Exam #5

After teaching the parents of a newborn with retinopathy of prematurity (ROP) about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "Can we schedule follow-up vision screenings with the pediatric ophthalmologist now?" B) "We can fix the problem with surgery." C) "We'll make sure to administer eye drops each day for the next few weeks." D) "I'm sure the baby will grow out of it."

A) "Can we schedule follow-up vision screenings with the pediatric ophthalmologist now?" Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination.

The nurse is weighing a newborn and documents AGA (appropriate for gestational age) on the newborn record. Which weight percentile is anticipated? A) 20th B) 9th C) 5th D) 95th

A) 20th Appropriate for gestation age infants fall between the 10th and 90th percentile for weight.

In pulse oximetry for a newborn, what is the percentage of oxygen that is considered abnormal? A) 75% B) 95% C) 85% D) 87%

A) 75%

A baby is born with congenital rubella. Which of the following would be an important assessment to be made before hospital discharge? A) Hearing assessment B) Assessment for cerebral palsy C) Skin assessment for hemangiomas D) Intravenous pyelogram for kidney function

A) Hearing assessment Congenital rubella (German measles) is strongly associated with hearing disorders.

What type of test should be performed to monitor an infant of a substance abuse? To monitor the infant's mother? A) NAS B) CBC C) Ballard D) PKU

A) NAS The NAS or neonatal abstinence score should be performed on the infant with each assessment. A score above 7 requires intervention.

The neonatal intensive care nurse admits an infant of a diabetic mother to the unit with symptoms of respiratory distress. The infant is jaundiced with a ruddy skin color. Which action would be a priority? A) Prepare for repeat hematocit levels q12h. B) Continue to monitor blood glucose levels q6h. C) Review maternal history for bleeding disorders. D) Prepare for continued positive airway pressure.

A) Prepare for repeat hematocit levels q12h. Newborn infants of diabetic mothers (IDM) are at risk for polycythemia. A priority for the nurse is to observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy) and monitor blood results with hematocrit levels repeated every 12 hours. Blood glucose levels would be monitored more often than Q6H. Bleeding disorders do not correlate with the situation. CPAP may be needed but not as the priority.

The neonatal intensive care nurse is assessing a new admission and suspects the newborn to have meconium aspiration syndrome. Which assessment finding would correlate with the nurse's suspicion? A) a barrel-shaped chest with an increased anterior-posterior chest diameter B) a sunken chest with a decreased anterior-posterior chest diameter C) PaO2 90 mm/Hg, PaCO2 40 mm/Hg, O2 saturation 96% D) heart rate 110 bpm, respiratory rate 56 breaths/minute, acrocynosis present

A) a barrel-shaped chest with an increased anterior-posterior chest diameter Observe the newborn with MAS for a barrel-shaped chest with an increased anterior-posterior chest diameter, prolonged tachypnea, progression of respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Arterial blood gas analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. The arterial blood gas values listed are normal as well as the vital signs. Acrocynosis is a normal expectation of a newborn immediately after birth.

In an effort to decrease complications for the infant right after birth, the nurse would expect to administer which medication for prophylaxis of potential eye conditions? A) tetracycline ophthalmic ointment B) silver nitrate solution C) vitamin K D) gentamicin ophthalmic ointment

A) tetracycline ophthalmic ointment Erythromycin or tetracycline ophthalmic ointment is the agent of choice for newborn eye prophylaxis. Silver nitrate solution was once used for eye prophylaxis, but it is no longer used because it has little efficacy in preventing chlamydial eye disease. Vitamin K is used to promote blood clotting in the newborn. Gentamicin is not used for newborn eye prophylaxis.

A cesarean birth results in an 11-pound (5-kg) infant. The nurse assesses the infant for which complication? A) transient lung fluid B) diaphragmatic paralysis C) broken clavicle D) serum glucose 45 mg/dL (2.50 mmol/L)

A) transient lung fluid A large for gestational age (LGA) infant born by cesarean is at risk for transient lung fluid. Broken clavicle and diaphragmatic paralysis are birth injuries associated with a vaginal birth of an LGA infant. All LGA infants are at risk for a serum glucose 45 mg/dL (2.50 mmol/L).

What is a classic sign of neonatal respiratory distress syndrome? Select all that apply. expiratory grunting nasal flaring retractions tachypnea bradypnea

ALL but bradypnea

The nurse assesses an infant's body temperature as 36.2°C during an extended resuscitation at birth. What consequence of a temperature of 36.2°C would the nurse anticipate? Select all that apply. Fetal shunts remain open. Anaerobic glycolysis occurs. Pulmonary perfusion decreases. Metabolism increases. Immune function decreases.

