OB FINAL STACK 14
12. The nurse is providing support for the parents of a neonate born with anencephaly. The parents repeatedly state, "I don't believe this is happening to us. We were so careful during pregnancy." The nurse associates the parents' comments with which stage of grief? 1. Disbelief 2. Depression 3. Denial of reality 4. Anger with each other
1 This is correct. The parents' comments indicate that they are experiencing the stage of grief associated with avoidance, disbelief, shock, or guilt
6. The nurse is providing care for a premature neonate born at 28 weeks gestation who is experiencing respiratory distress syndrome (RDS). Which assessment finding indicates to the nurse that the neonate's respiratory status is deteriorating? 1. Pao2 is 48 and Paco2 is 55 mm Hg on 90% oxygen. 2. Respiratory rate is 58 breaths per minute. 3. Breath sounds on auscultation are decreased. 4. Heart rate is 162 beats per minute.
1 This is correct. A sign that the neonate's respiratory status is deteriorating is if increased oxygen levels fail to maintain a Pao2 and Paco2 within normal limits. The normal range of Pao2 is 60 to 70 mm Hg and the normal range of Paco2 is 35 to 45 mm Hg. The neonate is unable to maintain a normal range on 90% oxygen, which is a sign of deterioration
13. The nurse is present in the delivery room when a mother is told her neonate was stillborn. The mother begins to wail loudly and pull at her hair. Which action does the nurse take? 1. Allow the mother to express grief in her own way. 2. Attempt to calm the mother and prevent self-harm. 3. Ask for a sedative to calm the mother's reaction. 4. Ask a family member to comfort the mother.
1 This is correct. Culture, religion, and personal experience and beliefs will impact how individuals and families respond to loss. The nurse needs to support the mother and allow her to grieve in her own way
14. The premature neonate is more susceptible to skin breakdown than a term neonate. Which skin care interventions will the nurse implement for the premature neonate? Select all that apply. 1. Use a neutral pH cleanser and sterile water for bathing. 2. Gently apply emollients to avoid unnecessary friction. 3. Perform daily skin assessment to identify problems early. 4. Use water, air, or gel mattresses. 5. Provide a full bath every other day
14. ANS: 1, 2, 4 1 This is correct. Use a neutral pH cleanser and sterile water for bathing to help prevent skin breakdown on a premature neonate. 2 This is correct. Emollients should be applied gently to avoid unnecessary friction, which can cause skin breakdown 4 This is correct. Water, gel, or air mattresses are used to help prevent skin breakdown in the premature neonate
15. The postnatal nurse is providing care for a neonate being treated with phototherapy for hyperbilirubinemia. For which side effects of phototherapy will the nurse contact the neonatal care provider? Select all that apply. 1. Hyperthermia 2. Lethargy 3. Hypocalcemia 4. Thrombocytopenia 5. Bronze baby syndrome
15. ANS: 1, 3, 4 1 This is correct. The nurse will recognize hyperthermia as an elevation of temperature in the neonate. The nurse will report this assessment finding to the neonatal care provider 3 This is correct. Hypocalcemia in a neonate is a serum calcium level below 7.5 mg/dL. Neonatal hypocalcemia symptoms are often similar to those of hypoglycemia and include jitteriness, tetany, and seizures. The nurse will report this assessment finding to the neonatal care provider. 4 This is correct. Thrombocytopenia is indicative of a deficiency of platelets in the blood, which can result in bruising or bleeding. The nurse will report this assessment finding to the neonatal care provider.
16. The nurse is preparing for the discharge of a neonate diagnosed with a congenital breathing disorder. Which health team members does the nurse include in discharge planning? Select all that apply. 1. Respiratory therapist 2. Community agency manager 3. Social worker 4. Home health agency nurse 5. Case manager
16. ANS: 1, 3, 4, 5 1 This is correct. The nurse will include the respiratory therapist in the discharge planning for a neonate with a congenital breathing disorder. Respiratory therapy may be a significant lifetime need for this neonate. . 3 This is correct. The social worker will play a key role in helping the family find agencies that can provide support for the parents and the neonate. Consideration is focused on meeting financial, psychosocial, and medical needs. 4 This is correct. The family is likely to benefit from a home health agency who can assist with the physiological needs of the neonate. This may be a long-term or short-term need, but the nurse would include a home agency nurse in discharge planning. 5 This is correct. The case manager is included in the discharge planning because the family with a neonate with a congenital breathing disorder is likely to have needs for special equipment and/or therapies.
