Chapter 17: High-Risk Neonatal Nursing Care

28. A baby has just been admitted into the neonatal intensive care unit with a diagnosis of intrauterine growth restriction (IUGR). Which of the following maternal problems could have resulted in this complication? (Select all that apply.) a. Cholecystitis b. Hypertension c. Cigarette smoker d. Candidiasis e. Cerebral palsy

ANS: b, c Babies born to women with cholecystitis are not especially high risk for IUGR. Babies born to women with PIH or who smoke are high risk for IUGR. Babies born to women with candidiasis or cerebral palsy are not especially high risk for IUGR.

8. The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist? a. Intermittent strabismus b. Startling c. Grunting d. Vaginal bleeding

ANS: c a. Pseudostrabismus is a normal finding. b. Startling is a normal finding. c. Grunting is a sign of respiratory distress. The neonatologist should be notified. d. Vaginal bleeding is a normal finding.

16. The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of: a. Lecithin b. Calcium c. Surfactant d. Magnesium

ANS: c a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess maturity of fetal lungs. b. Calcium is needed to prevent undermineralization of bones. c. Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance. d. Magnesium is needed to prevent undermineralization of bones.

29. The perinatal nurse assessing a newborn for jaundice recalls that __________ is a process that converts the yellow lipid-soluble (nonexcretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

ANS: conjugation Conjugation of bilirubin constitutes a major function of the newborn's liver. Conjugation is a process that converts the yellow lipid-soluble (nonexcretable) bilirubin pigment (present in bile) into a water-soluble (excretable) pigment.

6. The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible? a. 1-day-old, HR 170 bpm, crying b. 2-day-old, T 98.9°F, slightly jaundice c. 3-day-old, breastfeeding q 2 h, rooting d. 4-day-old, RR 70 rpm, dusky coloring

ANS: d a. A slight tachycardia—170 bpm—is normal when a baby is crying. b. Slight jaundice on day 2 is within normal limits. c. It is normal for a breastfed baby to feed every 2 hours. d. A dusky skin color is abnormal in any neonate, whether or not the respiration rate is normal, although this baby is also slightly tachypneic.

31. The NICU nurse recognizes that the infant who requires ventilation for meconium aspiration syndrome is most often __________.

ANS: post-term Meconium aspiration pneumonia occurs in 10% to 26% of all deliveries, and the incidence increases directly with gestational age. (Before 37 weeks' gestation there is a 2% incidence, and at 42 weeks' gestation there is a 44% incidence.)

32. The NICU nurse's patient assignment includes an infant who is 25 weeks' gestation. The nurse knows that according to the gestational age, this infant would be described as __________.

ANS: very premature The definition of very premature is a neonate born at less than 32 weeks' gestation. The definition of premature is a neonate born between 32 and 34 weeks' gestation. The definition of late premature is a neonate born between 34 and 37 weeks' gestation.

15. The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks' gestation. The most appropriate term for this is: a. Preterm birth b. Term birth c. Small for gestational age infant d. Large for gestational age infant

ANS: a a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks. b. Term births are infants born between 37 and 40 weeks. c. SAG infants at 36 weeks weigh less than 2000 grams. d. LAG infants at 36 weeks weigh over 3400 grams.

10. A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication? a. Meconium aspiration syndrome b. Failure to thrive c. Necrotizing enterocolitis d. Intraventricular hemorrhage

ANS: a a. Although there is nothing in the scenario that states that the amniotic fluid is green tinged, post-term babies are high risk for meconium aspiration syndrome. b. Post-term babies often gain weight very quickly. c. Preterm, not post-term, babies are high risk for necrotizing enterocolitis. d. Preterm, not post-term, babies are high risk for intraventricular hemorrhages.

