOR PHARYNX JUST AFTER THE HEAD IS DELIVERED
6. Which of the following is the most important concept associated with the high-risk newborn?
ANSWER: SUPPORT THE HIGH-RISK NEWBORN'S CARDIOPULMONARY ADAPTATION BY MAINTAINING ADEQUATE AIRWAY
16. A 4-year-old with Tetralogy of Fallot is seen in a squatting position near his bed. The nurse should:
ANSWER: TAKE NO ACTION IF HE LOOKS COMFORTABLE BUT CONTINUE TO OBSERVE HIM
18. Myer, 2 months is suspected of having coarctation of the aorta. The cardinal sign of this defect is:
ANSWER: UPPER EXTREMITY HYPERTENSION
14. The family is caring for their youngest child Justin who is suffering from Tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?
ANSWER: VENTRICULAR SEPTAL DEFECT, OVERRIDING AORTA, PULMONIC STENOSIS AND RIGHT VENTRICULAR HYPERTROPHY