_ 17. The nurse is providing support to parents of a premature neonate in NICU. Which actions by the nurse will best provide psychosocial support to the parents? Select all that apply. 1. Assess the parents' ability to care for their neonate. 2. Ask the parents how they are coping with the experience. 3. Provide equipment for breast pumping and storage of milk. 4. Encourage parents to take photos to share with family and friends. 5. Praise parents for their involvement in the care of their neonate.
17. ANS: 2, 4, 5 2 This is correct. Asking the parents how they are coping with the experience provides the parents with an opportunity to talk about their feelings and responses. This action by the nurse is providing psychosocial support. 4 This is correct. Encouraging parents to take photos of their neonate to share with family and friends is providing psychosocial support. 5 This is correct. Praising the parents for their involvement in providing care for their neonate is meeting the need for psychosocial support.
18. The nurse is providing care for a neonate born to a mother with preexisting diabetes mellitus. Which neonatal assessment findings do the nurse expect? Select all that apply. 1. Macrosomia 2. Hyperglycemia 3. Hypocalcemia 4. Jaundice 5. Dyspnea
18. ANS: 1, 3, 4, 5 1 This is correct. Macrosomia is an expected assessment finding in neonates born to mothers with preexisting diabetes mellitus. 3 This is correct. Hypocalcemia is an expected assessment finding in neonates born to mothers with preexisting diabetes mellitus. 4 This is correct. Hyperbilirubinemia is an expected assessment finding in neonates born to mothers with preexisting diabetes mellitus, because of polycythemia. 5 This is correct. Dyspnea and respiratory distress syndrome are expected assessment findings in neonates born to mothers with preexisting diabetes mellitus.
4. A mother of a premature neonate in NICU asks the nurse when her baby will begin getting oral feedings. The nurse is aware that multiple conditions are desired. Which condition is most essential? 1. The neonate demonstrates proper feeding actions. 2. The neonate exhibits cardiorespiratory regulation. 3. The neonate is able to demonstrate hunger cues. 4. The neonate is able to maintain a quiet alert state.
2 This is correct. The nurse will observe the neonate for respiratory status, apnea, bradycardia, oxygenation, and feeding tolerance. The neonate needs to exhibit cardiorespiratory regulation before oral feedings are started. This is the most essential condition for oral feedings.
9. The nurse notices that a neonate being treated for hyperbilirubinemia with phototherapy has had a daily increase of total bilirubin serum levels greater than 5 mg/dL for the past 2 days. The neonatal care provider prescribes an exchange transfusion. Which knowledge does the nurse apply to the procedure? 1. The bilirubin indicates a severe hemolytic disease. 2. Approximately 85% of the neonate's RBCs are replaced. 3. Donor RBCs are obtained from the neonate's mother. 4. The procedure is exclusive to pathological jaundice.
2 This is correct. The nurse is aware that approximately 85% of the neonate's RBCs are replaced with donor cells.
10. The nurse is preparing for the discharge of a premature neonate to home with the parents. The nurse explains the neonate must be able to pass the infant car seat challenge before discharge. For which reason would the neonate be considered unsafe in a car seat? 1. Inability to remain at a 45-degree angle for a period of 1 hour 2. Reluctance of parents to use the car seat because of the small size of the baby 3. Inability to maintain adequate oxygenation, heart rate, and respiratory rate during trial 4. Inability to continue prescribed oxygen therapy for the neonate while in a car seat
3 This is correct. In order to pass the infant care seat challenge, the premature neonate must be able to maintain adequate oxygenation, heart rate, and respiratory rate during trial.
3. The nurse is providing care for a premature neonate in the NICU nursery. The neonate is diagnosed with bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Which specific intervention does the nurse expect for this neonate? 1. Monitor of hemoglobin and hematocrit levels. 2. Obtain blood glucose levels. 3. Maintain fluid restrictions. 4. Administer enteral feedings
3 This is correct. Maintaining fluid restrictions is specific for this neonate due to bronchopulmonary dysplasia (BPD) and patent ductus arteriosus (PDA). Fluid restrictions are appropriate for premature neonates with BPD, PDA, or other complications that can lead to pulmonary edema.