13. The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following? a. The baby's lung fields are mature. b. The mother is high risk for hemorrhage. c. The baby's kidneys are functioning poorly. d. The mother is high risk for eclampsia

ANS: a a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature. b. L/S ratios are unrelated to maternal blood loss. c. L/S ratios are unrelated to fetal renal function. d. L/S ratios are unrelated to maternal risk for becoming eclamptic.

12. A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby? a. Grunting b. Acrocyanosis c. Pseudostrabismus d. Hydrocele

ANS: a a. This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting. b. Acrocyanosis is a normal finding. c. Pseudostrabismus is a normal finding. d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization in the mother.

1. A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as: a. Low birth weight b. Very low birth weight c. Extremely low birth weight d. Very premature

ANS: a a. Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight. b. Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight. c. Neonates with birth weight less than 1000 grams are classified as extremely low birth weight. d. Neonates born less than 32 weeks' gestation are classified as very premature.

20. Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.) a. Using gelled mattresses b. Using emollients in groin and thigh areas c. Using transparent dressings d. Drying thoroughly

ANS: a, b, c a. Use of gelled mattresses decreases the risk of pressure sores. b. Use of emollients reduces the risk of irritation from urine. c. Use of transparent dressings reduces the risk of friction injuries. d. Drying thoroughly is important in maintaining body heat.

25. A nurse is completing the initial assessment on a neonate of a mother with type I diabetes. Important assessment areas for this neonate include which of the following? (Select all that apply.) a. Assessment of cardiovascular system b. Assessment of respiratory system c. Assessment of musculoskeletal system d. Assessment of neurological system

ANS: a, b, c, d a. Neonates of mothers with type I diabetes are at higher risk for cardiac anomalies. b. Neonates of mothers with type I diabetes are at higher risk for RDS due to a delay in surfactant production related to high maternal glucose levels. c. Neonates of mothers with type I diabetes are usually large and are at risk for a fractured clavicle. d. Neonates of mothers with type I diabetes are at higher risk for neurological damage and seizures due to neonatal hyperinsulinism.

23. Which of the following are common assessment findings of postmature neonates? (Select all that apply.) a. Dry and peeling skin b. Abundant vernix caseosa c. Hypoglycemia d. Thin, wasted appearance

ANS: a, b, c, d a. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. Vernix prevents water loss from the skin to the amniotic fluid; as the amount of vernix decreases, an increasing amount of water is lost from the skin. This contributes to the dry and peeling skin seen in postmature neonates. b. Vernix caseosa covers the fetus's body around 17 to 20 weeks' gestation; as pregnancy advances, the amount of vernix decreases. c. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth. d. Placental insufficiency related to the aging of the placenta may result in postmaturity syndrome, in which the fetus begins to use its subcutaneous fat stores and glycemic stores. This results in the thin and wasted appearance of the neonate and risk for hypoglycemia during the first few hours post-birth.

24. A nurse is caring for a 40 weeks' gestation neonate. The neonate is 12 hours post-birth and has been admitted to the NICU for meconium aspiration. The nurse recalls that the following are potential complications related to meconium aspiration (select all that apply): a. Obstructed airway b. Hyperinflation of the alveoli c. Hypoinflation of the alveoli d. Decreased surfactant proteins

ANS: a, b, d a. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. b. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. c. The presence of meconium in the neonate's lungs can cause a partial obstruction of the lower airway that leads to a trapping of air and a hyperinflation of the alveoli. d. The presence of meconium in the lungs can also cause a chemical pneumonitis and inhibit surfactant production.

18. A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.) a. Exogenous surfactant b. Corticosteroids c. Continuous positive airway pressure (CPAP) d. Bronchodilators

ANS: a, c a. This is a common medical treatment for RDS. b. Corticosteroids are given to women in preterm labor to decrease the risk of RDS. c. CPAP is used to assist neonates with RDS. d. Bronchodilators are given to neonates with bronchopulmonary dysplasia (BPD).

