Chapter 24: PrepU - Conditions and Care Related to Gestational Age, Size, Injury, and Pain in the Newborn

Which sign appears early in a neonate with respiratory distress syndrome? 1- Bilateral crackles 2- Pale gray skin color 3- Tachypnea more than 60 breaths/minute 4- Poor capillary filling time (3 to 4 seconds)

3

A newborn is being monitored for retinopathy of prematurity. Which condition predisposes an infant to this condition? 1- respiratory distress syndrome 2- Down syndrome 3- hydrocephalus 4- esophageal atresia

1

In pulse oximetry for a newborn, what is the percentage of oxygen that is considered abnormal? 1- 75% 2- 95% 3- 85% 4- 87%

1

Why is thermoregulation a problem for the preterm newborn? 1- A preterm infant is not born with brown fat. 2- A decrease in skin surface to body mass is noted. 3- Water cannot escape easily through the skin. 4- The CNS is overactive, leading to excessive shivering and use of glucose stores.

1

When examining a neonate, which characteristic would indicate to the nurse that the infant is preterm? Select all that apply. 1- extended extremities 2- covered with vernix caseosa 3- absence of sole creases 4- bulging posterior fontanelle 5- elevated breast bud

1,2,3

Which condition may cause intrauterine asphyxia? Select all that apply. 1- cord compression 2- placenta abruption 3- intrauterine growth restriction 4- gestational diabetes 5- group B strep infection

1,2,3

The nurse is evaluating the neonate for gestational age. Which assessment finding will the nurse note when determining the infant is post-term? 1- A scarf sign shows resistance and the elbow is unable to reach midline 2- Breast buds are 4.5 mm and have a raised areola 3- Flexed positions show good muscle tone 4- Ear cartilage is thick and the pinna is stiff

4

What is a typical feature of a small for gestational age (SGA) newborn that differentiates it from a preterm baby with a low birth weight? 1- decreased muscle mass 2- face is angular and pinched 3- decreased body temperature 4- ability to tolerate early oral feeding

4

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was born at 35 weeks' gestation. How would the nurse classify this newborn? 1- preterm 2- late preterm 3- full term 4- postterm

2

At what day of life does jaundice peak in a newborn? 1- 1 to 2 days 2- 7 to 10 days 3- 3 to 5 days 4- 10 to 12 days

3

The nursery nurse is providing shift handoff on a newborn documented as small for gestational age. Which clinical manifestations would be communicated? Select all that apply. 1- Sunken abdomen 2- Narrow skull sutures 3- Increased subcutaneous fat stores 4- Poor muscle tone over buttocks 5- Dry or thin umbilical cord

1,4,5

What would be appropriate for the nurse to document in a child suffering from meconium aspiration syndrome? 1- heart rate as normal 2- respirations as increased and high 3- skin as pink 4- chest expansion as normal

2

A mother asks when a preterm infant receives basic immunizations. Which response by the nurse is most accurate? 1- Basic immunizations are given according to the chronologic age of an infant. 2- The infant will receive basic immunizations before discharge from the NICU. 3- The infant's immunizations will all be delayed until 6 months corrected age. 4- Basic immunizations are given according to the infant's corrected gestational age.

1

A newborn girl who was born at 38 weeks of gestation weighs 2000 g and is below the 10th percentile in weight. The nurse recognizes that this girl will be placed in which classification? 1- term, small for gestational age, and low-birth-weight infant 2- term, small for gestational age, and very-low-birth-weight infant 3- late preterm and appropriate for gestational age 4- late preterm, large for gestational age, and low-birth-weight infant

1

A newborn is experiencing cold stress. Which findings would the nurse expect to assess? Select all that apply. 1- respiratory distress 2- decreased oxygen needs 3- hypoglycemia 4- metabolic alkalosis 5- jaundice

1,3,5

The nurse is teaching a group of parents who have preterm newborns about the differences between a full-term newborn and a preterm newborn. Which characteristic would the nurse describe as associated with a preterm newborn but not a term newborn? 1- fewer visible blood vessels through the skin 2- more subcutaneous fat in the neck and abdomen 3- well-developed flexor muscles in the extremities 4- greater surface area in proportion to weight

4

A nurse places a newborn under a radiant heat warmer. At which location should the temperature probe be placed? 1- Abdomen, between the umbilicus and the xiphoid process 2- Gluteus maximus 3- Abdomen, over the liver 4- Back, over the rib cage

1

After a gavage feeding of a preterm neonate, the nurse aspirates 4 mL of undigested formula. This finding may indicate the development of which complication? 1- necrotizing enterocolitis 2- malabsorption syndrome 3- dumping syndrome 4- acute gastroenteritis

1

A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? 1- "You are lucky to have given birth to a term newborn." 2- "We still need to monitor him closely for problems." 3- "How do you feel about giving birth to your baby at 36 weeks?" 4- "Your baby is premature and needs monitoring in the NICU."

