Chapter 34: Nursing Care of the High Risk Newborn, Chapter 36: Hemolytic Disorders & Congenital Abnomalies, Chapter 35: Acquired Problems of the Newborn

9. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process? a. Maternal diabetes b. Maternal folic acid deficiency c. Socioeconomic status d. Maternal use of anticonvulsant

ANS: B All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

When evaluating the preterm infant, the nurse understands that compared with the term infant, what information is important for the nurse to understand? a.Few blood vessels visible through the skin b.More subcutaneous fat c.Well-developed flexor muscles d.Greater surface area in proportion to weight

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

With regard to hemolytic diseases of the newborn, nurses should be aware that: A. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. B. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. C. Exchange transfusions frequently are required in the treatment of hemolytic disorders. D. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

D A. Incorrect: Only the Rh-positive offspring of an Rh-negative mother is at risk. B. Incorrect: ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. C. Incorrect: Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility. D. Correct: An indirect Coombs' test may be performed on the mother a few times during pregnancy. p. 1028

A major nursing intervention for an infant born with myelomeningocele is to: A. Protect the sac from injury B. Prepare the parents for the child's paralysis from the waist down C. Prepare the parents for closure of the sac at around 2 years of age D. Assess for cyanosis

A A. Correct: A major preoperative nursing intervention for a neonate with a myelomeningocele is protection of the protruding sac from injury to prevent its rupture and the resultant risk of CNS infection. B. Incorrect: The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. C. Incorrect: A myelomeningocele should be surgically closed within 24 hours. D. Incorrect: Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury. p. 1036

The abuse of which of the following substances during pregnancy is the leading cause of mental retardation in the United States? A. Alcohol B. Tobacco C. Marijuana D. Heroin

A A. Correct: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. B. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. C. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. D. Incorrect: Alcohol abuse during pregnancy is recognized as one of the leading causes of mental retardation in the United States. p. 1013

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply): A. Amphetamine B. Heroin C. Nicotine D. PCP E. Morphine

A, B, C, D These drugs of abuse are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome. p. 1019

The corrected age of an infant who was born at 25 1/7 weeks and is preparing for discharge 124 days past delivery is ______________.

ANS: 42 6/7 weeks The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. For example, an infant born at 32 weeks of gestation 4 weeks ago would now be considered 36 weeks of age. (32 + 4 = 36).

1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia? a. Hepatic disease b. Hemolytic disorders c. Postmaturity d. Congenital heart defect

ANS: B Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes. DIF: Cognitive Level: Apply REF: p. 882 TOP: Nursing Process: Diagnosis

Which clinical findings would alert the nurse that the neonate is expressing pain? a.Low-pitched crying; tachycardia; eyelids open wide b.Cry face; flaccid limbs; closed mouth c.High-pitched, shrill cry; withdrawal; change in heart rate d.Cry face; eyes squeezed; increase in blood pressure

ANS: D Crying and an increased heart rate are manifestations indicative of pain in the neonate. Typically, infants tightly close their eyes when in pain, not open them wide. In addition, infants may display a rigid posture with the mouth open and may also withdraw limbs and become tachycardic with pain. A high-pitched, shrill cry is associated with genetic or neurologic anomalies.

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.Delayed growth and development b.Ineffective thermoregulation c.Ineffective infant feeding pattern d.Risk for infection

ANS: D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: A. Congenital infection progresses slower than nosocomial infection. B. Nosocomial infection can be prevented by effective handwashing; early onset cannot. C. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. D. The clinical sign of a rapid, high fever makes infection easier to diagnose.

B A. Incorrect: Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. B. Correct: Handwashing is an effective preventative measure for late onset (nosocomial) infections, because these infections come from the environment around the infant. Early onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. C. Incorrect: Infection occurs about twice as often in boys and results in higher mortality. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. D. Incorrect: Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult. Congenital (early onset) infections progress more rapidly than nosocomial (late onset) infections. p. 1002

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?" The nurse responds: A. "It is an eye ointment to help your baby see you better." B. "It is to protect your baby from contracting herpes from your vaginal tract." C. "Erythromycin is given prophylactically to prevent a gonorrheal infection." D. "This medicine will protect your baby's eyes from drying out over the next few days."