22. A nurse is caring for a 10-day-old neonate who was born at 33 weeks' gestation. Which of the following actions assist the nurse in assessing for signs of feeding tolerance? (Select all that apply.) a. Check for presence of bowel sounds b. Assess temperature c. Check gastric residual by aspirating stomach contents d. Assess stools

ANS: a, c, d a. Feedings should be held and physician notified if bowel sounds are absent. b. The neonate's temperature has no direct effect on feeding tolerance. c. Aspirated stomach contents are assessed for amount, color, and consistency. This assists in the evaluation of the degree of digestion and absorption. d. Stools are assessed for consistency, amount, and frequency. This assists in the evaluation of the degree of digestion and absorption.

19. Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.) a. Early oral feedings with formula b. Prolonged use of mechanical ventilation c. Hyperbilirubinemia d. Nasogastic feedings

ANS: a, d a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosis of the bowel. b. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response. d. Bacterial colonization in the intestines can occur from contaminated feeding tubes causing an inflammatory response in the bowel.

14. Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level? a. Low glucose b. Poor feeding c. Hyperactivity d. Hyperthermia

ANS: b a. Hypoglycemia is not a sign that is related to an elevated bilirubin level. b. The baby is likely to feed poorly. An elevated bilirubin level adversely affects the central nervous system. Babies are often sleepy and feed poorly when the bilirubin level is elevated. c. Hyperactivity is the opposite of the behavior one would expect the baby to exhibit. d. Hyperthermia is not directly related to an elevated bilirubin level.

3. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions? a. Phototherapy b. Feeding neonate every 2 to 3 hours c. Switch from breastfeeding to bottle feeding d. Assess red blood cell count

ANS: b a. Phototherapy is considered when the levels are 12 mg/dL or higher when the neonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility. b. Adequate hydration promotes excretion of bilirubin in the urine. c. Colostrum acts as a laxative and assists in the passage of meconium. d. Assessing RBC is not a treatment for hyperbilirubinemia.

27. The perinatal nurse caring for Emily, a 24-year-old mother of an infant born at 26 weeks' gestation, is providing discharge teaching. Emily is going to travel to the specialty center approximately 200 miles away where her daughter is receiving care. The nurse tells Emily that it is normal for Emily to feel (select all that apply): a. In control b. Anxious c. Guilty d. Overwhelmed

ANS: b, c, d a. Parents usually feel out of control. b. Correct answer. c. Correct answer. d. Correct answer.

11. A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom? a. Prolonged periods of sleep b. Hypovolemic anemia c. Repeated bouts of diarrhea d. Pronounced pustular rash

ANS: c a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly. b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic. c. Babies who are experiencing withdrawal often experience bouts of diarrhea. d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.

4. A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is: a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?" b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?" c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?" d. "I see that this is very upsetting for you. I will come back later and answer your questions."

ANS: c a. Correct information, but does not fully address the woman's concern. b. Correct, but GBS is not a sexually transmitted disease. c. Correct. This response answers her questions and allows her to ask additional questions about her baby's health. d. Acknowledges that she is upset but does not provide immediate information.

7. A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

ANS: c a. It is inappropriate for the nurse to advise prayer. The parents must decide for themselves how they wish to express their spirituality. b. This is an inappropriate suggestion. c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during the grieving process. d. This is an inappropriate suggestion. It is very important for the parents to clearly communicate the baby's death with their other children.

9. It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time? a. Perform a gavage feeding immediately. b. Assess the brachial pulse. c. Assist a physician with intubation. d. Stimulate the baby to cry.

ANS: c a. This action is not appropriate. The baby needs tracheal suctioning. b. The baby needs to have tracheal suctioning. The most important action to promote health for the baby is for the health-care team to establish an airway that is free of meconium. c. This action is appropriate. The baby needs to be intubated in order for deep suctioning to be performed by the physician. A nurse would not intubate and suction but rather would assist with the procedures. d. It is strictly contraindicated to stimulate the baby to cry until the trachea has been suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.

21. Nursing actions that minimize oxygen demands in the neonate include which of the following? (Select all that apply.) a. Providing frequent rest breaks when feeding b. Placing neonate on back for sleeping c. Maintaining a neutral thermal environment (NTE) d. Clustering nursing care

ANS: c, d a. A prolonged feeding session increases energy consumption that increases oxygen consumption. b. Placing the neonate on the back for sleeping has no effect on oxygen consumption. c. A decrease in environmental temperature leads to a decrease in the neonate's body temperature which leads to an increase in respiratory and heart rate that leads to an increase in oxygen consumption. d. Clustering of nursing care decreases stress which decreases oxygen requirements.

26. A baby was born 4 days ago at 34 weeks' gestation. She is receiving phototherapy as ordered by the physician for physiological jaundice. She has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. The nurse's priority nursing action(s) is (are) to (select all that apply): a. Verify laboratory results to check for hypomagnesia. b. Verify laboratory results to check for hypoglycemia. c. Monitor the baby's temperature to check for hypothermia. d. Calculate 24-hour intake and output to check for dehydration

ANS: c, d There are two priority nursing interventions for hyperbilirubinemia. Hydration status is important if the newborn shows signs of dehydration such as dry skin and mucus membranes, poor intake, concentrated urine or limited urine output, and irritability. The newborn should also be kept warm while receiving phototherapy. When an infant is under phototherapy, the temperature needs to be monitored closely because the lights give off extra heat, but if the newborn is in an open crib and undressed, hypothermia may occur. Hypomagnesia and hypoglycemia are not related to phototherapy.

2. A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to: a. Respiratory Distress Syndrome (RDS) b. Bronchopulmonary Dysplasia (BPD) c. Periventricular Hemorrhage (PVH) d. Necrotizing Enterocolitis (NEC)

ANS: d a. Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring. b. Assessment findings for BPD include chest retractions; audible wheezing, rales, and rhonchi; hypoxia; and bronchospasm. c. Assessment findings for PVH include bradycardia, hypotonia, full and/or tense anterior fontanel, and hyperglycemia. d. Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate's inability to fully digest stomach contents and limitation in absorptive function.

17. The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be: a. "Pumping is hard work and you are doing very well. It is good to get about 1 ounce of milk every 3 hours." b. "Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often." c. "Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home." d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more often to prepare to take your baby home."

ANS: d a. This is correct information but does not assist the women in producing more milk. b. This does not provide her with a plan to increase her milk. c. This does not provide her with a plan. d. The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk will help the mother keep her milk flow steady and provide enough nutrients for the infant after discharge.

33. Part of the assessment of a preterm infant includes obtaining an abdominal girth measurement. The NICU nurse performs this assessment because the patient is at risk for __________.

ANS: necrotizing enterocolitis (NEC) When caring for a child with necrotizing enterocolitis, the nurse must measure and record frequent abdominal circumferences, auscultate bowel sounds before every feeding, and observe the abdomen for distention (observable loops or shiny skin indicating distention).

5. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following? a. Hypoglycemia b. Hypercalcemia c. Cold stress d. Neonatal withdrawal

ANS: d a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion. b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias. c. Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting. d. These are common signs and symptoms of neonatal withdrawal.

30. Providing information to parents about jaundice constitutes an important component of the nurse's discharge teaching. Ensuring that parents know when and who to call if their infant develops signs of jaundice will help decrease the risk of __________, or permanent brain damage.

ANS: kernicterus All newborns are screened before discharge for physiological jaundice. The central nervous system can be damaged from unconjugated bilirubin. If bilirubin crosses the blood-brain barrier, it can damage the cerebrum, causing a condition called kernicterus. Kernicterus occurs from brain cell necrosis and can permanently damage a newborn, depending on the amount of time the neurons are exposed to bilirubin, the susceptibility of the nervous system, and the function of the surviving neurons.