Chapter 23 - practice questions
a client has given birth to a full-term infant weighing 10 pounds 5 ounces (4678 grams). what priority assessment should be completed by the nurse? a. blood glucose b. temperature control c. feeding difficulty d. perfusion
a. blood glucose feedback: hypoglycemia is a common concern with a large-for-gestational age (LGA) infant. this infant will deplete the glucose stores very rapidly. therefore, it is important to assess the glucose level within 30 minutes of birth and to repeat every hour until stable. hypoglycemia is defined as a gluose level less than 35 to 45 mg/dl (1.94 to 2.50 mmol/l) in the first 4 hours of life, and intervention should occur when the glucose is less than 40 mg/dl (2.22 mmol/l). intervention should also occur if the blood glucose is less than 45 mg/dl (2.50 mmol/l) at 4 and 24 hours of life respectively. generally the nurse assesses symptoms of jitteriness, irritability and tachypnea first. these symptoms can progress to temperature instability, lethargy, bradycardia, hyponia and seizures.
the nurse prepares to assess a newborn who is considered to be large-for-gestational age (LGA). which characteristic would the nurse correlate with this gestational age variation? a. strong, brisk motor skills b. difficulty in arousing to a quiet alert state c. birthweight of 7 lb, 14 oz d. waster appearance of extremities
b. difficulty in arousing to a quiet alert state feedback: LGA newborns typically are more difficult to arouse to a quiet alert state. they have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb, 13 oz (4,000 g) at term.
a thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions, a heart rate of 120 beats/min, temperature of 96.8 F and persisting oxygen saturation of <87%. the nurse interprets these findings as: a. cardiac distress b. respiratory alkalosis c. bronchial pneumonia d. respiratory distress
d. respiratory distress feedback: ineffective breathing pattern related to immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation less than 87%. these assessment findings do not indicate bronchial pneumonia respiratory alkalosis or cardiac distress at this time.
a macrosomic infant in the newborn nursery is being observed for a possible fractured clavicle. for which would the nurse assess? select all that apply. a. facial grimacing with movement b. bruising over area c. asymmetrical movement d. edema present e. positive Babinski reflex
a. facial grimacing with movement b. bruising over area c. asymmetrical movement d. edema present feedback: birth trauma for LGA newborns would be demonstrated by an obvious deformity, with bruising at the site and edema noted. there would be asymmetrical movement when the newborn moves the limb. babinski reflex is a neurological test and would be normal to be positive.
a premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bili-lights with evidence of hyperbilirubinemia. which assessment findings would the neonate demonstrate? select all that apply. a. increased serum bilirubin levels b. clay-colored stools c. tea-colored urine d. cyanosis e. Mongolian spots
a. increased serum bilirubin levels b. clay-colored stools c. tea-colored urine feedback: hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. cyanosis would not be seen in infants in this scenario. mongolian spots are not associated with newborn jaundice.
a preterm newborn has received large concentrations of oxygen therapy during a 3-month stay in the NICU. as the newborn is prepared to be discharged home, the nurse anticipates a referral for which specialist? a. ophthalmologist b. nephrologist c. cardiologist d. neurologist
a. ophthalmologist feedback: use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy of prematurity (ROP) and further respiratory complications in the preterm newborn (Martin & Deakins, 2020). for these reasons, oxygen should be used judiciously to prevent the development of further complications. a guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn. as a result, an ophthalmology consult for follow-up after discharge is essential for preterm infants who have received extensive oxygen. although referrals to other specialists may be warranted depending on the newborn's status, there is no information to suggest that any would be needed.
a neonate is born at 42 weeks gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar scores. two hours later birth the neonate's blood sugar indicates hypoglycemia. which symptoms would the baby demonstrate? select all that apply. a. poor sucking b. respiratory distress c. weak cry d. jitteriness e. blood glucose >40 mg/dL
a. poor sucking b. respiratory distress c. weak cry d. jitteriness feedback: some of the common problems associated with newborns experiencing a variation in gestational age, such as a postterm newborn, are respiratory distress, jitteriness, feeble sucking, weak cry, and a blood glucose of 40 mg/dL.