C A. Incorrect: Erythromycin has no bearing on enhancing vision. B. Incorrect: Erythromycin is used to prevent an infection caused by gonorrhea, not herpes. C. Correct: With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. D. Incorrect: Erythromycin is given to prevent infection, not for lubrication. p. 1004

____________________ is a condition in which the ventricles of the brain are enlarged as a result of an imbalance between the production and absorption of the CSF. An infant with this condition initially has a bulging anterior fontanel and a head circumference that increases at an abnormal rate, resulting from the increase in CSF pressure.

Hydrocephalus p. 1037

2. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.) a. Phenylketonuria (PKU) b. Galactosemia c. Hemoglobinopathy d. Cytomegalovirus (CMV) e. Rubella

NS: A, B, C PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus. DIF: Cognitive Level: Understand REF: p. 904 TOP: Nursing Process: Planning

____________________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth.

Methadone p. 1015

All infants born to mothers with diabetes are at some risk for complications. True or false?

True The degree of risk is influenced by the severity and duration of maternal disease. p. 996

Which TORCH infection could be contracted by the infant because the mother owned a cat? A. Toxoplasmosis B. Varicella zoster (chicken pox) C. Parvovirus B19 D. Rubella

A A. Correct: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. B. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. C. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. D. Incorrect: Cats that eat birds infected with the Toxoplasma gondii protozoan excrete infective oocysts. Humans (including pregnant women) can become infected if they fail to wash their hands after cleaning the litter box. The infection is passed through the placenta. p. 1004

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: A. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. B. Erb palsy is damage to the lower plexus. C. Parents of children with brachial palsy are taught to pick up the child from under the axillae. D. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

A A. Correct: However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. B. Incorrect: Erb palsy is damage to the upper plexus and is less serious than brachial palsy. C. Incorrect: Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. D. Incorrect: Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start. p. 994

Which infant would be more likely to have Rh incompatibility? A. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor B. Infant who is Rh negative and whose mother is Rh negative C. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor D. Infant who is Rh positive and whose mother is Rh positive

A A. Correct: If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. B. Incorrect: Only the Rh-positive offspring of an Rh-negative mother are at risk. C. Incorrect: If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative. D. Incorrect: Only the Rh-positive offspring of an Rh-negative mother are at risk. p. 1026

A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth, the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: A. Are benign if they disappear within 48 hours of birth B. Result from increased blood volume C. Should always be further investigated D. Usually occur with forceps delivery

A A. Correct: Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. B. Incorrect: Petechiae may result from decreased platelet formation. C. Incorrect: In this situation, the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. D. Incorrect: Petechiae usually occur with a breech presentation vaginal birth. p. 993

A careful review of the literature on the various recreational and illicit drugs reveals that: A. More, longer term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. B. Heroin and methadone cross the placenta; marijuana, cocaine, and PCP do not. C. Mothers should get off heroin (detox) any time they can during pregnancy. D. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

A A. Correct: Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More, longer range studies are needed. B. Incorrect: Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. C. Incorrect: Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later, in pregnancy. D. Incorrect: Methadone withdrawal is more severe and more prolonged than heroin withdrawal. p. 1015

With regard to congenital anomalies of the cardiovascular and respiratory systems, nurses should be aware that: A. Cardiac disease may be manifested by respiratory signs and symptoms. B. Screening for congenital anomalies of the respiratory system need only be done for infants having respiratory distress. C. Choanal atresia can be corrected by a suction catheter. D. Congenital diaphragmatic hernias are diagnosed and treated after birth.

A A. Correct: The cardiac and respiratory systems function together. B. Incorrect: Screening for congenital respiratory system anomalies is necessary even for infants who appear normal at birth. C. Incorrect: Choanal atresia requires emergency surgery. D. Incorrect: Congenital diaphragmatic hernias are discovered prenatally on ultrasound. p. 1033

A pregnant woman presents 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? A. Alcohol B. Cocaine C. Heroin D. Marijuana

A A. Correct: The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. B. Incorrect: Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. C. Incorrect: Heroin use in pregnancy frequently results in IUGR. The infant may have a shrill cry and sleep cycle disturbances and may present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. D. Incorrect: Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy. p. 1013

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman questions the nurse as to why, the nurse's best response would be: A. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." B. "You and your baby can be exposed to the HIV virus in your cats' feces." C. "It's just gross. You should make your husband clean the litter boxes." D. "Cat feces are known to carry E. coli, which can cause a severe infection in both you and your baby."

