Nursing Care of a Family With a High-Risk Newborn. CH26

5. A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the: A) ductus arteriosus remains open. B) foramen ovale closes prematurely. C) aorta or aortic valve strictures. D) pulmonary artery closes.

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 701 Feedback: Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

22. The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant? A) To detect rebound hypoglycemia B) To determine insulin dosage to administer C) To explain the effects of maternal hyperglycemia on the baby D) To estimate the amount of calories to provide the infant through formula

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 695 Feedback: Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled, the infant would have had an increased blood glucose level in utero to match the mother's glucose level; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age infants is not done to determine insulin dosage, to explain the effects of maternal hyperglycemia on the baby, or to estimate the amount of calories to provide the infant through formula.

15. A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge? A) Hearing assessment B) Assessment for cerebral palsy C) Skin assessment for hemangiomas D) Intravenous pyelogram for kidney function

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 676 Feedback: Congenital rubella (German measles) is strongly associated with hearing disorders.

27. The nurse is caring for a small-for-gestational-age infant born to a drug-dependent patient. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? (Select all that apply.) A) Tremors B) Convulsions C) High-pitched cry D) Constant movement E) Sluggish respiratory rate

Ans: A, B, C, D Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 709 Feedback: Infants of drug-dependent women tend to be small for gestational age. If the patient took a drug close to birth, the infant may show withdrawal symptoms shortly after birth that include tremors, convulsions, high-pitched cry, and constant movement. Respiratory rate would be rapid and not sluggish.

28. The nurse is instructing the parents of a preterm infant about the care the infant will receive within the neonatal intensive care unit. What should the nurse include when teaching the parents at this time? (Select all that apply.) A) Bring in a small toy to be placed in the baby's bassinette. B) Coordinate the times to visit the baby with the primary nurse. C) Ask the nurse to explain equipment and the purpose for their use. D) Write down the name of the baby's primary nurse and primary care provider. E) Limit telephone calls to the care area since the nurses will not be able to respond.

Ans: A, B, C, D Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 690 Feedback: When teaching parents of a newborn in the intensive care unit, the nurse should encourage the parents to bring in a small toy to be placed in the baby's bassinette. The parents should also coordinate the times to visit the baby with the primary nurse so that quality time will be available. The parents should be reminded to ask questions about equipment being used for the baby's care. The name of the primary nurse and primary care provider should be recorded in case the parents have any questions. Telephone calls are encouraged and should not be limited. The parents play an active part in the care of the baby.

19. The nurse manager of a labor and delivery unit is reviewing the skill set needed for the nursing staff to meet the 2020 National Health Goals regarding preterm births. Which skills should the manager validate that the nursing staff has to meet these goals? (Select all that apply.) A) Resuscitation at birth B) Actions to prevent apnea C) Identify characteristics of preterm labor D) Actions to prevent maternal hypotension E) Interventions to prevent intraventricular hemorrhage

Ans: A, B, C, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 672 Feedback: Nurses can help the nation achieve the 2020 National Health Goals for preterm births by teaching women the symptoms of preterm labor so that birth can be delayed until infants reach term. Nurses also need to be prepared for resuscitation at birth of high-risk infants and to plan developmental care that can help prevent conditions such as apnea and intraventricular hemorrhage. Actions to prevent maternal hypotension would not help achieve the 2020 National Health Goals for preterm labor.

20. The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.) A) Provide audio stimulation with the use of music. B) Stop procedures if the infant shows signs of distress. C) Provide a nest with blankets to provide a sense of security. D) Provide tactile stimulation by tickling the bottom of the feet. E) Provide care consistently so the infant develops sleep/wake cycles.

Ans: A, B, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 692 Feedback: Developmental care for a preterm infant in the neonatal intensive care unit should include audio stimulation, stop procedures at signs of distress, provide a nest of blankets for security, and provide consistent care so sleep/wake cycles develop. Tactile stimulation should be provided by gentle back rubbing or massage. Tickling the feet would be too harsh for this young patient.

25. A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid balance. What did the nurse assess that supports this nursing diagnosis? (Select all that apply.) A) Specific gravity of 1.022 B) Respiratory rate of 40 breaths/min C) Urine output less than 2 ml/kg/hr D) Heart rate of 135 beats/min E) Abdominal skin temperature of 96.9°F

Ans: A, C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 687 Feedback: An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. Respiratory rate of 40 breaths/min, heart rate of 135 beats/min, and abdominal skin temperature of 96.9°F are all within normal limits and do not suggest inadequate fluid balance.

4. A preterm infant is transferred to a distant hospital for care. When her parents visit her, which action would be most important for the nurse to urge them to do? A) Call the baby by her name. B) Touch and, if possible, hold her. C) Stand so the baby can see them. D) Bring a piece of clothing for her.