a nurse is developing the plan of care for a small-for-gestational-age newborn. which action would the nurse determine as a priority? a. preventing hypoglycemia with early feedings b. observing for newborn reflexes c. promoting bonding between the parents and the newborn d. monitoring vital signs every 2 hours
a. preventing hypoglycemia with early feedings feedback: the nurse must consider the implications of a small-for-gestational-age newborn. with the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. this is achieved by early oral intermittent feedings. observing for newborn reflexes, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn.
a neonate is admitted to the neworn observation nursery with the possible diagnosis of polycythemia. the nurse would be observing for which findings? select all that apply. a. ruddy skin color b. respiratory distress c. cyanosis d. pink gums and tongue e. jitteriness
a. ruddy skin color b. respiratory distress c. cyanosis e. jitteriness feedback: observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results.
a client expresses concerns that her grandmothers had complicated pregnancies. what principle(s) should the nurse discuss to allay the fears of the client? select all that apply. a. "we work to ensure that birth of high-risk infants happens in settings where we are able to care for them." b. "we will work with you to identify prenatal risk factors early and take actions to reduce their impact." c. "we support those at risk of having a preterm births with the goal of delaying early births." d. "we work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." e. "we allow families to grieve the loss of a newborn, should it occur."
a. "we work to ensure that birth of high-risk infants happens in settings where we are able to care for them." b. "we will work with you to identify prenatal risk factors early and take actions to reduce their impact." c. "we support those at risk of having a preterm births with the goal of delaying early births." d. "we work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death." feedback: the nurse will attempt to allay the client's fears by discussing the actions the facility enacts to promote a healthy brith and infant. this includes ensuring the birth of high-risk infants takes place in settings that have the technological capacity to care for them, identifying risk factors early and taking action to reduce their impact, working to delay the birth of those pregancies identified at risk of preterm birht, and promoting an overall reduction in infant illness, disability, and death to proper care of the mother and infant. although allowing a family to greive in instances of infant death, discussing this factor with the client is likely to create more fear.
a 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. the nurse notes on assessment her uterus suggests 12 weeks' gestation, a blood pressure of 110/70 mm Hg, and a BMI of 17.5. the client admits to using cocaine a few times. the client has been pregnant before and indicates she "loses them early." what characteristic(s) place the client in the high-risk pregnancy category? select all that apply. a. BMI 17.5 b. blood pressure 110/70 mm Hg c. prenatal history d. homelessness e. age f. prenatal care
a. BMI 17.5 c. prenatal history d. homelessness f. prenatal care feedback: the key to identifying a newborn with special needs related to birthweight or gestational age variation is an awareness of the factors that could place a newborn at risk. these factors are similar to those that would suggest a high-risk pregnancy and include maternal nutrition (malnutrition or overweight), substandard living conditions or low socioeconomic status, maternal age of less than 20 or more than 35 years, lack of prenatal care, and history of previous preterm birth.
a small-for-gestational age infant is admitted to the observational care unit with the nurse diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent low temperatures. which are appropriate nursing interventions? select all that apply. a. assess the axillary temperatures every hour b. review maternal history c. assess environment for sources of heat loss d. bathe the neonate with warmer water e. minimize kangaroo care f. encourage skin-to-skin contact
a. assess the axillary temperatures every hour b. review maternal history c. assess environment for sources of heat loss f. encourage skin-to-skin contact feedback: proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to identify risk factors contributing to problem, assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to prevent cold stress, and encouraging kangaroo care to provide warmth.
a 42-year-old woman is 26 weeks' pregnant. she lives at a shelter for female victims of intimate partner violence. her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. what findings put her at risk of giving birth to a small-for-gestational-age (SGA) infant? select all that apply. a. the age of the client b. living in a shelter for victims of intimate partner violence c. vaginal bleeding d. fetal heart rate e. blood pressure f. positive test for TORCH
a. the age of the client b. living in a shelter for victims of intimate partner violence c. vaginal bleeding e. blood pressure f. positive test for TORCH feedback: some factors contributing to the birth of SGA newborns include maternal age of 20 or 35 year old, low socioeconomic status, and preeclampsia with increased blood pressure. the vaginal bleeding indicates placental problems, and she tests positive for sexually transmitted diseases by TORCH group infections.