A A. Correct: Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. B. Incorrect: HIV is not transmitted by cats. C. Incorrect: Although this may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. D. Incorrect: E. coli is found in normal human fecal flora. It is not transmitted by cats. p. 1004

The most important nursing action in preventing neonatal infection is: A. Good handwashing B. Isolation of infected infants C. Separate gown technique D. Standard Precautions

A A. Correct: Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. B. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. C. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. D. Incorrect: Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing. p. 1002

Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Such factors include (choose all that apply): A. Alcohol consumption B. Female gender C. Use of some antiepileptics D. Maternal cigarette smoking E. Antibiotic use in pregnancy

A, C, D Factors that are associated with the potential development of cleft lip or palate are maternal infections, radiation exposure, corticosteroids, anticonvulsants, male gender, Native American or Asian descent, and smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate. p. 1039

3. What is the highest priority nursing intervention for an infant born with myelomeningocele? a. Protect the sac from injury. b. Prepare the parents for the childs paralysis from the waist down. c. Prepare the parents for closure of the sac when the child is approximately 2 years of age. d. Assess for cyanosis.

ANS: A A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

2. Which infant is most likely to express Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor b. Infant who is Rh negative and a mother who is Rh negative c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor d. Infant who is Rh positive and a mother who is Rh positive

ANS: A If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive. DIF: Cognitive Level: Understand REF: p. 883 TOP: Nursing Process: Planning

An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. What is the nurse's most appropriate action at this time? a.Listening to breath sounds, and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician b.Continuing to observe and making no changes until the saturations are 75% c.Continuing with the admission process to ensure that a thorough assessment is completed d.Notifying the parents that their infant is not doing well

ANS: A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygen saturation should be maintained above 92%, and oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determining fetal status.

A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician's office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. What should the nurse caring for the infant after birth anticipate? a.Meconium aspiration, hypoglycemia, and dry, cracked skin b.Excessive vernix caseosa covering the skin, lethargy, and RDS c.Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat d.Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa, lethargy, and RDS are consistent with a very premature infant. The skin may be meconium stained, but the infant will most likely have long hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

10. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn? a. Mild cases involve a single surgical procedure. b. Infant should be circumcised. c. Repair is performed as soon as possible after birth. d. No correlation exists between hypospadia and testicular cancer.

ANS: A Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation. DIF: Cognitive Level: Apply REF: p. 902

During the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. In this situation, which condition should the nurse suspect? a.Hypovolemia and/or shock b.Excessively cool environment c.Central nervous system (CNS) injury d.Pending renal failure

ANS: A Other symptoms might include hypotension, prolonged capillary refill, and tachycardia, followed by bradycardia. Intervention is necessary. Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat. CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities. Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to be delivered with respiratory distress.

A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents? a."Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." b."The drug keeps your baby from requiring too much sedation." c."Surfactant is used to reduce episodes of periodic apnea." d."Your baby needs this medication to fight a possible respiratory tract infection."

ANS: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With the administration of an artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate the production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

6. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct? a. Cardiac disease may demonstrate signs and symptoms of respiratory illness. b. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress. c. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage. d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

ANS: A The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

What is the most important nursing action in preventing neonatal infection? a.Good handwashing b.Isolation of infected infants c.Separate gown technique d.Standard Precautions

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

3. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.) a. Positive Ortolani click b. Unequal gluteal folds c. Negative Babinski sign d. Trendelenburg sign e. Telescoping of the affected limb

ANS: A, B A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH. DIF: Cognitive Level: Apply REF: p. 900 TOP: Nursing Process: Planning

Which risk factors are associated with NEC? (Select all that apply.) a.Polycythemia b.Anemia c.Congenital heart disease d.Bronchopulmonary dysphasia e.Retinopathy

ANS: A, B, C Risk factors for NEC include asphyxia, RDS, umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection. Bronchopulmonary dysphasia and retinopathy are not associated with NEC

1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.) a. Alcohol consumption b. Female gender c. Use of some anticonvulsant medications d. Maternal cigarette smoking e. Antibiotic use in pregnancy

ANS: A, C, D Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate. DIF: Cognitive Level: Understand REF: p. 895 TOP: Nursing Process: Planning

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 b.Cardiac distress c.Hyperbilirubinemia d.Sepsis e.Hyperglycemia

ANS: A, C, D Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is adequately feeding before discharge and that parents are taught the signs and symptoms of these complications. Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and inconsolably cries until held. What is the correct nursing diagnosis beginning with "ineffective coping, related to"? a.Severe immaturity b.Environmental stress c.Physiologic distress d.Behavioral responses

ANS: B "Ineffective coping, related to environmental stress" is the most appropriate nursing diagnosis for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must closely monitor the environment for sources of overstimulation. Although the infant may be severely immature in this case, she is responding to environmental stress. Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system. The infant's behavioral response to the environmental stress is crying. The appropriate nursing diagnosis reflects the cause of this response.