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 700 Feedback: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

26. The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem? A) "Once the infection clears up, the baby will be fine." B) "We will need to plan for special care to help with learning disabilities." C) "In a few months, more brain tissue will grow to fill in the hollow areas in the brain." D) "In a few months, the baby will need to have physical therapy to train muscles to work."

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 703 Feedback: Periventricular leukomalacia (PVL) is abnormal formation of the white matter of the brain and is caused by an anoxic episode that interferes with circulation to a portion of the brain. Phagocytes and macrophages invade the area to clear away necrotic tissue. What is left is an abnormality in the white matter of the brain seen as a hollow space. Once the condition has occurred, there is no therapy. Infants may die of the original insult; they may be left with long-term effects such as learning disabilities or cerebral palsy. The parents will need to plan for special care to help with the infant's learning disabilities. The baby does not have an infection. Brain tissue will not grow to fill in the hollow areas. There is no therapy for the condition, and there is no information to support that physical therapy will be beneficial.

9. A preterm infant will be hospitalized for an extended time. Assuming the infant's condition is improving, which environment would the nurse feel is most suitable for the child? A) Keep the environment free of color to reduce eye straining. B) Provide a mobile the child can see no matter how the child is turned. C) Place the infant's Isolette near the window so the child can see outside. D) Bring the child's open bassinet near the desk area so the infant sees people.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 706 Feedback: Preterm infants are able to focus at short distances before they can see well at long distances. A mobile offers short-distance stimulation.

2. At an amniocentesis just prior to birth, a fetus's lecithin/sphingomyelin ratio was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth? A) Wheezing from excess fluid accumulation B) Bronchial constriction from room air C) Alveolar collapse on expiration D) Inspiratory constricture from air contaminants

Ans: C Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 686 Feedback: Without adequate surfactant, infants are unable to sustain respiratory function and, thus, develop respiratory distress syndrome with alveolar collapse on expiration.

16. The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient? A) Glucose water B) 20 calories per ounce C) 22 calories per ounce D) Iron supplemented

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 689 Feedback: The caloric concentration of formulas used for preterm infants is usually 22 calories per ounce compared with 20 calories per ounce for a term baby. Glucose water will not provide the infant with adequate calories. Iron supplementation will depend on laboratory values.

23. A preterm infant is receiving oxygen to maintain respiratory status. When assessing this patient, at which level should the nurse maintain oxygenation to prevent retinopathy of prematurity? A) 40 mmHg B) 50 mmHg C) 100 mmHg D) 180 mmHg

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 706 Feedback: When blood Po2 levels rise to higher than 100 mmHg, the risk of retinopathy of prematurity increases. All preterm infants who receive oxygen must have blood oxygen levels monitored by pulse oximeter, transcutaneous oxygen saturation, or blood gas monitoring so the blood Po2 level can be kept within normal limits. Oxygenation at 40 mmHg or 50 mmHg is not sufficient for the infant. Oxygenation at 180 mmHg is too high and can predispose the infant to develop retinopathy of oxygenation.

30. At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate? A) postterm B) preterm C) SGA D) LGA

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Remember Page: 696 Feedback: These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

18. Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which nursing diagnosis is this intervention addressing? A) Ineffective thermoregulation related to immaturity B) Risk for imbalanced nutrition, less than body requirements C) Risk for deficient fluid volume related to insensible water loss D) Impaired gas exchange related to immature pulmonary functioning

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 686 Feedback: Placing the preterm infant in a radiant heat warmer is addressing the diagnosis of ineffective thermoregulation related to immaturity. Interventions regarding intake would be appropriate for the diagnosis of risk for imbalanced nutrition. Interventions related to intravenous fluids would be appropriate for the diagnosis of risk for deficient fluid volume. Interventions related to oxygenation would be appropriate for the diagnosis of impaired gas exchange.

17. The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered? A) Alveolar collapse on expiration B) Bronchial constriction from room air C) Wheezing from excess fluid accumulation D) Inspiratory constriction from air contaminants

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Physiological Adaptation Cognitive Level: Analyze Page: 686 Feedback: Respiratory distress syndrome (RDS) of the newborn most often occurs in preterm infants. Pulmonary surfactant is not present in preterm infant. Surfactant is needed to prevent alveolar collapse upon expiration. RDS rarely occurs in mature infants. Dating a pregnancy by sonogram and by documenting the level of lecithin in surfactant obtained from amniotic fluid exceeds that of sphingomyelin by a 2:1 ratio are both important ways to be certain that an infant is mature enough that RDS is not likely to occur. RDS does not present as bronchial constriction from room air, wheezing from excess fluid accumulation, or inspiratory constriction from air contaminants.