ALL but immune function decreases

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? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about giving birth to your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

B) "We still need to monitor him closely for problems." A baby born at 36 weeks' gestation is considered a late preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the birth demonstrates caring but does not address the woman's lack of understanding about her newborn.

A newborn has ambiguous genitalia. The parents are quite emotional and do not know what to do, or if they should raise the child as a boy or girl. What is the best advice for the nurse to offer at this time? A) "It is important to make the decision based on your desire to have either a girl or boy." B) "It is not that important right now. You have lots of time to make that decision." C) "Research shows that it is best for anatomical structure to determine the sex of rearing." D) "Surgery can be done to correct anomalies, so that's the important thing to consider."

C) "Research shows that it is best for anatomical structure to determine the sex of rearing." Regardless of the cause, it is important to establish the genetic sex and the sex of rearing as early as possible so that surgical correction of the anomalies may occur before the child begins to function in a sex-related social role. Authorities believe that the newborn's anatomical structure, rather than the genetic sex, should determine the sex of rearing. Parents may feel guilt, anxiety, and confusion about their child's condition and need understanding and support to help them cope with this emergency.

A preterm infant is receiving oxygen to maintain respiratory status. When assessing this patient, at which level should the nurse maintain oxygenation to prevent retinopathy of prematurity? A) 40 mmHg B) 50 mmHg C) 100 mmHg D) 180 mmHg

C) 100 mmHg When blood Po2 levels rise to higher than 100 mmHg, the risk of retinopathy of prematurity increases. All preterm infants who receive oxygen must have blood oxygen levels monitored by pulse oximeter, transcutaneous oxygen saturation, or blood gas monitoring so the blood Po2 level can be kept within normal limits. Oxygenation at 40 mmHg or 50 mmHg is not sufficient for the infant. Oxygenation at 180 mmHg is too high and can predispose the infant to develop retinopathy of oxygenation.

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient? A) Glucose water B) 20 calories per ounce C) 22 calories per ounce D) Iron supplemented

C) 22 calories per ounce The caloric concentration of formulas used for preterm infants is usually 22 calories per ounce compared with 20 calories per ounce for a term baby. Glucose water will not provide the infant with adequate calories. Iron supplementation will depend on laboratory values.

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? A) Anemia B) Oligohydramnios C) Polycythemia D) Small fetus

C) Polycthemia The recipient twin in twin-to-twin transfusion syndrome (also known as twin-twin transfusion syndrome) is transfused by the other twin. The recipient twin then becomes polycythemic and commonly has heart failure due to circulatory overload. The donor twin becomes anemic. The recipient twin has polyhydramnios, not oligohydramnios. The recipient twin is usually large, whereas the donor twin is usually small.

A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this gestational age variation? A) moist, supple, plum skin appearance B) abundant lanugo and vernix C) thin umbilical cord D) absence of sole creases

C) thin umbilical cord A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

Tetralogy of Fallot

Decreased pulmonary blood flow S&S: Dyspnea, fatigue, cyanosis

Sign or symptom suggestive of meconium aspiration syndrome?

Expiratory grunting

Erythromycin ointment is a preventative for what STI?

Gonorrhea

Hypospadias

a congenital anomaly in which the urethral opening is either placed dorsally on the top of the shaft of the penis or malpositioned ventrally.

hyrdocephalus

an anomaly with infants having an abnormally large head

atelectasis

collapsed lung; incomplete expansion of alveoli

esophageal atresia

congenital absence of part of the esophagus. Food cannot pass from the baby's mouth to the stomach. Choking and cyanosis.

omphalocele

herniation at the umbilicus (a part of the intestine protrudes through the abdominal wall at birth)

Ventricular septal defect

large hole between two ventricles lets venous blood pass from the right to the left ventricle and out to the aorta without oxygenation. Loud hard murmur- systolic thrill

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

D) Ear cartilage is thick and the pinna is stiff In the post-term newborn, the ear cartilage is thick and the pinna is stiff; in the term newborn, cartilage is present within the pinna and the ear shows the ability for natural recoil when folded. In both post-term and term newborns, a scarf sign test shows resistance and the elbow is unable to reach midline. A post-term newborn will have full areolas with 5 to 10 mm breast buds and will be capable of full flexion of arms and legs.

A nurse is performing a newborn assessment and notes the blood pressures in the upper extremities are higher than the lower extremities. The nurse should suspect which congenital newborn abnormality? A) patent ductus arteriosus B) truncus arteriosus C) ventricular septal defect D) coarctation of the aorta

D) coarctation of the aorta In congenital heart defects, coarctation of the aorta occurs when there is a narrow or constricted area of the aorta. This causes blood pressures to be higher in the upper extremities and lower in the lower extremities. Patent ductus arteriosus refers to an open patent foramen ovale after birth, and a ventricular septal defect is an opening in the ventricle. Both of these latter disorders cause increased pulmonary flow in the heart. Truncus arteriosus means there is one main branch for all vessels coming off the top of the heart.

