Quiz 11
Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?
a. Risk for infection
A neonate born at 36 weeks gestation is classified as which of the following?
c. Late preterm
Which condition might premature infants who exhibit 5 to 10 seconds of respiratory pauses, followed by 10 to 15 seconds of compensatory rapid respiration, be experiencing?
. Breathing in a respiratory pattern common to premature infants
By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. Which significant symptoms will the infant display when experiencing cold stress?
. Mottled skin with acrocyanosis
Supportive care of the infant with neonatal abstinence syndrome (NAS) include both pharmacologic and nonpharmacologic therapy. Nonpharmacologic therapy would include which of the following
a. Quiet environment with low lighting and use of soft voices c. Swaddling, clustering care, use of pacifiers to promote "self-soothing"
Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is similar to that of a full-term baby. These infants are at increased risk for which conditions? (Select all that apply.)
a. Problems with thermoregulation c. Hyperbilirubinemia d. Sepsis
A 3.8-kg infant was vaginally delivered at 39 weeks after a 30-minute second stage. A nuchal cord was found at delivery. After birth, the infant is noted to have petechiae over the face and upper back. Which information regarding petechiae is most accurate and should be provided to the parents?
a. Are benign if they disappear within 48 hours of birth
Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored maculopapular rash on the palms and around the mouth and anus. The newborn is displaying signs and symptoms of which condition?
a. Congenital syphilis
In appraising the growth and development potential of a preterm infant, the nurse should be cognizant of the information that is best described in which statement?
a. Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. b. Tell
What is the most important nursing action in preventing neonatal infection?
a. Good handwashing or hand hygiene
Which statement most accurately describes complicated grief?
a. Is an extremely intense grief reaction that persists for a long time
A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats per minute with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. Based on the maternal history, what is the most likely cause of this newborn's distress?
a. Sepsis
A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?
b. "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide."
An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths per minute with significant substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). What level of partial pressure of arterial oxygen (PaO2) indicates hypoxia?
b. 45 mmHg
A pregnant woman arrives at the birth unit in labor at term, having had no prenatal care. After birth, her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. Based on her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy?
b. Alcohol
According to the CDC, which of the following has the highest maternal mortality rate in the United States?
b. Black Women
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed, and the birth weight is 4550 g (9 lb, 6 oz). What is the nurse's first priority?
b. Frequently monitor blood glucose levels, and closely observe the infant for signs of hypoglycemia.
According to the CDC, which of the following are true?
b. Maternal mortality rate in the US has increased from 1987-2013
Which finding would indicate to the nurse that the grieving parents have progressed to the reorganization phase of grieving?
b. The parents are discussing sex and a future pregnancy, even if they have not yet sorted out their feelings.
The nurse should be cognizant of which condition related to skeletal injuries sustained by a neonate during labor or childbirth?
b. Unless a blood vessel is involved, linear skull fractures heal without special treatment.
A NICU nurse is caring for a full-term neonate being treated for group B streptococcus (GBS). 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:
c. "Approximately 15% to 40% of women have no symptoms but are carriers of group B streptococcus which is found in the vaginal and lower intestinal areas. What other questions do you have regarding your baby's health?"
Which statement is the most appropriate for the nurse to make when caring for bereaved parents?
c. "What can I do for you?"
Which clinical findings would alert the nurse that the neonate is expressing pain?
c. Cry face; eyes squeezed; increase in blood pressure
Which of the following is true regarding physiologic jaundice?
c. Jaundice is noted 24 hours after birth e. Jaundice is more common in preterm infants
Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. What is the first step in the provision of care for the infant?
c. Neonatal abstinence syndrome (NAS) scoring
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?
c. Provide opportunities for grieving parents and family members to spend time with the baby
Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?
c. Risk for infection
Parents are often asked if they would like to have an autopsy performed on their infant. Nurses who are assisting parents with this decision should be aware of which information?
c. Some religions prohibit autopsy.
Which statement regarding hemolytic diseases of the newborn is most accurate?
c. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
During the initial acute distress phase of grieving, parents still must make unexpected and unwanted decisions about funeral arrangements and even naming the baby. What is the nurse's role at this time?
c. To ensure that the parents, themselves, approve the final decisions
A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" How should the nurse respond? Select one:
d. "Erythromycin is prophylactically given to prevent a gonorrheal infection."
On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Considering that this newborn is physiologically stable, what response should the nurse provide?
d. "You may hold your baby during the feeding."
Which substance, when abused during pregnancy, is the most significant cause of cognitive impairment and dysfunction in the infant?
d. Alcohol
When assisting the mother, father, and other family members to actualize the loss of an infant, which action is most helpful?
d. Ensuring the baby is clothed or wrapped if the parents choose to visit with the baby
A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until the premature rupture of membranes and preterm birth. The newborn's parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. What is the nurse's most appropriate action?
d. Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the equipment first, and then focus on the newborn.
Which information regarding to injuries to the infant's plexus during labor and birth is most accurate?
d. If the nerves are stretched with no avulsion, then they should completely recover in 3 to 6 months.
The nurse is evaluating a neonate who was delivered 3 hours ago by vacuum-assisted delivery. The infant has developed a cephalhematoma. Which statement is most applicable to the care of this neonate?
d. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests.
Which infant is most likely to express Rh incompatibility?
d. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
Which statement most accurately describes complicated grief?
d. Is an extremely intense grief reaction that persists for a long time
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?
d. Neonatal withdrawal This infant is most likely going through withdrawal