24. The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective? A) Newborn is placed on the back to sleep. B) Mother removes a pacifier from the baby's mouth. C) The baby is on an every-2-hour formula-feeding schedule. D) Parents signed a waiver refusing routine immunizations after birth.

Ans: A Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 711 Feedback: Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to 60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding, and having routine immunizations. Removing the pacifier, bottle feeding, and refusing routine immunizations after birth all increase the infant's risk for experiencing SIDS.

21. While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply.) A) Grunting B) Nasal flaring C) Intercostal retractions D) Oxygen saturation 96% E) Increasing respiratory rate

Ans: A, B, C, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 676 Feedback: A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions, which reflect the degree of difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits and does not indicate respiratory distress.

6. A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: A) inspiratory stridor. B) expiratory grunting. C) expiratory wheezing. D) inspiratory "crowing."

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 697 Feedback: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

11. Which finding would the nurse expect to assess in an infant with hypoglycemia? A) prolonged jaundice B) limpness or jitteriness C) pain along the sixth cranial nerve D) excessive hunger

Ans: B Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 708 Feedback: Hypoglycemia (reduced glucose serum level) usually presents with jitteriness.

3. A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure? A) Prevent the infant from crying. B) Ensure that the infant is kept warm. C) Assess the infant's cranial vascular tension. D) Evaluate the infant's urinary output.

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 686 Feedback: Preterm infants must be protected from chilling during all procedures, because maintaining warmth is a major concern because of immaturity.

10. All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? A) an infant whose labor began with ruptured membranes B) an infant who had difficulty establishing respirations at birth C) an infant who has marked acrocyanosis of his hands and feet D) an infant whose mother craved chocolate during pregnancy

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 708 Feedback: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

1. A preterm infant born at 32 weeks' gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best? A) Low iron formula diluted with glucose water. B) Infant formula with rice cereal. C) A 24 cal/oz infant formula. D) A formula with an iron supplement.

Ans: C Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 662 Feedback: Because preterm babies continue to grow at their intrauterine rate, they need more calories per ounce than full-term newborns. Iron formulas and those which included rice cereal are not a first choice as they may not be tolerated.

8. With the administration of oxygen, a preterm infant's Pa02 level is monitored carefully. It is important to keep this level under which value to help prevent retinopathy of prematurity? A) 40 mm Hg B) 50 mm Hg C) 100 mm Hg D) 180 mm Hg

Ans: C Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 706 Feedback: Retinal capillaries can be damaged by excessive oxygen levels. Keeping the Pa02 level under 100 mm Hg helps prevent this.

14. To administer oxygen by bag and mask to a newborn, you would position the baby A) in Trendelenburg's position. B) on the back with the neck slightly flexed. C) on the back with the head slightly extended. D) position is unimportant as long as the tongue is pulled forward.

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 676 Feedback: Slightly extending the neck best opens the airway (a "sniffing" position). Trendelenburg is rarely used with newborns because it increases cerebral vascular pressure.

12. Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? A) 100 mg/100 mL whole blood B) 80 mg/100 mL whole blood C) 40 mg/100 mL whole blood D) 30 mg/100 mL whole blood

Ans: C Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 709 Feedback: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 40 mg/100 mL whole blood is considered hypoglycemia.

13. A newborn does not breathe spontaneously at birth. The nurse administers oxygen by bag and mask. If oxygen is entering the lungs, the nurse should notice that the: A) abdomen rises while the chest falls with bag compressions. B) infant's pupils dilate after 3 minutes. C) infant's neck veins become prominent and palpable. D) chest rises with each bag compression.

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 709 Feedback: If air is entering the lungs of a newborn, his or her chest muscles are so elastic that the chest can be seen rising and falling with bag compression.

7. A preterm infant is placed on ventilatory assistance for respiratory distress syndrome. In light of her lung pathology, which additional ventilatory measure would you anticipate planning? A) Administration of chilled oxygen to reduce lung spasm B) Increased inspiratory pressure; decreased expiratory pressure C) Administration of dry oxygen to avoid over-humidification D) Positive end-expiratory pressure to increase oxygenation

Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 697 Feedback: Positive end-expiratory pressure, like expiratory grunting, prevents alveoli from fully closing on expiration and reduces the respiratory effort needed for inspiration.

29. In which position should the nurse place a newborn to administer oxygen by bag and mask? A) Trendelenburg B) On the back with the neck slightly flexed C) On the back with the head slightly extended D) Position is unimportant as long as the tongue is pulled forward.

ns: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 690 Feedback: If a newborn does not draw in a first breath spontaneously following gentle stimulation, place the infant under a radiant heat warmer in a "sniffing" position, which is the head slightly tipped back. Trendelenburg is not a recommended position since this increases intracranial pressure. Flexing the neck could occlude the airway. The position is very important; the tongue will not occlude the airway if the correct position is used.