8. A patient who is at 41 weeks gestation is concerned when the primary care provider decides to induce labor. Which reason does the nurse explain as the most important need for this procedure? 1. Increasing size of the neonate 2. Ability to deliver vaginally 3. Risk for placental dysfunction 4. Likelihood of meconium aspiration
3 This is correct. With the postmature fetus, the greatest reason to induce labor is to minimize complications related to placental dysfunction. With postmaturity, placental function decreases, resulting in altered oxygenation and nutrient transport, which increases the risk for hypoxia and hypoglycemia at the onset of labor. This is the most important reason for labor induction
1. The nurse in NICU is assessing a neonate delivered at 32 weeks gestation. Which pathophysiological manifestation is the nurse's greatest concern? 1. Absent or weak reflexes 2. Presence of a heart murmur 3. Apnea 20 seconds or longer 4. Low hemoglobin lab level
3 This is correct. Apnea for 20 seconds or longer is the nurse's greatest concern. Even though this is expected in premature neonates, the nurse will still focus on ABCs.
11. The nurse is providing support to a mother whose newborn is diagnosed with a life-threatening defect. The mother states, "I just want to go home and never come back." Which reaction by the mother does the nurse recognize? 1. Guilty feelings by the mother 2. Delay of attachment process 3. Maternal emotional distancing 4. Disruption of family life
3 This is correct. Emotional distancing of parents from their newborn is a protective mechanism related to fear of their child's death. The mother's comment reflects emotional distancing.
5. The NICU nurse encourages the mother of a premature neonate to bring breast milk to the unit for enteral feedings to her baby. For which reason does the nurse make this suggestion? 1. The baby will be more likely to breastfeed later. 2. The mother will feel more involved with the baby. 3. The neonate will gain weight faster on breast milk. 4. Breast milk helps prevent necrotizing enterocolitis.
4 This is correct. It is a known fact that babies fed on breast milk are less likely to develop necrotizing enterocolitis.
2. The labor and delivery nurse is present for the delivery of a premature neonate. Which action by the nurse is most important? 1. Stabilize and transfer neonate to NICU. 2. Review pregnancy history for risk factors. 3. Maintain fluid and electrolyte balance. 4. Provide a neutral temperature environment
4 This is correct. When attending a premature birth, the most important nursing action is to provide a neutral temperature environment (NTE). The premature neonate is at risk for increased loss of heat because of diminished amounts of subcutaneous fat. The nurse needs to take measures to prevent cold stress, which can be fatal.
7. The nurses in a NICU are concerned about the appropriate levels of oxygen therapy during the care of premature neonates. The nurses referenced an article by Newman (2014) titled, "Oxygen Saturation Limits and Evidence supporting the Targets." On which evidence-based conclusion will the nurses develop guidelines? 1. Oxygen saturation limits of 85% to 89% are effective. 2. Oxygen saturation rates of 91% to 95% are effective. 3. Infants are within saturation limits about 75% of the time. 4. Oxygen saturation limits need to be between 87% to 94%
4 This is correct. Rapid and consistent assessment with appropriate interventions are required to maintain oxygen saturation limits of 87% to 94% to decrease risk of ROP and neonatal death.
17. The priority assessment for the Rh-negative infant whose mother's indirect Coombs test was positive at 36 weeks is a. skin color. b. temperature. c. respiratory rate. d. blood glucose level
ANS: A An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor due to erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated specifically to an infant with an Rh incompatibility issue.
7. Which intervention will increase the effectiveness in reducing the indirect bilirubin in an affected newborn? a. Turn the infant every 2 hours. b. Place eye patches on the newborn. c. Wrap the infant in triple blankets to prevent cold stress. d. Increase the oral intake of water between and before feedings.
ANS: A Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from accessing the skin and being effective. The infant should be uncovered and unclothed. It is important to increase oral feedings, although water should not necessarily be given. Breast milk or formula will increase the reduction of bilirubin
3. Decreased surfactant production in the preterm lung is a problem because a. surfactant keeps the alveoli open during expiration. b. surfactant causes increased permeability of the alveoli. c. surfactant dilates the bronchioles, decreasing airway resistance. d. surfactant provides transportation for oxygen to enter the blood supply.