NEC is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. Which intervention has the greatest effect on lowering the risk of NEC? a.Early enteral feedings b.Breastfeeding c.Exchange transfusion d.Prophylactic probiotics

ANS: B A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances the maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohn disease, and celiac illness. The NICU nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

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.Tell the parents that their child will not catch up until approximately age 10 years (for girls) to age 12 years (for boys). b.Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age. c.Know that the greatest catch-up period is between 9 and 15 months postconceptual age. d.Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth.

ANS: B Corrections are made with a formula that adds gestational age and postnatal age. Whether a girl or boy, the infant experiences catch-up body growth during the first 2 to 3 years of life. Maximum catch-up growth occurs between 36 and 40 weeks of postconceptual age. The head is the first to experience catch-up growth.

With regard to infants who are SGA and intrauterine growth restriction (IUGR), the nurse should be aware of which information? a.In the first trimester, diseases or abnormalities result in asymmetric IUGR. b.Infants with asymmetric IUGR have the potential for normal growth and development. c.In asymmetric IUGR, weight is slightly larger than SGA, whereas length and head circumference are somewhat less than SGA. d.Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; infants who are SGA have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? a.NEC b.ROP c.BPD d.Intraventricular hemorrhage (IVH)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from the rupture of the fragile blood vessels in the ventricles of the brain and is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. What are generalized signs and symptoms of this condition? a.Hypertonia, tachycardia, and metabolic alkalosis b.Abdominal distention, temperature instability, and grossly bloody stools c.Hypertension, absence of apnea, and ruddy skin color d.Scaphoid abdomen, no residual with feedings, and increased urinary output

ANS: B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

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? a.Wait quietly at the newborn's bedside until the parents come closer. b.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. c.Leave the parents at the bedside while they are visiting so that they have some privacy. d.Tell the parents only about the newborn's physical condition and caution them to avoid touching their baby.

ANS: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infant's condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infant's appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents to avoid touching their baby is inappropriate and unhelpful.

11. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching? a. Apply lotion or powder to minimize skin irritation. b. Remove the harness several times a day to prevent contractures. c. Return to the clinic every 1 to 2 weeks. d. Place a diaper over the harness, preferably using an absorbent disposable diaper.

ANS: C Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

An infant is to receive gastrostomy feedings. Which intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise? a.Rapid bolusing of the entire amount in 15 minutes b.Warm cloths to the abdomen for the first 10 minutes c.Slow, small, warm bolus feedings over 30 minutes d.Cold, medium bolus feedings over 20 minutes

ANS: C Feedings by gravity are slowly accomplished over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Applying warm cloths to the abdomen would not be appropriate because the environment is not thermoregulated. In addition, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

With regard to an eventual discharge of the high-risk newborn or the transfer of the newborn to a different facility, which information is essential to provide to the parents? a.Infants stay in the NICU until they are ready to go home. b.Once discharged to go home, the high-risk infant should be treated like any healthy term newborn. c.Parents of high-risk infants need special support and detailed contact information. d.If a high-risk infant and mother need to be transferred to a specialized regional center, then waiting until after the birth and until the infant is stabilized is best.

ANS: C High-risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high-risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Simply because high-risk infants are eventually discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant's gestational age. Which statement regarding this intervention is most appropriate? a.Kangaroo care was adopted from classical British nursing traditions. b.This intervention helps infants with motor and CNS impairments. c.Kangaroo care helps infants interact directly with their parents and enhances their temperature regulation. d.This intervention gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parent's bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits. Kangaroo care was established in Bogota, Colombia, assists the infant in maintaining an organized state, and decreases pain perception during heelsticks. Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

For clinical purposes, the most accurate definition of preterm and postterm infants is defined as what? a.Preterm: Before 34 weeks of gestation if the infant is appropriate for gestational age (AGA); before 37 weeks if the infant is small for gestational age (SGA) b.Postterm: After 40 weeks of gestation if the infant is large for gestational age (LGA); beyond 42 weeks if the infant is AGA c.Preterm: Before 37 weeks of gestation and postterm beyond 42 weeks of gestation; no matter the size for gestational age at birth d.Preterm: Before 38 to 40 weeks of gestation if the infant is SGA; postterm, beyond 40 to 42 weeks gestation if the infant is LGA

ANS: C Preterm and postterm are strictly measures of time—before 37 weeks and beyond 42 weeks, respectively—regardless of the size for gestational age.

12. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

ANS: C Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention. DIF: Cognitive Level: Understand REF: p. 901 TOP: Nursing Process: Planning

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? a.Decreased respiratory rate b.Bradycardia, followed by an increased heart rate c.Mottled skin with acrocyanosis d.Increased physical activity

ANS: C The infant has minimal-to-no fat stores. During times of cold stress, the skin becomes mottled and acrocyanosis develops, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and to respond quickly if signs and symptoms of cold stress occur. The respiratory rate increases, followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant who is experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, increased physical activity is the natural response to heat loss. However, in a term infant who is experiencing respiratory distress or in a preterm infant, physical activity is decreased.

An infant is being discharged from the NICU after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including RDS, mild bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP), requiring surgical treatment. During discharge teaching, the infant's mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. What is the nurse's most appropriate response? a."Your baby will develop exactly like your first child." b."Your baby does not appear to have any problems at this time." c."Your baby will need to be corrected for prematurity." d."Your baby will need to be followed very closely."

ANS: C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infant's responses are accordingly evaluated against the norm expected for the corrected age of the infant. The baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing. Although predicting with complete accuracy the growth and development potential of each preterm infant is impossible, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. Development needs to be evaluated over time. The growth and developmental milestones are corrected for gestational age until the child is approximately years old.

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? a.67 mm Hg b.89 mm Hg c.45 mm Hg d.73 mm Hg

ANS: C The laboratory value of PaO2 of 45 mm Hg is below the range for a normal neonate and indicates hypoxia in this infant. The normal range for PaO2 is 60 to 80 mm Hg; therefore, PaO2 levels of 67 and 73 mm Hg fall within the normal range, and a PaO2 of 89 mm Hg is higher than the normal range.

13. Which statement regarding hemolytic diseases of the newborn is most accurate? a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions are frequently required in the treatment of hemolytic disorders. d. The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.

ANS: D An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

7. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform? a. Be able to perform the Ortolani and Barlow tests. b. Teach double or triple diapering for added support. c. Explain to the parents the need for serial casting. d. Carefully monitor infants for DDH at follow-up visits.

ANS: D Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH. DIF: Cognitive Level: Apply REF: p. 899 TOP: Nursing Process: Planning

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? a.Suffering from sleep or wakeful apnea b. Experiencing severe swings in blood pressure c.Trying to maintain a neutral thermal environment d.Breathing in a respiratory pattern common to premature infants

ANS: D Breathing in a respiratory pattern is called periodic breathing and is common to premature infants. This pattern may still require nursing intervention of oxygen and/or ventilation. Apnea is the cessation of respirations for 20 seconds or longer and should not be confused with periodic breathing.

When providing an infant with a gavage feeding, which infant assessment should be documented each time? a.Abdominal circumference after the feeding b.Heart rate and respirations before feeding c.Suck and swallow coordination d.Response to the feeding

ANS: D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infant's response to the procedure. Abdominal circumference is not measured after a gavage feeding. Although vital signs may be obtained before feeding, the infant's response to the feeding is more important. Similarly, some older infants may be learning to suck; the most important factor to document would still be the infant's response to the feeding, including the attempts to suck.

4. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia? a. Risk for impaired parent-infant attachment b. Imbalanced nutrition, related to less than body requirements c. Risk for infection d. Impaired gas exchange

ANS: D Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

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? a."Parents are not allowed to hold their infants who are dependent on oxygen." b."You may only hold your baby's hand during the feeding." c."Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you should hold the baby." d."You may hold your baby during the feeding."

ANS: D Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. Allowing the parents to hold their baby is the most appropriate response by the nurse. Parental interaction by holding should be encouraged during gavage feedings; nasal cannula oxygen therapy allows for easy feedings and psychosocial interactions. The parent can swaddle the infant or provide kangaroo care while gavage feeding their infant. Both swaddling and kangaroo care during feedings provide positive interactions for the infant and help the infant associate feedings with positive interactions.

8. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy? a. High-pitched cry b. Severe muscle spasms (opisthotonos) c. Fever and seizures d. Hypotonia, lethargy, and poor suck

ANS: D The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

The most common cause of pathologic hyperbilirubinemia is: A. Hepatic disease B. Hemolytic disorders in the newborn C. Postmaturity D. Congenital heart defect

B A. Incorrect: Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. B. Correct: Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. C. Incorrect: Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. D. Incorrect: Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates. p. 1025

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: A. A newborn's skull is still forming and fractures fairly easily. B. Unless a blood vessel is involved, linear skull fractures heal without special treatment. C. Clavicle fractures often need to be set with an inserted pin for stability. D. Other than the skull, the most common skeletal injuries are to leg bones.

B A. Incorrect: Because the newborn skull is flexible, considerable force is required to fracture it. B. Correct: About 70% of neonatal skull fractures are linear. C. Incorrect: Clavicle fractures need no special treatment. D. Incorrect: The clavicle is the bone most often fractured during birth. p. 993

An infant diagnosed with erythroblastosis fetalis would characteristically exhibit: A. Edema B. Immature red blood cells C. Enlargement of the heart D. Ascites

B A. Incorrect: Edema would occur with hydrops fetalis, a more severe form of erythroblastosis fetalis. B. Correct: Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. C. Incorrect: The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces. D. Incorrect: The infant with hydrops fetalis displays signs of ascites. p. 1026

When planning care for an infant with a fractured clavicle, the nurse should recognize that in addition to gentle handling: A. Prone positioning will facilitate bone alignment. B. No special treatment is necessary. C. Parents should be taught range of motion exercises. D. The shoulder should be immobilized with a splint.

B A. Incorrect: Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. B. Correct: Fractures in newborns generally heal rapidly. Except for gentle handling, no accepted treatment for a fractured clavicle exists. C. Incorrect: Movement should be limited, and the infant should be gently handled. It is not necessary to perform range of motion exercises on the infant. D. Incorrect: A fractured clavicle does not require immobilization with a splint. p. 994

With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: A. Infants born to addicted mothers are also addicted. B. Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties. C. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. D. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

B A. Incorrect: Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." B. Correct: Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. C. Incorrect: The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. D. Incorrect: Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure. p. 1017

With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that: A. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. B. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. C. In many infants, signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. D. Spinal cord injuries almost always result from forceps-assisted deliveries.

C A. Incorrect: ICH as a result of birth trauma is more likely to occur in the full-term, large infant. B. Incorrect: Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants, it is a result of hypoxia. C. Correct: Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on CT scan might reveal a hemorrhage. D. Incorrect: Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation. p. 995

Infants of mothers with diabetes are at higher risk for developing: A. Anemia B. Hyponatremia C. Respiratory distress syndrome D. Sepsis

C A. Incorrect: Infants of diabetic mothers (IDMs) are not at risk for anemia. They are at risk for polycythemia. B. Incorrect: IDMs are not at risk for hyponatremia. They are at risk for hypocalcemia and hypomagnesemia. C. Correct: IDMs are at risk for macrosomia, birth trauma, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. D. Incorrect: IDMs are not at risk for sepsis. p. 996

With regard to congenital abnormalities involving the central nervous system, nurses should be aware that: A. Although the death rate from most congenital anomalies has decreased over the past several decades, neural tube defects (NTDs) have gone up in the last few years. B. Spina bifida cystica usually is asymptomatic and may not be diagnosed unless associated problems are present. C. A major preoperative nursing intervention for a neonate with myelomeningocele is to protect the protruding sac from injury. D. Microcephaly can be corrected with timely surgery.

C A. Incorrect: Most congenital anomalies have had a stable neonatal death rate since the 1930s; NTDs are declining because of mandatory food fortification with folic acid. B. Incorrect: Spina bifida occulta often is asymptomatic; spina bifida cystica has a visible sac. C. Correct: The nurse protects the infant by laying the baby on his or her side. D. Incorrect: Microcephaly is a tiny head; there is no treatment. p. 1036

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. The first step in the provision of this care is: A. Pharmacologic treatment B. Reduction of environmental stimuli C. Neonatal abstinence syndrome scoring D. Adequate nutrition and maintenance of fluid and electrolyte balance

C A. Incorrect: Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. B. Incorrect: Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system disturbances. C. Correct: Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay and the treatment plan is adjusted accordingly. D. Incorrect: Poor feeding is one of the GI symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage. pp. 1017-1019