a term neonate has been admitted to the observational newborn nursery with the diagnosis of being small for gestational age. which factors would predispose the neonate to this diagnoses? select all that apply. a. the mother had chronic placental abruption b. at birth the placenta was noted to be decreased in weight c. on assessment the placenta had areas of infarction d. at birth the placeta was a shiny shcultz presentation e. placental talipes was present at birth
a. the mother had chronic placental abruption b. at birth the placenta was noted to be decreased in weight c. on assessment the placenta had areas of infarction d. at birth the placeta was a shiny shcultz presentation feedback: placental factors that can contribute to a small for gestational age infant include chronic placental abruption, infarction on surface of placenta, and a decreased placental weight. a shiny schultz placenta is a normal description because the fetal side of the placenta comes out first, which is shiny. placenta talipes does not exist.
a late preterm newborn is being prepared for discharge to home after being in the neonatal intensive care unit for 4 days. the nurse instructs the parents about the care of their newborn and emphasizes warning signs that should be reported to the pediatrician immediately. the nurse determines that additional teaching is needed based on which parental statement? a. "We will call 911 if we start to see that our newborn's lips or skin are looking bluish." b. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." c. "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician." d. "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)."
b. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay." feedback: the parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practioner. these include: displaying a yellow color to the skin (jaundice); having difficulty breathing or turning blue (call for emergency services in this cise); having a temperature below 97 F or above 100.4; and failing to void for 12 hours.
a set of newborn twins has been admitted to the neonatal intensive care unit with the diagnosis of fetal growth restriction (FGR). which maternal factors would predispose the newborn to this diagnosis? select all that apply. a. hemoglobin 15 g/dl (150 g/l) b. A1C levels of 8% (0.08) c. heroin use disorder d. blood pressure baseline of 170/90 mm Hg e. age 39 years f. multiple gestation
b. A1C levels of 8% (0.08) c. heroin use disorder d. blood pressure baseline of 170/90 mm Hg e. age 39 years f. multiple gestation feedback: assessment of the small-for-gestational-age (SGA) or FGR infant begins by reviewing the maternal history to identify risk factors such as maternal age over 30 years, a substance abuse disorder, HTN, multiple gestation. gestational diabetes or diabetes mellitus is also a factor. normal A1C level is 5.7% for a person without diabetes. hemoglobin is normal for pregnant woman in third trimester.
a nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn. which factor, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of this newborn? a. substance use disorder b. diabetes c. preeclampsia d. infection
b. diabetes feedback: maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of macrosomic infant, postdate gestation, maternal obesity, male fetus, and genetics. substance use disorder is associated with SGA newborns and preterm newborns. a maternal history of preeclampsia and infection would be associated with preterm birth.
the nurse is providing care to a newborn who was born at 36 weeks gestation. based on the nurse's understanding of gestational age, the nurse identifies this newborn as: a. preterm b. late preterm c. term d. postterm
b. late preterm feedback: gestational age is typically measured in weeks: a newborn born before completion of 37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is classified as a postterm newborn. an infant born from the first day of the 38th week through 42 weeks is classified as a term newborn. the late preterm newborn (near term) is one who is born between 34 weeks and 36 weeks, 6 days of gestation.
a couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. the neonatologist has given a poor prognosis to the newborn, who is not expected to live. which interventions are appropriate at this time? select all that apply. a. advise the parents that the hospital can make the arrangements b. offer to pray with the family if appropriate c. leave the parents to talk through their next steps d. initiate spiritual comfort by calling the hospital clergy, if appropriate e. respect variations in the family's spiritual needs and readiness
b. offer to pray with the family if appropriate d. initiate spiritual comfort by calling the hospital clergy, if appropriate e. respect variations in the family's spiritual needs and readiness feedback: when assisting the parents to cope with a perinatal loss, the nurse must respect variations in the family's spiritual needs and readiness. the nurse will also initiate spirtual comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if appropriate.
which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? a. avoid using the terms death or dying b. provide opportunities for them to hold the newborn c. refrain from initiating conversations with the parents d. quickly refocus the parents to a more pleasant topic
b. provide opportunities for them to hold the newborn feedback: when dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. in addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. these interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. the nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process.
a neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the newborn nursery for observation only. what is the nurse's first observation about the infant? a. the neonate is average for its gestational age b. the neonate is small for its gestational age c. the neonate is large for its gestational age d. the neonate is fetal growth restricted
b. the neonate is small for its gestational age feedback: small for gestational age (SGA) describes newborns that typically weigh less than 2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. a newborn is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. in some SGA newborns, the rate of growth does not meet the expected growth pattern. these infants are considered to have fetal growth restriction resulting in pathology.
a one-day neonate born at 32 weeks gestation is in the neonatal intensive care unit under a radiant overhead warmer. the nurse assesses the morning axilla temperature at 95 degrees F. what could explain the assessment finding? a. conduction heat loss is a problem in the baby b. the supply of brown adipose tissue is not developed c. axillary temperatures are not accurate d. this is a normal temperature
b. the supply of brown adipose tissue is not developed feedback: typically newborns use nonshivering thermogenesis for heat production by metabolizing their own brown adipose tissue. however, this preterm newborn has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. conduction heat loss allows an increased transfer of heat from their bodies to the environment, but there is nothing to substantiate conduction heat loss. axillary temperatures are accurate and the mode of taking temperatures for neonates.
the parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. the newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices. which action by the nurse would be most appropriate? a. suggest that the parents stay for just a few minutes to reduce their anxiety b. reassure them that their newborn is progressing well c. encourage the parents to touch their ptreterm newborn d. discuss the care they will be giving the newborn upon discharge
c. encourage the parents to touch their ptreterm newborn feedback: the NICU environment can be overwhelming. therefore, the nurse should address their reactions and explain all the equipment being used. on entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. the parents should be allowed to stay for as long as they feel comfortable. reassurance, although helpful, may be false reassurance at this time. discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated.
a jaundiced neonate must have heel sticks to assess bilirubin levels. which assessment findings would indicate that the neonate is in pain? select all that apply. a. there is flaccid muscle tone of the affected limb b. respiration rate is 52 breaths per minute c. heart rate is 180 beats per minute d. oxygen saturation level is 88% e. the infant has facial grimacing and quivering chin
c. heart rate is 180 beats per minute d. oxygen saturation level is 88% e. the infant has facial grimacing and quivering chin feedback: suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when disturbed. oxygen desaturation will be noted with an increase in heart rate. increase in the normal blood pressure, pulse, and respiration are noted.
a nurse is assessing a postterm newborn. which finding would the nurse correlate with this gestational age variation? a. moist, supple, plum skin appearance b. abundant lanugo and vernix c. thin umbilical cord d. absence of sole creases
c. thin umbilical cord feedback: a postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.
rapid assessment of a newborn indicates the need for resuscitation. the newborn has copious secretions. the newborn is dried and placed under a radiant warmer. which action would the nurse do next? a. intubate with an appropriate-sized endotracheal tube b. give chest compressions at a rate of 80 times per minute c. administer epinephrine intravenously d. clear the airway with a bulb syringe
d. clear the airway with a bulb syringe feedback: after placing the newborn's head in a neutral position, the nurse would clear the airway with a bulb syringe or suction. this is followed by assessment of breathing and bagging if needed, placing a pulse oximeter, ventilating the newborn, assessing the heart rate and giving chest compressions if needed, and then admnistering epinephrine and/or volume expansion if needed.
the nurse is teaching a group of parents who have preterm newborns about the differences between a full-term and preterm newborn. which characteristic would the nurse describe as associated with preterm newborn but not term newborn? a. fewer visible blood vessels through the skin b. more subcutaneous fat in the neck and abdomen c. well-developed flexor muscles in the extremities d. greater body surface area in proportion to weight
d. greater body surface area in proportion to weight feedback: preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. preterm newborns often have thin transparents skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone.
a nurse is assessing a preterm newborn. which finding would alert the nurse to suspect that a preterm newborn is in pain? a. bradycardia b. oxygen saturation level of 94% c. decreased muscle tone d. sudden high-pitched cry
d. sudden high-pitched cry feedback: the nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone.