High-Risk Neonatal Nursing Care

A nurse is assessing a preterm baby with a gestational age of 32 weeks and birth weight of 1,389 grams. Which of the following signs if present would be a possible indication of RDS. A. Expiratory grunting and intercostal retractions. B. Respiratory rate of 46 breaths per minute and presence of acrocyanosis. C. Mild nasal flaring and heart rate of 140 beats per minute. D. Bradycardia and bounding pulse

A. Expiratory grunting and intercostal retractions

Which is not a risk to the infant of a diabetic mother A. hyperglycemia B. poor feeding C. Marcosomia D. respiratory distress

A. hyperglycemia

Clinical management strategies for prevention of retinopathy of prematurity focus on targeting appropriate ______ranges for infants at risk A. Arterial pH B. Oxygen saturation C. Heart rate D. Core temperature

B. Oxygen saturation

If a pregnant woman is group beta strep positive, prophylactic antibiotics should be administered if A. she is a planned c section B. the gestational age of her baby is less than 37 weeks C. she has vomiting and diarrhea during labor D. her baby has a known congenital anomaly

B. the gestational age of her baby is less than 37 weeks

A common characteristic of a premature infant is A. Absence lanugo B. Dry skin C. Increased flexion of arms and legs D. Transparent and red skin

D. Transparent and red skin

Which of the following treatments is recommended for the infant experiencing drug withdrawal symptoms? A. morphine B. diluted formula C. frequent awakening D. well-lit room

A. morphine

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.

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.

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.

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.

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.

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.

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.

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.

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).

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.

A mother was diagnosed with gonorrhea immediately after delivery. When providing nursing care for the infant, what is an important goal of the nurse? 1. Prevent the development of ophthalmia neonatorum. 2. Lubricate the eyes. 3. Prevent the development of thrush. 4. Teach the danger of breastfeeding with gonorrhea.

Answer: 1 Rationale: A newborn can become infected with gonorrhea as he or she passes through the birth canal. Gonorrhea can cause permanent blindness in the newborn, called ophthalmia neonatorum. All babies' eyes are treated with an antibiotic prophylactically after birth. The eyes require antibiotic prophylaxis, not lubrication. Thrush would result from a yeast infection rather than gonorrhea. There is no risk for breastfeeding because of gonorrhea. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is providing safety for the newborn of a mother with a gonococcal infection. The correct answer would be the option that contains a true statement to prevent spread of infection from mother to infant. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 738-739.

Which nursing diagnosis should have highest priority for the nurse who is caring for a preterm newborn? 1. Ineffective Thermoregulation related to lack of subcutaneous fat 2. Grieving related to loss of "perfect delivery" 3. Imbalanced Nutrition: Less Than Body Requirements related to immature digestive system 4. Risk for Injury related to thin epidermis

Answer: 1 Rationale: Newborns compensate for hypothermia by metabolizing brown fat. This process requires glucose and oxygen. Preterm newborns are at risk for hypoglycemia and respiratory distress, so hypoglycemia can further increase their needs for oxygen and glucose and cause serious complications. The other diagnoses are appropriate but not the highest priority. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Remember ABCs. The correct answer would be the option that contains a true statement that could negatively impact breathing and circulation. Cold stress can contribute to respiratory distress. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 709

On admission to the nursery it is noted that the mother's membranes were ruptured for 48 hours before delivery and her temperature is 102°F (38.9°C). What information from this newborn's assessment should the nurse evaluate further? 1. Temperature instability 2. Irregular respiratory rate 3. Jitteriness 4. Excessive bruising of presenting part

Answer: 1 Rationale: This newborn is at risk for sepsis caused by prolonged rupture of membranes and maternal fever. A primary sign of sepsis in the newborn is temperature instability, particularly hypothermia. An irregular respiratory pattern is normal. Jitteriness may be a sign of hypoglycemia. Excessive bruising is often related to a difficult delivery with an increased risk of hyperbilirubinemia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is the risk for neonatal sepsis. The correct answer would be the option that contains abnormal assessment data related to infection in the newborn. Eliminate incorrect options because they are not related to sepsis. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 482, 783-787.