2

A client gives birth to a newborn baby at term. The nurse records the weight of the baby as 1.2 kg, interpreting this to indicate that the newborn is of: 1- normal birth weight. 2- low birth weight. 3- very low birth weight. 4- extremely low birth weight.

3

A nurse is implementing measures to prevent hypothermia in a premature newborn. The nurse determines that the newborn is experiencing an effect of hypothermia based on which assessment finding? 1- No breathing for 15 seconds 2- Respiratory rate of 45 breaths per minute 3- Heart rate of 130 beats per minute 4- Pink skin color

1

A nurse is caring for an infant born with polycythemia. Which intervention is most appropriate when caring for this infant? 1- Focus on decreasing blood viscosity by increasing fluid volume. 2- Check blood glucose within 2 hours of birth by reagent test strip. 3- Repeat screening every 2 to 3 hours or before feeds. 4- Focus on monitoring and maintaining blood glucose levels.

1

A nurse is conducting a class for a group of expectant couples on fetal growth and development. The nurse determines that additional teaching is needed when the class identifies which factor as playing an important role in fetal growth and development? 1- paternal factors 2- genetic factors 3- placental factors 4- maternal factors

1

A client has given birth to a small-for-gestation-age (SGA) newborn. Which finding would the nurse expect to assess? 1- head larger than body 2- round flushed face 3- brown lanugo body hair 4- protuberant abdomen

1

A newborn has scheduled heel sticks for bilirubin checks every 4 hours. The mother asks the nurse "what can be done to calm my baby after those heel pricks?" What is the nurse's most appropriate response? 1- "You can give your baby a sucrose solution by bottle for pain relief." 2- "Offer your baby a feeding of sterile water solution by bottle." 3- "The fussiness will go away shortly with tight swaddling." 4- "Your baby is not feeling pain but irritated with all the handling."

1

A newborn is designated as very low birth weight. When weighing this newborn, the nurse would expect to find which weight? 1- less than 1,500 g 2- more than 4,000 g 3- approximately 2,500 g 4- less than 1,000 g

1

A newborn is diagnosed with hemolytic disease of the newborn. When developing the plan of care for this child, the nurse would expect which of the following to be included as part of the treatment plan? 1- Exchange transfusion 2- Surfactant administration 3- Radiant warming 4- Mechanical ventilation

1

A newborn is exhibiting signs and symptoms of hypoglycemia. The nurse prepares to administer IV glucose based on which blood glucose level? 1- 36 mg/dL 2- 45 mg/dL 3- 50 mg/dL 4- 55 mg/dL

1

A newborn is receiving bag and mask ventilation and cardiac compression. The resuscitation is paused, and the nurse reassesses the infant. The infant's heart rate is 70 bpm with irregular gasping respirations. What is the appropriate action in this situation? 1- Continue bag and mask ventilation only. 2- Continue bag and mask ventilation and cardiac compressions. 3- Continue cardiac compressions only. 4- Allow the infant a chance to stabilize without further intervention.

1

A nurse is administering prescribed enteral feedings to assist in preparing the gut of a preterm newborn. The nurse integrates understanding of this measure, administering the feedings at which rate? 1- 0.5 to 1 mL/kg/h 2- 1 to 1.5 mL/kg/h 3- 1.5 to 2 mL/kg/h 4- 2 to 2.5 mL/kg/h

1

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication? 1- atelectasis 2- infection 3- intracranial hemorrhage 4- hypoglycemia

1

A nurse is assessing a preterm newborn. The nurse determines that the newborn is comfortable and without pain based on which finding? 1- lack of body posturing 2- sudden high-pitched cry 3- increased muscle tone 4- fussiness

1

A nurse is assessing a term newborn and finds the blood glucose level is 23 mg/dl. The newborn has a weak cry, is irritable, and exhibits bradycardia. Which intervention is most appropriate? 1- Administer dextrose intravenously. 2- Monitor the infant's hematocrit levels closely. 3- Administer PO glucose water immediately. 4- Place the infant on a radiant warmer.