A plan of care for an infant experiencing symptoms of drug withdrawal should include: A. Administering chloral hydrate for sedation B. Feeding every 4 to 6 hours to allow extra rest C. Swaddling the infant snugly and holding the baby tightly D. Playing soft music during feeding

C A. Incorrect: Phenobarbital or diazepam may be administered to decrease CNS irritability. B. Incorrect: The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. C. Correct: The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. D. Incorrect: The infant should not be stimulated (such as with music), because this will increase activity and potentially increase CNS irritability. p. 1017

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. B. Two-thirds of newborns with fetal alcohol syndrome (FAS) are boys. C. Alcohol-related neurodevelopmental disorders (ARND) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. D. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

C A. Incorrect: The pattern of growth restriction persists after birth. B. Incorrect: Two-thirds of newborns with FAS are girls. C. Correct: Some learning problems do not become evident until the child is at school. D. Incorrect: Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal. p. 1013

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 showing signs of: A. Gonorrhea B. Herpes simplex virus infection C. Congenital syphilis D. HIV

C A. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. B. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. C. Correct: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. D. Incorrect: The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities. p. 1005

An infant was born 2 hours ago at 37 weeks of gestation, weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: A. Birth injury B. Hypocalcemia C. Hypoglycemia D. Seizures

C A. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. B. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. C. Correct: Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis. D. Incorrect: This infant is macrosomic and at risk for hypoglycemia. The description is indicative of a macrocosmic infant. The tremors are jitteriness that is associated with hypoglycemia. p. 998

The priority nursing diagnosis for a newborn diagnosed with a diaphragmatic hernia would be: A. Risk for impaired parent-infant attachment B. Imbalanced nutrition: less than body requirements C. Risk for infection D. Impaired gas exchange

D A. Incorrect: Although this issue may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. B. Incorrect: Although this issue may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. C. Incorrect: Although this issue may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. D. Correct: Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. p. 1038

What bacterial infection is definitely decreasing because of effective drug treatment? A. Escherichia coli infection B. Tuberculosis C. Candidiasis D. Group B streptococcal infection

D A. Incorrect: E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Group B streptococcus has been beaten back by penicillin. B. Incorrect: Tuberculosis is increasing in the United States and in Canada. Group B streptococcus has been beaten back by penicillin. C. Incorrect: Candidiasis is a fairly benign fungal infection. Group B streptococcus has been beaten back by penicillin. D. Correct: Penicillin has significantly decreased the incidence of group B streptococcal infection. pp. 1010-1011

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 pounds, 6 ounces). The nurse's most appropriate action is to: A. Leave the infant in the room with the mother B. Take the infant immediately to the nursery C. Perform a gestational age assessment to determine whether the infant is large for gestational age D. Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia

D A. Incorrect: Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. This can be achieved in the mother's room with nursing interventions, depending on the condition of the fetus. It may be more appropriate for observation to occur in the nursery. B. Incorrect: Macrosomic infants are at high risk for hypoglycemia after birth and need to be observed closely. Observation may occur in the nursery or in the mother's room, depending on the condition of the fetus. C. Incorrect: Regardless of gestational age, this infant is macrosomic. Macrosomia is defined as fetal weight over 4000 g. Hypoglycemia affects many macrosomic infants. Blood glucose levels should be observed closely. D. Correct: This infant is macrosomic (over 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. p. 997

What finding supports the diagnosis of pathologic jaundice? A. Serum bilirubin concentrations greater than 2 mg/dl in cord blood B. Serum bilirubin levels increasing more than 1 mg/dl in 24 hours C. Serum bilirubin levels greater than 10 mg/dl in a full-term newborn D. Clinical jaundice evident within 24 hours of birth

D A. Incorrect: Serum bilirubin concentrations greater than 4 mg/dl in cord blood would support a diagnosis of pathologic jaundice. B. Incorrect: Total serum bilirubin levels that increase by more than 5 mg/dl in 24 hours would support a diagnosis of pathologic jaundice. C. Incorrect: A serum bilirubin level in a preterm newborn that exceeds 10 mg/dl would support a diagnosis of pathologic jaundice. D. Correct: Clinical jaundice evident within 24 hours of birth would support a diagnosis of pathologic jaundice. p. 1025