A newborn's mother has a history of prenatal narcotic abuse. Which interventions would be most appropriate for the infant of a substance abusing mother (ISAM) in the immediate postpartum period? Select all that apply. 1. Monitor the weight every eight hours. 2. Offer infant a pacifier. 3. Assess blood glucose levels. 4. Allow breastfeeding if alcohol is the addiction. 5. Keep the infant in high-Fowler's position.

Answer: 1, 2, 3, 4 Rationale: Infants experiencing neonatal abstinence syndrome (NAS) have needs immediately after birth that change as the hours pass. These infants need frequent weights as intake may be diminished due to withdrawal symptoms. It may be helpful to the infant to be offered opportunity for nonnutritive sucking, such as with a pacifier to soothe and quiet the infant. These infants are at high risk for glucose abnormalities, making glucose monitoring important. Breastfeeding is allowed if the mother is addicted to alcohol but she must not breastfeed after alcohol ingestion. It is unnecessary to keep the infant in high-Fowler's position. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is a newborn experiencing abstinence syndrome, a condition associated with hyperstimulation. The correct answer(s) would be options that reduce stimulation and quiet the infant. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 735-737.

The nurse is caring for a preterm infant who is at risk for an intraventricular hemorrhage (IVH). Which assessment is most critical for this infant? Select all that apply. 1. Increasing head circumference 2. Sudden drop in hemoglobin 3. Pink skin with blue extremities 4. "Waxy" skin color with rapid onset 5. Intake and output

Answer: 1, 2, 4 Rationale: A frequent sign of IVH is an increase in head circumference, since the cranial bones have not fused and can separate as the bleed accumulates in the cranium. A sudden drop in hemoglobin can be indicative of IVH. A change in skin color to a 'waxy' appearance can occur with drop in hemoglobin. Pink skin with blue extremities is not indicative of an IVH. Intake and output are routine measurements that are not directly helpful in this situation. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is intraventricular hemorrhage. Evaluate each option and choose those that are consistent with blood loss into the cranium. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 716.

A nurse is admitting an infant of a diabetic mother (IDM). At 1 hour of age, the nurse notices that the newborn is very jittery. Which action by the nurse is most appropriate? 1. Begin oxygen by nasal cannula. 2. Assess the newborn's blood glucose. 3. Place the newborn under a radiant warmer. 4. Initiate use of a cardiac/apnea monitor.

Answer: 2 Rationale: Infants of diabetic mothers are at risk for hypoglycemia after delivery. A primary sign of hypoglycemia is jitteriness. The newborn is not showing any signs of hypoxia so oxygen would not be appropriate. Putting the newborn under a warmer or on a monitor would not harm the infant, but they are not the priority interventions at this time. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Knowledge of the care of the newborn of a diabetic mother will aid in answering the question correctly. Recall that blood glucose is the primary test to assess diabetic control. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 704-707.

A baby's mother is HIV-positive. Which intervention is most important for the nurse to include when planning care for this newborn? 1. Encourage the mother to breastfeed. 2. Administer zidovudine (ZDV) after delivery. 3. Cuddle the baby as much as possible. 4. Place the baby's crib in a quiet corner of the nursery.

Answer: 2 Rationale: Administering zidovudine (ZDV, formerly AZT) to the mother prenatally and intrapar-tally, as well as to the infant immediately after delivery, decreases the prenatal risk of transmission of HIV by 60-70%. Breastfeeding is contraindicated in an HIV-positive mother because the virus can be passed through breast milk. Cuddling the infant is important, but not the highest priority in this situation. Decreasing environmental stimulation is not indicated. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The core focus of the question is reduction of HIV transmission from mother to infant. The correct option contains a true statement to reduce the risk of transmission of the disease to the newborn. Eliminate options that are either unrelated to HIV transmission or that would increase risk of transmission. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 669, 737-738.

The nurse would take which action as part of nursing care of the infant experiencing neonatal abstinence syndrome? 1. Place stuffed animals and mobiles in the crib to provide visual stimulation. 2. Position the baby's crib in a quiet corner of the nursery. 3. Avoid the use of pacifiers. 4. Spend extra time holding and rocking the baby.