A nurse places a newborn under a radiant heat warmer. At which location should the temperature probe be placed? A) Abdomen, between the umbilicus and the xiphoid process B) Gluteus maximus C) Abdomen, over the liver D) Back, over the rib cage

A) Abdomen, between the umbilicus and the xiphoid process Be certain, with the infant lying on the back, you tape the probe or disk onto the infant's abdomen between the umbilicus and the xiphoid process. Do not tape it on the underside of an infant or it will register a falsely high reading. Be certain as well it is not over the liver, because the heat generated by the liver can lead to false high readings, or over the rib cage where the thin subcutaneous tissue is also apt to yield an inaccurate reading.

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? A) Administer intravenous glucose. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.

A) Administer intravenous glucose. If a large for gestational age newborn's blood glucose level is below 25 mg/dL, the nurse should institute immediate treatment with intravenous glucose regardless of the clinical symptoms. Oral feedings would be used to maintain the newborn's glucose level above 40 mg/dL. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress.

The nurse is caring for a neonate in the neonatal intensive care unit (NICU). Which nursing action exemplifies developmental care? A) Clustering care and activities B) Giving a bath C) Administering medications D) Holding the infant

A) Clustering care and activities Clustering care and activities in the NICU decreases stress and helps developmentally support premature and sick infants. Developmental care can decrease assistance needed and length of hospital stay. The other choices are part of basic infant care.

The nurse is caring for a baby with esophageal atresia. Which situation during the mother's pregnancy indicates that this health problem was developing? A) Hydramnios B) Oligohydramnios C) A difficult second stage of labor D) Bleeding at 32 weeks of pregnancy

A) Hydramnios Esophageal atresia must be ruled out in any infant born to a woman with hydramnios or excessive amniotic fluid. Normally, a fetus swallows amniotic fluid during intrauterine life. With esophageal atresia, the fetus cannot swallow so the amount of amniotic fluid grows abnormally large, leading to hydramnios. Oligohydramnios, a difficult second stage of labor, or bleeding at 32 weeks of pregnancy does not indicate that esophageal atresia was developing during fetal development.

Newborns born to a mother with diabetes are at risk for which of the following? A) Hypoglycemia, delayed fetal lung maturity, respiratory distress, and shoulder dystocia B) Hyperglycemia, meconium aspiration syndrome, cerebral ischemia, and polycythemia C) Hypoglycemia, polycythemia, respiratory distress, and hyperviscosity of the blood D) Hyperglycemia, intrauterine hypoxia, hemolytic disease of the newborn, and hyperviscosity of the blood

A) Hypoglycemia, delayed fetal lung maturity, respiratory distress, and shoulder dystocia Maternal diabetes can lead to a delay in fetal lung maturity, resulting in respiratory distress. Newborns are also susceptible to hypoglycemia because they have been producing a higher level of insulin in utero as a result of high maternal glucose levels. They are at increased risk for LGA and subsequent shoulder dystocia.

A nurse is assessing a preterm newborn's status based on the understanding that the newborn is at greatest risk for which complication? A) atelectasis B) infection C) intracranial hemorrhage D) hypoglycemia

A) atelectasis The respiratory system is the last system to mature. Therefore, the preterm newborn is at great risk for respiratory complications, one of which is atelectasis.

When examining a neonate, which characteristic would indicate to the nurse that the infant is preterm? Select all that apply. A) extended extremities B) covered with vernix caseosa C) absence of sole creases D) bulging posterior fontanelle E) elevated breast bud

A) extended extremities B) covered with vernix caseosa C) absence of sole creases

A small-for-gestational age neonate is admitted to the observational nursery for blood work. Which result would require further assessment? A) hematocrit: 80% B) hemoglobin: 15.6 grams/dL C) total bilirubin: 0.3 to 1.9 mg/dL D) serum glucose: 40 mg/dL (2.5 mmol/L)

A) hematocrit: 80% Polycythemia is not uncommon and is a potentially serious disorder of newborns. It is defined as a venous hematocrit above 65% and hemoglobin of more than 20 grams. Polycythemia occurs in up to 12% of neonates, very commonly in SGA newborns 6 to 12 hours after birth. The other test results are normal for a newborn.

The nurse assesses a newborn considered to be large-for-gestational age. What finding corresponds with this gestational age diagnosis? A) meconium-stained skin and fingernails B) abundant vernix caseosa and lanugo C) Wharton's jelly D) few creases on soles

A) meconium-stained skin and fingernails Postterm newborns typically exhibit the following characteristics: dry, cracked, peeling, wrinkled skin; vernix caseosa and lanugo are absent; long, thin extremities; creases that cover the entire soles of the feet; abundant hair on scalp; thin umbilical cord; long fingernails; limited vernix and lanug; and meconium-stained skin and fingernails.