ANS: A Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, surfactant permits enhanced oxygen exchange. Infants treated with surfactant have higher survival rates
4. A preterm infant is on a ventilator, with intravenous lines and other medical equipment. When the parents come to visit for the first time, what is the most important action by the nurse? a. Encourage the parents to touch their infant. b. Reassure the parents that the infant is progressing well. c. Discuss the care they will give their infant when the infant goes home. d. Suggest that the parents visit for only a short time to reduce their anxiety
ANS: A Touching the infant will increase the development of attachment. As the infant's condition improves the parents should be encouraged to provide Kangaroo care. It is important to keep the parents informed regarding the infant's progress; however, the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching, although is not the most important priority during the first visit. Parents should be encouraged to visit for as long as they are comfortable.
5. The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.
ANS: A Persistent pulmonary hypertension has been associated with hypoxemia and acidosis as a result of the aspiration of meconium. Bronchopulmonary dysplasia is a complication of the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is the result of inadequate absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.
21. A newborn assessment finding that would support the nursing diagnosis of postmaturity would be a. loose skin. b. ruddy skin color. c. presence of vernix. d. absence of lanugo.
ANS: A Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.
1. Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.) a. Sepsis b. Hyperglycemia c. Hyperbilirubinemia d. Cardiac distress e. Problems with thermoregulation
ANS: A, C, E Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the problem and determine ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. These infants are at risk for respiratory distress and hypoglycemia
1. Infection can be transmitted to the neonate from mother during the pregnancy or birth or from the mother, family members, visitors, or agency staff after birth. Which viral infections are most likely to be transmitted during the birth process? (Select all that apply.) a. Hepatitis B b. Rubella c. Herpes d. Varicella Zoster e. Cytomegalovirus
ANS: A, C, E Hepatitis B, herpes, cytomegalovirus, and HIV are usually transmitted during birth; however, they can also be acquired through transplacental transfer or from breast milk. Rubella and varicella zoster (Chickenpox) are acquired in utero and may result in fetal death or significant abnormalities
19. An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of a. RDS. b. PIVH. c. BPD. d. ROP
ANS: B IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.
20. Following a traumatic birth of a 10-lb infant, the nurse should evaluate a. gestational age status. b. flexion of both upper extremities. c. infant's percentile on growth chart. d. blood sugar to detect hyperglycemia.
ANS: B Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Gestational age or the infant's growth chart percentile will not provide data about potential injuries from a traumatic birth. A large infant is at increased risk for hypoglycemia.
15. Following the vaginal birth of a macrosomic infant, the nurse should evaluate the infant for a. hyperglycemia. b. clavicle fractures. c. hyperthermia. d. an increase in red blood cells.
ANS: B Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to become hypoglycemic and would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant
1. Which is the most useful factor in preventing premature birth? a. High socioeconomic status b. Adequate prenatal care c. Aid to Families with Dependent Children d. Women, Infants, and Children (WIC) nutritional program
ANS: B Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention of premature births. Lower socioeconomic groups do not seek out health care, which puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC assist in the nutritional status of the pregnant woman; however, the most helpful intervention for the prevention of premature births is adequate prenatal care
1. The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to a. prevent hyperglycemia. b. provide fluids and protein . c. decrease gastrointestinal motility . d. prevent rapid emptying of the bilirubin from the bowel
ANS: B Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant's system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. Breast milk or formula is more effective in promoting stooling and removal of bilirubin.
8. In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level? a. Necrotizing enterocolitis (NEC) b. Retinopathy of prematurity (ROP) c. Intraventricular hemorrhage (IVH) d. Bronchopulmonary dysplasia (BPD)
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. IVH is caused by 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. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.
2. Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D10W. d. Document the event in the nurses' notes.
ANS: B These symptoms are indications of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain. It is not common practice to administer intravenous glucose to a newborn unless their condition does not allow for enteral feedings. Feeding the infant is preferable as formula or breast milk will maintain glucose stability. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.
16. An infant delivered prematurely at 28 weeks' gestation weighs 1200 g. Based on this information the infant is classified as a. SGA. b. VLBW. c. ELBW. d. low birth weight at term.
ANS: B VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. This option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks' gestation.
11. The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice a. may result in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.
ANS: B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. This type of jaundice may lead to kernicterus; however, screening and appropriate treatment needs to take place in a time sensitive manner in order to prevent kernicterus. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Nonphysiologic jaundice is caused by an underlying condition, such as Rh incompatibility
16. The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse should immediately assess for other signs of a. hyperglycemia. b. neonatal infection. c. hemolytic anemia. d. increased bilirubin levels.