Answer: 2 Rationale: Neonatal abstinence syndrome, or drug withdrawal, causes hyperstimulation of the neonate's nervous system. Nursing interventions should focus on decreasing environmental and sensory stimulation during the withdrawal period. Pacifiers allow for nonnutritive sucking by the infant. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recall that neonatal abstinence syndrome is accompanied by hyperstimulation of the central nervous system. The correct answer would be the option that contains a strategy to reduce stimulation. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 724, 729, 731.

The parents of a 28 weeks' gestation neonate ask the nurse, "Why does he have to be fed through a tube in his mouth?" What is the nurse's best response? 1. "It allows us to accurately determine the baby's intake since he is so small." 2. "The baby's sucking, swallowing, and breathing are not coordinated yet." 3. "The baby's stomach cannot digest formula at this time." 4. "It helps to prevent thrush, an infection that could affect the baby's mouth."

Answer: 2 Rationale: Neonates generally are not able to effectively coordinate sucking, swallowing, and breathing until 34-36 weeks' gestation. If fed orally before that time, they are at greater risk of aspiration. Typically they will be fed through a gavage tube until they are able to drink from a bottle or breastfeed. Intake can be accurately assessed with oral and gavage feedings but this is not the primary reason. The stomach of a preterm infant can digest small amounts of formula or breast milk. Thrush is an oral yeast infection commonly caused during passage through the birth canal and gavage feedings will not prevent it from occurring. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that the correct option is also a true statement. Recall the preterm neonate's capabilities regarding nutritional intake to choose the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 714-715.

A full-term newborn weighed 10 pounds, 5 ounces at birth. What would be a priority nursing diagnosis for this infant? 1. Ineffective Thermoregulation related to lack of subcutaneous fat 2. Risk for Injury related to macrosomia 3. Impaired Gas Exchange related to lack of surfactant 4. Deficient Knowledge related to newborn care

Answer: 2 Rationale: Newborns experiencing macrosomia are more likely to experience birth injuries during delivery. Nursing care after delivery should focus on assessing for signs of birth injuries and intervening if appropriate. The risks related to ineffective thermoregulation are the same as for other infants born at term. A mature newborn has sufficient surfactant for gas exchange. Teaching would be a priority for the parents, but is a psychosocial need and takes precedence once the infant's physiological needs are attended to. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The core issue of the question is an abnormally large infant. The correct answer would be the option that contains a true statement of a risk for this newborn. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 517-518.

A nurse is assessing a neonate born 12 hours ago and notes a yellow tint to the sclera. The nurse should read the medical record for what other assessment that is important to note at this time? 1. Blood glucose level 2. Blood type and Rh factor of both mother and newborn 3. Most recent infant blood pressure 4. Length of time membranes ruptured prior to delivery

Answer: 2 Rationale: This newborn has signs of jaundice, which include a yellow tint to the sclera and skin. Jaundice is considered pathologic if it occurs within the first 24 hours of life, when it is most often caused by Rh or ABO incompatibility. It would be important to assess both the mother's and newborn's blood type and Rh factor to determine if this could be causing the jaundice. A bilirubin level should also be obtained. A blood glucose level would be important if the infant showed signs of hypoglycemia. The most recent infant blood pressure is not relevant. The length of time membranes ruptured prior to delivery would affect the risk of maternal infection. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: This question requires further assessment of jaundice, an abnormal finding in a newborn at this age. The correct answer would be the option that contains information related to pathologic jaundice. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 771.

A newborn is admitted with a diagnosis of transient tachypnea of the newborn (TTN). When planning nursing care for this baby, what nursing goal should the nurse formulate? 1. Promote adequate quantity of surfactant. 2. Promote absorption of fetal lung fluid. 3. Assist in removal of meconium from airway. 4. Stimulate respirations.