1

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? 1- a sudden drop in hemocrit 2- soft, flat anterior fontanels 3- pink skin with noted blue extremities 4- intake and output for 8 hours

1

A nurse is providing care to a large for gestational age newborn. The nurse checks the newborn's blood glucose level and finds it to be 23 mg/dL. Which action would the nurse do first? 1- Administer intravenous glucose. 2- Feed the newborn 2 ounces of formula. 3- Initiate blow-by oxygen therapy. 4- Place the newborn under a radiant warmer.

1

A postterm newborn develops perinatal asphyxia. The nurse understands that this condition is most likely the result of: 1- aging placenta. 2- hypoxia from cord compression. 3- loss of subcutaneous fat. 4- increased production of red blood cells.

1

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the: 1- ductus arteriosus remains open. 2- foramen ovale closes prematurely. 3- aorta or aortic valve strictures. 4- pulmonary artery closes.

1

A preterm newborn has just received synthetic surfactant through an endotracheal tube by a syringe. Which intervention should the nurse implement at this point? 1- Tip the infant into an upright position. 2- Immediately suction the infant's airway. 3- Place the infant supine in a radiant heat warmer. 4- Take a blood sample.

1

After teaching a group of nursing students about the normal progression of neurobehavioral development, the instructor determines that the teaching was effective when the students identify which of the following as helping to promote the normal progression ? 1- Adequate pain relief 2- Intrauterine drug exposure 3- Prematurity 4- Surgery

1

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which action would the nurse do next? 1- Administer intravenous glucose immediately. 2- Feed the newborn 2 ounces of formula. 3- Initiate blow-by oxygen therapy. 4- Place the newborn under a radiant warmer.

1

Assessment of a 26-week-old premature newborn reveals that the newborn is having problems with thermoregulation. The nurse would be alert for the development of which of the following? 1- Apnea 2- Tachycardia 3- Sleepiness 4- Crying

1

At birth, a term infant has irregular respirations and a weak cry. What is the sequence of events initiated by the nurse when caring for this infant? 1- Dry the infant, stimulate the infant, and keep the infant warm. 2- Dry the infant, administer blow-by oxygen, and keep the infant warm. 3- Open the airway, initiate respirations, and dry the infant. 4- Open the airway, suction the trachea, and administer oxygen.

1

At birth, the newborn was at the 8th percentile with a weight of 2350g and born at 36 weeks gestation. Which documentation is most accurate? 1- The infant was a preterm, low birth weight and small for gestational age 2- The infant was born at term but at a low birth weight and small for gestational age 3- The infant was born at term but a very low birth weight and small for gestational age 4- The infant was a preterm, very low birthweight and small for gestational age

1

Following resuscitation, a 4-pound infant is admitted to the NICU. The nurse would initiate enteral feedings based on which assessment? 1- stabilized respiratory effort 2- absence of apnea 3- stabilized cardiac function 4- presence of bowel sounds

1

If the nurse suspects intraventricular hemorrhage (IVH) in a preterm newborn, which of the following would the nurse be likely to find? 1- No signs or only subtle signs 2- Restlessness, crying, irritability 3- Redness and bruising on the scalp 4- Tachycardia and hyperperfusion

1

The health care provider has determined that the source of dystocia for a woman is related to the fetus size. The nurse understands that macrosomia would indicate the fetus would weigh: 1- 4,000 g or more. 2- 3,500 g or more. 3- 4,500 g or more. 4- 3,000 g or more.

1

The neonate's respirations are gasping and irregular with a rate of 24 bpm. Which circulatory alteration will the nurse assess for in this infant? 1- Blood flows from the aorta to the pulmonary artery. 2- Blood flows from the pulmonary vein to the alveoli. 3- Blood flows from the right atrium to the left atrium. 4- Blood flows from the lungs to the left ventricle.

1

The newborn nursery nurse is admitting a small-for-gestational-age (SGA) infant and is reviewing the maternal history. What factor in the maternal history would the nurse correlate as a risk factor for a SGA infant? 1- placental factors 2- blood group incompatabilty 3- grand multiparity 4- age of 30 years

1

The nurse is assessing a small-for-gestational age (SGA) newborn, 12 hours of age, and notes the newborn is lethargic with cyanosis of the extremities, jittery with handling, and a jaundiced, ruddy skin color. The nurse expects which diagnosis as a result of the findings? 1- polycythemia 2- hyperglycemia 3- hypercalcemia 4- hyponatremia

1

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? 1- 20th 2- 9th 3- 5th 4- 95th

1

The nurse places a newborn experiencing respiratory difficulty under a radiant warmer to prevent which complication? 1- acidosis 2- alkalosis 3- hypoxia 4- hypercapnia

1

When an infant is jaundiced, what is the nurse's main role in treatment? 1- Educate the caregiver 2- Comfort the infant 3- Feed the infant 4- Draw blood for analysis

1

Which assessment finding by the nurse would indicate that a neonate is being comforted? 1- increased oxygen saturation 2- decreased oxygen saturation 3- increased heart rate 4- decreased heart rate

1

A nurse is documenting the weights of several newborns and determines them to be appropriate for gestational age (AGA). Which percentile would the nurse identify for this classification? Select all that apply. 1- 35 2- 50 3- 80 4- 5 5- 95

1,2,3

Prevention and early identification of newborns at risk are necessary nursing functions. A nurse anticipates the need for newborn resuscitation secondary to birth asphyxia based on which prenatal risk factors? Select all that apply. 1- gestational hypertension 2- maternal infection 3- congenital heart disease 4- nulliparous mother 5- labor and birth without anesthesia

1,2,3

The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.) 1- Provide audio stimulation with the use of music. 2- Stop procedures if the infant shows signs of distress. 3- Provide a nest with blankets to provide a sense of security. 4- Provide tactile stimulation by tickling the bottom of the feet. 5- Provide care consistently so the infant develops sleep/wake cycles.

1,2,3,5

While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply.) 1- Grunting 2- Nasal flaring 3- Intercostal retractions 4- Oxygen saturation 96% 5- Increasing respiratory rate

1,2,3,5

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which findings would support the nurse's suspicion? Select all that apply. 1- shallow, slow respirations 2- cyanotic hands and feet 3- irritability 4- hypertonicity 5- feeble cry

1,2,5

A preterm infant of 32 weeks' gestation is admitted from the birth suite to the neonatal intensive care unit with symptoms of respiratory distress. What would the nurse expect to see during assessments? Select all that apply. 1- pH 7 2- PaCO2 54 mm Hg 3- heart rate 110 bpm 4- respiratory rate 34 breaths/min 5- temperature 99.5° F (37.5° C) 6- PaO2 35

1,2,6

A nurse is assessing a newborn who has been classified as small for gestational age. Which characteristics would the nurse expect to find? Select all that apply. 1- wasted extremity appearance 2- increased amount of breast tissue 3- sunken abdomen 4- adequate muscle tone over buttocks 5- narrow skull sutures

1,3,5

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which measures would the nurse include? Select all that apply. 1- clustering care to promote rest 2- positioning newborn in extension 3- using kangaroo care 4- loosely covering the newborn with blankets 5- providing nonnutritive sucking

1,3,5

A 2-month-old infant is brought to the wellbaby clinic for a first checkup. On initial assessment, the nurse notes the infant's head circumference is at the 95th percentile. Which action would the nurse take initially? 1- Assess vital signs. 2- Measure the head again. 3- Assess neurologic signs. 4- Notify the primary health care provider

2

A new mother is concerned because she fears that her infant's head is larger than normal. What would be the nurse's best response? 1- A large head at birth suggests hydrocephalus. 2- A large head at birth in itself is not indicative of hydrocephalus, but we will keep a check on it. 3- It will become even larger as the baby grows. 4- If we do not drain the excessive fluid building up the child will have a problem raising the head when older.

2

A newborn is returned to the newborn observational nursery demonstrating signs of cold stress after a prolonged bath. Which action would be a priority for the nurse? 1- Perform a neurological assessment. 2- Assess blood sugar level. 3- Request arterial blood gases. 4- Assess feeding patterns.

2

A nurse is conducting a class for expectant parents about newborns. As part of the class, the nurse describes newborns with birth weight variations. The nurse identifies which variation if the newborn weighs 5.2 lb (2,358 g) at any gestational age? 1- small for gestational age 2- low birth weight 3- very low birth weight 4- extremely low birth weight

2

A preterm infant has an umbilical vessel catheter inserted so that blood can be drawn readily. Which would be most important to implement during this procedure? 1- Prevent the infant from crying. 2- Ensure that the infant is kept warm. 3- Assess the infant's cranial vascular tension. 4- Evaluate the infant's urinary output.

2

A preterm newborn receives oxygen therapy to treat respiratory distress syndrome (RDS). Which complication should the nurse consider a result of oxygen administration at a high concentration? 1- Bronchopulmonary dysplasia 2- Retinopathy of prematurity 3- Diminished erythropoiesis 4- Necrotizing enterocolitis

2

After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? 1- "We'll make sure to cover both of his eyes to protect them." 2- "Our newborn could develop a learning disability later on." 3- "Once the bleeding ceases, there won't be any more worries." 4- "We need to get family members to donate blood for transfusion."

2

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? 1- an infant whose labor began with ruptured membranes 2- an infant who had difficulty establishing respirations at birth 3- an infant who has marked acrocyanosis of his hands and feet 4- an infant whose mother craved chocolate during pregnancy

2

At a prenatal class the nurse describes the various birth weight terms that may be used to describe a newborn at birth. The nurse feels confident learning has has occurred when a participant makes which statement? 1- "Appropriate for gestational age means a newborn is born with a weight that falls in the 10th percentile." 2- "Newborns who are appropriate for gestational age at birth have lower chance of complications than others." 3- "Appropriate for gestational age describes a newborn with a weight over the 90th percentile at birth." 4- "Infants who are larger for gestational age at birth have fewer complications than the other groups."

2

The health care provider is reluctant to provide pain medication to a patient delivering a preterm fetus. What should the nurse explain to the patient as the reason for the preterm fetus being more affected by medication? 1- Affinity of the preterm fetus to fat-soluble drugs 2- Inability of the immature liver to metabolize or inactivate drugs 3- Affinity of the preterm fetus to drugs that are strongly bound to protein 4- Inability of the preterm fetus to use drugs with a molecular weight over 1,000

2

The nurse notes a newborn has a temperature of 97.4oF (36.3oC) on assessment. The nurse takes action to prevent which complication first? 1- Seizure 2- Respiratory distress 3- Cardiovascular distress 4- Hypoglycemia

2

The nurse notes in a newborn's chart that the newborn has been diagnosed with physiologic jaundice. The nurse recognizes that physiologic jaundice is determined by what criteria? 1- The jaundice occurred within the first 24 hours after birth. 2- The bilirubin peaked between days 3 and 5 after birth. 3- The bilirubin level rose 6 mg/dL to 13 mg/dL over the last 24 hours. 4- The conjugated bilirubin is higher than the unconjugated bilirubin.

2

Which finding would the nurse expect to assess in an infant with hypoglycemia? 1- prolonged jaundice 2- limpness or jitteriness 3- pain along the sixth cranial nerve 4- excessive hunger

2

An assessment done in the neonatal intensive care unit reveals a small-for-gestational age newborn. Which findings would the nurse connect with this gestational age variation? Select all that apply. 1- large umbilical cord 2- sunken abdomen 3- decreased amount of breast tissue 4- closed cranial skull sutures 5- poor muscle tone 6- ruddy color

2,3,5

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply. 1- covering the newborn loosely with a blanket 2- encouraging kangaroo care during procedures 3- removing tape gently from the skin 4- increasing the volume on device alarms 5- using cool blankets to soothe the newborn 6- using a colorful mobile for distraction

2,3,6

A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? 1- increased appetite 2- increase in the body temperature 3- lethargy and hypotonia 4- hyperglycemia

3

A client has just given birth at 42 weeks' gestation. What would the nurse expect to find during her assessment of the neonate? 1- a sleepy, lethargic neonate 2- lanugo covering the neonate's body 3- peeling and wrinkling of the neonate's epidermis 4- vernix caseosa covering the neonate's body

3

A mother of a 32-week-gestation neonate is encouraged to perform kangaroo care in the neonatal intensive care unit. What would best correlate with this suggestion? 1- The infant will have more awake periods. 2- There will be a decrease in episodes of apnea. 3- Breastfeeding attempts will be enhanced. 4- The infant will adjust better to the environment.

3

A preterm infant born at 32 weeks gestation is being started on formula. When planning care, the nurse anticipates that which formula type is best? 1- Low iron formula diluted with glucose water. 2- Infant formula with rice cereal. 3- A 24 cal/oz infant formula. 4- A formula with an iron supplement.

3

A preterm infant is experiencing cold stress after birth. For which symptom should the nurse assess to best validate the problem? 1- shivering 2- hyperglycemia 3- apnea 4- metabolic alkalosis

3

A ventilated 33 weeks' gestation newborn in the neonatal intensive care unit (NICU) receives surfactant therapy. Which would the nurse expect to assess as a positive response to this therapy? 1- Glucose is 60 mg/dl (3.3 mmol/L). 2- Heart rate is 60 bpm. 3- Oxygen saturation levels are at 98%. 4- PaCO2 is 35 to 45 mm Hg.

3

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? 1- 100 mg/100 mL whole blood 2- 80 mg/100 mL whole blood 3- 40 mg/100 mL whole blood 4- 30 mg/100 mL whole blood

3

In an infant who has hypothermia, what would be an appropriate nursing diagnosis? 1- Ineffective parental attachment 2- Alteration in nutrition 3- Impaired tissue perfusion 4- Impaired skin integrity

3

In twin-to-twin transfusion syndrome, the arterial circulation of one twin is in communication with the venous circulation of the other twin. One fetus is considered the donor twin, and one becomes the recipient twin. Observation of the recipient twin would most likely show which condition? 1- Anemia 2- Oligohydramnios 3- Polycythemia 4- Small fetus

3

The nurse assesses a large for gestational age infant admitted to the newborn observational unit with the diagnosis of hypoglycemia. What would best correlate with this diagnosis? 1- jaundice 2- positive Moro reflex 3- jitteriness 4- palmar creases

3

The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which factor? 1- inability to clear fluids 2- immature respiratory control center 3- deficiency of surfactant 4- smaller respiratory passages

3

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient? 1- Glucose water 2- 20 calories per ounce 3- 22 calories per ounce 4- Iron supplemented

3

The nurse is responding to an infant crying and notes it is very high pitched and shrill. The nurse predicts this is most likely related to which situation? 1- Normal cry from pain 2- Tired and stress from delivery 3- Neurologic dysfunction 4- Cold stress cry

3

What is a consequence of hypothermia in a newborn? 1- respirations of 46 2- heart rate of 126 3- holds breath 25 seconds 4- skin pink and warm

3

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress? 1- respiratory rate of 50 breaths/minute 2- acrocyanosis 3- asymmetrical chest movement 4- short periods of apnea (less than 15 seconds)

3

The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. 1- Handle the newborn as much as possible. 2- Give the newborn a warm bath immediately. 3- Dress the newborn in ways to preserve warmth. 4- Take the newborn's temperature often. 5- Supply oxygen for the newborn, if necessary. 6- Discourage contact with parents to maintain asepsis.

3,4,5

A nurse assesses a premature newborn and suspects hypothermia based on which of the following? 1- Regular respirations 2- Oxygen saturation of 95% 3- Pink skin 4- Nasal flaring

4

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? 1- "I'll be here to help you all along the way." 2- "What has helped you to deal with stressful situations in the past?" 3- "Let me tell you about what you will see when you visit your baby." 4- "Forget about what's happened in the past, and focus on the now."

4

A premature infant is admitted to the neonatal intensive care unit with respiratory distress syndrome and requires assisted ventilation. The parents asks the nurse, "Why won't our baby breath on its own?" What is the nurse's best response? 1- "Your infant's cardiovascular system is not developed yet in order to sustain respiration." 2- "Most preterm infants require additional oxygen through ventilation to sustain respiration." 3- "Premature infants have a respiratory system that takes time to adjust to extrauterine life." 4- "Your infant cannot sustain respirations yet due to the lack of assistance from surfactant."

4

The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2 oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse anticipate as a result of the birth? 1- fracture of the tibia 2- fracture of the femur 3- fracture of a rib 4- midclavicular fracture

4

The nurse is preparing expressed breast milk mixture for premature twins. What would the nurse do prior to mixing the milk? 1- Talk with the mom 2- Gather equipment 3- Change the infants' diapers 4- Clean milk prep area

4

The parents of a 2-day-old newborn are preparing for discharge from the hospital. Which teaching is most important for the nurse to include regarding sleep? 1- The infant may sleep through the night around 2 months of age. 2- Caregivers need to sleep while the baby is sleeping. 3- Newborns usually sleep for 16 or more hours each day. 4- Place the infant on the back when sleeping.

4

What is the best rationale for trying to decrease the incidence of cold stress in the neonate? 1- The neonate will stabilize its temperature by 8 hours after birth if kept warm and dry. 2- Evaporative heat loss happens when the neonate is not bundled and does not have a hat on. 3- It takes energy to keep warm, so the neonate has to remain in an extended position. 4- If the neonate becomes cold stressed, it will eventually develop respiratory distress.

4