ANS: B Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic anemia, and increased bilirubin levels are not associated with poor infant feeding.
2. The drug-exposed infant often presents with irritability, frantic crying, and is difficult to console. Which nursing measures can be used to prevent this behavior in this high-risk infant? (Select all that apply.) a. Keep the room well lit . b. Swaddle the infant. c. Rock slowly and gently. d. Coo softly and gently. e. Avoid pacifier use
ANS: B, C, D Comfort measures that will assist in consoling this infant and prevent crying include: swaddling, providing a pacifier, slow and smooth rocking in a vertical or horizontal position, cooing, gently stroking the back, keeping the room fairly dark, and avoiding both auditory and visual stimulation. These infants are particularly sensitive to light and should be placed in a darker corner of the nursery or have the lights in their room kept low. Pacifier use will assist the baby in meeting non-nutritive sucking needs and provide a method to self soothe.
14. Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample c. Infant bilirubin level d. Maternal blood type
ANS: C The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infant's bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice
14. Which statement regarding large-for-gestational age (LGA) infants is most accurate? 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 is the most common complication.
ANS: C Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Postmaturity syndrome is not an expected complication with LGA infants.
12. What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction? a. All body parts appear proportionate. b. The extremities are disproportionate to the trunk. c. The head seems large compared with the rest of the body. d. One side of the body appears slightly smaller than the other.
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 anticipated. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head.
4. Transitory tachypnea of the newborn (TTN) is thought to occur as a result of a. a lack of surfactant. b. hypoinflation of the lungs. c. inadequate absorption of fetal lung fluid. d. a delayed vaginal birth associated with meconium-stained fluid
ANS: C Inadequate absorption of fetal lung fluid is thought to be the clinical reason for TTN. Lack of surfactant in the premature infant is likely to result in respiratory distress syndrome. A delayed vaginal birth will help prevent TTN. This condition usually resolves within 24 to 48 hours. TTN is the most common respiratory cause of admissions to the NICU.
18. Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette? a. Hypothermia because of phototherapy treatment b. Impaired skin integrity related to diarrhea as a result of phototherapy c. Fluid volume deficit related to phototherapy treatment d. Knowledge deficit (parents) related to initiation of medical therapy
ANS: C Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for these parents; but, physiologic needs take precedence at this time.
9. When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find a. cyanosis. b. diuresis. c. signs of congestive heart failure. d. increased oxygenation of the tissues.
ANS: C Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion and congestive heart failure. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this type of cardiac defect.
17. The nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infant's color and heart rate remain unchanged. The nurse suspects that the infant a. is exhibiting signs of RDS. b. requires tactile stimulation around the clock to ensure that apneic periods do not progress further. c. is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit. d. requires the use of CPAP to promote airway expansion
ANS: C Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths per minute). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells
10. Which statement regarding newborns classified as small for gestational age (SGA) is accurate? a. They weigh less than 2500 g. b. They are born before 38 weeks of gestation. c. They are below the tenth percentile on gestational growth charts. d. Placental malfunction is the only recognized cause of this condition
ANS: C SGA infants are defined as below the tenth 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 classified as preterm. There are many factors that contribute to the development of an SGA infant, not just placental malfunction.
13. While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth? a. Risk for infection related to release of meconium b. Risk for injury related to high-risk birth interventions, such as amino infusion c. Risk for aspiration related to retained secretions d. Risk for thermoregulation because of high-risk labor status
ANS: C Because the fetus has already passed meconium in utero, the labor and birth assume a high-risk management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, therefore airway complications take precedence in terms of nursing diagnosis and medical management.
6. The nurse present at the birth is reporting to the nurse who will be caring for the neonate after the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant presented with depressed respirations and weak muscle tone. Which information should be included in the report for this infant? a. The parents spent an hour bonding with the baby after birth. b. An IV was started immediately after birth to treat dehydration. c. The infant required warmed humidified oxygen. d. The infant was placed skin to skin with the mother.