Answer: 2 Rationale: Transient tachypnea of the newborn (TTN) is caused by delayed absorption of fetal lung fluid. Nursing care is focused on supporting oxygenation needs to allow the newborn's body to reabsorb the fluid. Inadequate surfactant is related to prematurity and respiratory distress syndrome. Meconium in the airway results in meconium aspiration syndrome and is usually associated with fetal asphyxia. TTN causes tachypnea so stimulating respirations is not appropriate. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: Recall that transient tachypnea is associated with amniotic fluid in the newborn lungs. Eliminate incorrect options because they are not related to this problem. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 759-760.

A nurse is caring for a 12-hour-old newborn. The nurse notes a yellow tint to the baby's skin and sclera. What laboratory tests should the nurse anticipate being ordered? Select all that apply. 1. Serum glucose 2. Direct Coombs' test 3. Blood culture and sensitivity 4. Hemoglobin 5. Total bilirubin

Answer: 2, 4, 5 Rationale: Jaundice in an infant less than 24 hours of age is often caused by Rh or ABO incompatibility. A direct Coombs' test determines the presence of maternal antibodies in the baby's blood. Hemoglobin will provide additional crucial information about possible red blood cell destruction. Total bilirubin is a helpful test to determine the amount of circulating bilirubin that can lead to increased jaundice. A serum glucose test would be useful if the infant was showing signs of hypoglycemia. Blood culture and sensitivity would be useful for the infant suspected of being septic. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is jaundice. Eliminate incorrect options because they do not provide data related to this abnormal condition. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 772-773.

The nurse is admitting a neonate two hours after delivery. Which assessment data should the nurse be concerned about? Select all that apply. 1. Hands and feet blue with otherwise pink color 2. Bilateral nasal flaring 3. Minimal response to verbal stimulation 4. Apical heart rate 140-156 5. Chest retractions

Answer: 2, 5 Rationale: Nasal flaring and chest retractions could be signs of respiratory distress and require immediate intervention. Blue hands and feet, a minimal response to verbal stimulation and apical heart rate of 140-156 are normal findings for a neonate at two hours of age. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Critical words are neonate two hours after delivery and be concerned about. This indicates the need to look for abnormal signs that indicate a problem. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 608.

The nurse is assigned to a baby receiving phototherapy. Which assessment warrants further investigation by the nurse? 1. Loose, green stools 2. Yellow tint to skin 3. Temperature 97.2°F 4. Fine, red rash on trunk

Answer: 3 Rationale: Infants should be unclothed while receiving phototherapy to increase the circulating blood volume exposed to the phototherapy light. However, this increases the risk of temperature instability and infant temperature should be monitored carefully. Any temperature below 97.6°F is considered hypothermia and requires immediate attention. Loose, green stools and a yellow tint to the skin are expected findings with hyper-bilirubinemia. A fine, raised red rash may appear on the infant's skin as a side effect of the phototherapy and does not require intervention. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is an abnormal finding in the present treatment of jaundice. Eliminate incorrect options because they are normal findings in a newborn with jaundice being treated with phototherapy. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 773-777.

Of the following nursing diagnoses for a high-risk newborn, which requires the most immediate intervention by the nurse? 1. Acute Pain related to frequent heel sticks 2. Imbalanced Nutrition: Less Than Body Requirements related to limited oral intake 3. Ineffective Airway Clearance related to pulmonary secretions 4. Deficient Knowledge related to infant care needs

Answer: 3 Rationale: Maintaining a patent airway is the highest priority when providing care for a newborn. A newborn's condition will deteriorate rapidly without a patent airway. Pain is an important safety need, but airway, breathing, and circulation take priority. Nutrition is important to maintain life but is not the highest priority diagnosis for the high-risk newborn. Deficient Knowledge relates to the parents and has the lowest priority because it is psychosocial in nature. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Remember ABCs. Maintaining an open airway would be the priority. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 608-609.

The nurse finds the mother of a 28 weeks' gestation infant crying in her room. The mother states, "I just know my baby is going to die." What is the most therapeutic response by the nurse? 1. "I know this seems overly optimistic, but it is likely that everything will be fine." 2. "Why do you think that?" 3. "You seem very worried about what will happen to your baby." 4. "My baby was born at 27 weeks and he is fine now."

Answer: 3 Rationale: Reflecting on what the client said offers the client an opportunity to share feelings. It is important to avoid giving false reassurance. It is important to avoid asking clients "why" they feel the way they do. Talking about personal experiences is nontherapeutic and does not address the client's concerns. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The focus of the question is therapeutic communication. The correct answer would be the option that validates the client's feelings. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 721.

The nurse is preparing to initiate bottle-feeding in a preterm infant. In which situation would the nurse withhold the feeding and notify the health care provider? 1. Apical heart rate 120-130 2. Axillary temperature 97.2°F-98.4°F 3. Yellow tint to skin and sclera 4. Respiratory rate 62-68

Answer: 4 Rationale: Any sustained respiratory rate greater than 60 breaths/minute increases the risk of aspiration in the infant. Oral feedings should be withheld on infants experiencing tachypnea to decrease the risk of aspiration. An apical heart rate of 120-130 is a normal finding. Although an infant temperature of 97.2°F is considered hypothermia, it would not be a contraindication to oral feedings. Jaundice may be considered abnormal but it alone would not be an indication to withhold an oral feeding. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is identification of abnormal findings that would contraindicate feeding. The correct answer would be the option that contains an abnormal finding related to a condition that could be exacerbated by feeding. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 757-758.

A mother is crying while sitting by the isolette of her premature newborn who was born at 25 weeks' gestation. What is the most therapeutic communication by the nurse? 1. "It's important to try not to worry. Let's hope that everything will work out." 2. "Can you tell me some specific things that have gotten you upset?" 3. "Would you like me to call the hospital chaplain? This has helped many others." 4. "This must be hard for you. Can you share with me what has you most concerned at this time?"

Answer: 4 Rationale: Reflection allows the client to verbalize his or her feelings. The nurse should not give the client false hope. Clients often do not know why they feel the way they do and it is not helpful to ask them to determine this. Some clients may find comfort in a religious leader, but care should be taken not to stereotype the client's religious beliefs. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The focus of the question is therapeutic communication. The correct answer would be the option that validates the client's feelings and invites further communication by the client. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 791-794.

A newborn's temperature is 97.4°F. What is the priority nursing intervention by the nurse? 1. Notify the health care provider immediately. 2. Take the newborn to the nursery and observe for two hours. 3. Reassess the temperature in four hours. 4. Wrap the newborn in two warm blankets and place a cap on the head.

Answer: 4 Rationale: This newborn has a low temperature and the nurse must intervene quickly to prevent complications related to hypothermia. Wrapping the baby in warm blankets and covering the head will help prevent heat loss through conduction, convection, and radiation and is the most important initial intervention. It is unnecessary to notify the health care provider at this time. Observing the infant for two hours delays care and is unsafe. Reassessment of temperature does not do anything to raise the infant's temperature at this time. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is an abnormal finding indicating cold stress. The correct answer would be the option that counteracts this problem and safely warms the newborn. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 637-638.

Which of the following statements is true regarding hyperbilirubinemia? A. Jaundice covers the entire body in pathological jaundice versus only the face in physiological jaundice. B. Jaundice occurs within the first 24 hours post birth in pathological jaundice versus after 24 hours in physiological jaundice. C. Kernicterus only occurs in pathological jaundice. D. Jaundice begins to appear in term neonates when the bilirubin level is 3 mg/dL.

B. Jaundice occurs within the first 24 hours post birth in pathological jaundice versus after 24 hours in physiological jaundice.

A neonate born at 37 weeks gestation is determined to be small for gestational age. The most common immediate problem for this infant would be A. anemia B. hypovolemia C. hypoglycemia D. Hypocalcemia

C. Hypoglycemia

When gavage feeding a preterm neonate, the nurse should A. measure the tube before insertion from the mouth to the sternum B. Check for placement by injecting a small amount of sterile water into the feeding tube and listen for a gurgling noise C. Instill formula over a 20 minute period of time D. Flush the tube at the end of feeding with dextrose water.

C. Instill formula over a 20 minute period of time

The primary risk factor for necrotizing enterocolitis is A. Early oral feedings with formula B. Passage of meconium during labor C. Prematurity D. Low birth weight

C. Prematurity

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.

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.