As a home care nurse, you are visiting a 5-day-old male infant for a scheduled follow-up appointment to ensure that he is responding to home phototherapy for treatment of jaundice. Based on the diagnosis of hyperbilirubinemia, you are aware that the development of acute bilirubin encephalopathy is a risk for this infant. This disease process occurs after the bilirubin level has peaked. After completing a thorough assessment and obtaining a history from the parents, you recognize that this infant is in the first phase of encephalopathy when he exhibits: A. A high-pitched cry B. Severe muscle spasms (opisthotonos) C. Fever and seizures D. Hypotonia, lethargy, and poor suck

D A. Incorrect: Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase. Medical attention is necessary immediately. B. Incorrect: Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase. Medical attention is necessary immediately. C. Incorrect: Symptoms may progress from the subtle indications of the first phase to fever and seizures in as little as 24 hours. Only about half of these infants survive and will have permanent sequelae including auditory deficiencies, intellectual deficits, and movement abnormalities. D. Correct: The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and depressed or absent Moro reflex. pp. 999, 1027, 1028

When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should: A. Be able to perform the Ortolani and Barlow tests B. Teach double or triple diapering for added support C. Explain to the parents the need for serial casting D. Carefully monitor infants for DDH at follow-up visits

D A. Incorrect: The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. B. Incorrect: Double or triple diapering is not recommended, because it promotes hip extension, thus worsening the problem. C. Incorrect: Serial casting is done for clubfeet, not DDH. D. Correct: Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. p. 1044

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 before birth is 180 beats/min 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, the cause of this newborn's distress is most likely to be: A. Hypoglycemia B. Phrenic nerve injury C. Respiratory distress syndrome D. Sepsis

D A. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. B. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. C. Incorrect: The prolonged rupture of membranes is the most indicative clinical cue to this infant's condition. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis. D. Correct: The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. p. 1001

In order to provide comprehensive newborn care, the nurse should understand that kernicterus occurs if: A. The kidney excretes bilirubin. B. Bilirubin collects in the liver. C. Bilirubin deposits are concentrated in the cardiac muscle. D. Bilirubin deposits are in the brain.

D A. Incorrect: The term kernicterus is synonymous with bilirubin encephalopathy. It is caused by the deposition of bilirubin in the brain. B. Incorrect: The term kernicterus is synonymous with bilirubin encephalopathy. It is caused by the deposition of bilirubin in the brain. C. Incorrect: The term kernicterus is synonymous with bilirubin encephalopathy. It is caused by the deposition of bilirubin in the brain. D. Correct: Kernicterus describes the chronic and permanent results of bilirubin toxicity. p. 1025

With smaller families and increased genetic screening, many couples have come to expect a perfect baby. Mothers tend to have the greatest and most difficult adjustment to a child with unexpected disabilities. A metaanalysis of families in the United States and Canada has revealed that there are four developmental milestones that the mothers of "differently abled" children need to achieve. At a follow-up office visit, the nurse knows that she needs to listen carefully to the mother's cues in order to determine how well she is coping. Which phase has this mother reached when she states, "Don't you agree that my daughter has made a lot of progress since her last visit?" A. Becoming the mother of a disabled child B. Learning a new maternal role C. Realizing that daily life will never be the same D. Acceptance/denial

D A. Incorrect: This phase includes solving the puzzle of what is wrong, diminished interest in the mothering role, grief for loss of an ideal, learning to trust the health care system, and looking for blame. B. Incorrect: In the second phase the mother has to come to grips with the role of caregiver burden, finding support, protecting the child against prejudice, and the intensity of mothering a disabled child. C. Incorrect: This third phase includes adaptation of routine, control, change, mastering uncertainty, grief for lost choices, and identifying realistic goals. D. Correct: This is the fourth phase and is evidenced by the mother redefining normal, looking for progress, hope, strength, and life enrichment. The paradox is accepting the child for who she is, while never giving up hope. p. 1032

HIV may be perinatally transmitted: A. Only in the third trimester from the maternal circulation B. By a needlestick injury at birth from unsterile instruments C. Only through the ingestion of amniotic fluid D. Through the ingestion of breast milk from an infected mother

D A. Incorrect: Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases. B. Incorrect: Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally. C. Incorrect: Transmission of HIV may occur through the placenta from the mother to the fetus or through breast milk postnatally. D. Correct: Postnatal transmission of HIV through breastfeeding may occur. p. 1006

5. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis? a. Edema b. Immature red blood cells c. Enlargement of the heart d. Ascites

Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.