ANS: C If the infant with meconium in the amniotic fluid is not breathing effectively after drying, stimulation, and bulb syringe suctioning, they may require humidified O2 or positive-pressure ventilation. Insertion of a laryngoscope and suctioning of the infant's secretions below the vocal chords has not been found to reduce the incidence of meconium aspiration syndrome (MAS). Bonding after birth is an expected occurrence. There is no relationship between dehydration and meconium fluid. Infants with this clinical presentation should be moved to a radiant warmer rath
5. Which preterm infant should receive gavage feedings instead of bottle feedings? a. Sucks on a pacifier during gavage feedings b. Sometimes gags when a feeding tube is inserted c. Has a sustained respiratory rate of 70 breaths per minute d. Has an axillary temperature of 36.9C (98.4F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute
ANS: C Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle-feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths per minute. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle-feeding. Axillary temperature of 36.9C (98.4F), an apical pulse of 149 beats/minute, and respirations of 54 breaths per minute are within expected limits and an indication that the infant is not having respiratory problems at that time.
12. Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea of the neonate (TTN). The parents are notified and become anxious because they have no understanding of what this means for their infant. The best action that the nurse can take at this time is to a. refer them to the neonatologist for more information. b. reassure them not to worry. The infant will be monitored closely by trained staff. c. explain to them that this often occurs following a birth and it will most likely resolve in the next 24 to 48 hours. d. tell them that they will be able to come and see their baby, which will help make calm their anxiety.
ANS: C The clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition. The RN should be able to provide information to clarify the parents' concern without referral to the pediatric provider. Telling parents not to worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction with the newborn and parents may help ease anxiety; however, this does not address the parents' knowledge deficit.
7. A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is a. soft and supple skin. b. a hematocrit level of 55%. c. lack of subcutaneous fat. d. an abundance of vernix caseosa
ANS: C This post-term infant has actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.
3. Which newborn should the nurse recognize as being at the greatest risk for developing respiratory distress syndrome? a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin . b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes. c. A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension.
ANS: C Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.
11. Which nursing action is especially important for an SGA newborn? a. Promote bonding. b. Observe for and prevent dehydration. c. Observe for respiratory distress syndrome. d. Prevent hypoglycemia with early and frequent feedings.
ANS: D The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific to SGA infants. Dehydration is a concern for all infants and is not specific to SGA infants. Respiratory distress syndrome is most commonly seen in preterm infants.
6. 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. Keep charts on top of the incubator so the nurses can write on them there. c. While giving a report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation. d. Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.
ANS: D Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may under stimulate the infant during those long periods and overtire the infant during the procedures. Keeping charts on the incubator and giving the report in front of the incubator may cause overstimulation. Any clip boards or binders in use should be kept at the desk, never on top of the incubator.
9. In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n) a. hematocrit level of 58%. b. RBC count of 5 million/mcL. c. WBC count of 15,000 cells/mm3 . d. blood glucose level of 25 mg/dL
ANS: D Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3 . RBC count ranges from 3.9 to 5.5 million/mcL.
18. The nurse should be alert to a blood group incompatibility if a. both mother and infant are O-positive. b. mother is A-positive and infant is A-negative. c. mother is O-positive and infant is B-negative. d. mother is B-positive and infant is O-negative.
ANS: D Blood group incompatibilities occur because O-positive mothers who have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists. The mother with blood group B does not have any antibodies to group O.
8. Newborns whose mothers are substance abusers frequently exhibit which of the following behaviors? a. Hypothermia, decreased muscle tone, and weak sucking reflex b. Excessive sleep, weak cry, and diminished grasp reflex c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding
ANS: D Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. These infants may also present with hyperactive muscle tone, a high-pitched cry, and diarrhea.
13. Which data should alert the nurse caring for an SGA infant that additional calories may be needed? a. The latest hematocrit was 53%. b. The infant's weight gain is 40 g/day. c. The infant is taking 120 mL/kg every 24 hours. d. Three successive temperature measurements were 36.1C, 35.5C, and 36.1C (97, 96, and 97F).
ANS: D Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day
2. In comparison with the term infant, the preterm infant has a. more subcutaneous fat. b. well-developed flexor muscles. c. few blood vessels visible through the skin. d. greater surface area in proportion to weight
ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are features that are more characteristic of a term infant
10. In an infant with cyanotic cardiac anomaly, the nurse should expect to see a. feedings taken eagerly. b. a consistent and rapid weight gain. c. a decrease in the heart rate with activity. d. little to no improvement in color with oxygen administration
ANS: D With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity
15. Which of the following lab values indicates that an infant may have polycythemia? a. Hct 50% b. Hct 55% c. Hct 62% d. Hct 70%
ANS: D The presence of polycythemia in an infant is characterized by a hematocrit value greater than 65%.