A nurse is preparing a presentation for a group of perinatal nurses about common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the nurse includes which factor as contributing to the newborn's risk? Select all that apply. A) surfactant deficiency B) placental deprivation C) immaturity of the respiratory control centers D) decreased amounts of brown fat E) depleted glycogen stores

A) surfactant deficiency C) immaturity of the respiratory control centers

The nursing instructor is discussing congenital heart disease with a group of students. Which statement indicates that students need further teaching? A) "The foramen ovale allows blood to pass from the right atrium to the left atrium during fetal life." B) "The ductus arteriosus carries deoxygenated blood from the aorta to the pulmonary artery during fetal life." C) "Oxygenated blood goes out to the body through the aorta." D) "Blood returns to the heart from the inferior vena cava."

B) "The ductus arteriosus carries deoxygenated blood from the aorta to the pulmonary artery during fetal life." The students need additional teaching if they report that the ductus arteriosus takes deoxygenated blood from the aorta to the pulmonary artery during fetal life. The ductus arteriosus carries oxygenated blood from the pulmonary artery to the aorta during fetal life. Blood returns to the heart from the inferior vena cava, and oxygenated blood travels to the body through the aorta.

A nurse is caring for a newborn client diagnosed with spina bifida. Which assessment finding would be a priority for the nurse who is monitoring for the risk of hydrocephalus? A) Assess the motor function of the lower extremities. B) Assess head circumference measurements. C) Assess the newborn's weight. D) Assess the newborn's neurological response.

B) Assess head circumference measurements. Hydrocephalus is the extra accumulation of CSF fluid in the ventricles of the brain, which causes dilation. One of the main symptoms of hydrocephalus is increasing measurements of head circumference. A change in neurological status in hydrocephalus may not occur immediately but may be assessed at a later point. Weighing a newborn and checking motor function will not be a significant indicator of hydrocephalus.

The nurse is caring for a newborn of a mother with human immunodeficiency virus (HIV). What is the priority for the nurse to complete following delivery? A) Test the newborn for HIV B) Bathe the newborn thoroughly C) Administer zidovudine D) Assist the mother to breastfeed

B) Bathe the newborn thoroughly The newborn should have a thorough bath immediately after birth to decrease the possibility of HIV transmission. It is recommended the newborn be tested for HIV at 14 to 21 days after birth, at 1-2 months and again at 4-6 months. Zidovudine should be administered within 6-12 hours post-delivery to help prevent transmission of HIV from the mother to the newborn.

In hyperbilirubinemia, the decrease in bilirubin excretion could be caused by A) Being a term newborn B) Hypoxia C) Hyperthyroidism D) Infant feeding of formula

B) Hypoxia In hyperbilirubinemia there is a decrease in the amount of bilirubin excreted from the body. This can be caused by hypoxia, hypothyroidism, breast milk, a bowel obstruction or prematurity.

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? A) Assess vital signs. B) Measure the head again. C) Assess neurologic signs. D) Notify the primary health care provider

B) Measure the head again. Whenever there's a question about vital signs or assessment data, the first logical step is to reassess to determine if an error has been made initially. Notifying the primary health care provider and assessing neurologic and vital signs are important and would follow the reassessment, if warranted.

The nurse in the newborn nursery is placing a 30-minute-old newborn on a radiant warmer for thermoregulation. Where should she apply the temperature probe to be most accurate? A) Over the upper chest B) Over the liver on the abdomen C) On the upper thigh D) On the scalp

B) Over the liver on the abdomen

A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The nurse discusses the risk of transmitting the infection to her newborn, explaining that this infection is transmitted to the newborn through the: A) amniotic fluid. B) placenta. C) birth canal. D) breast milk.

B) Placenta The syphilis spirochete can cross the placenta after 9 weeks gestation. It is not transmitted via amniotic fluid, passage through the birth canal, or breast milk.

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? A) The jaundice occurred within the first 24 hours after birth. B) The bilirubin peaked between days 3 and 5 after birth. C) The bilirubin level rose 6 mg/dL to 13 mg/dL over the last 24 hours. D) The conjugated bilirubin is higher than the unconjugated bilirubin.

B) The bilirubin peaked between days 3 and 5 after birth. Physiologic jaundice involves the liver's inability to break down the bilirubin as fast as it is being produced due to the immaturity of the liver. The criteria for physiologic jaundice is that the jaundice occurs after 24 hours of age, it peaks between days 3 and 5 and does not rise more than 5 mg dL/day. Conjugated bilirubin is the water-soluble version of bilirubin and is excreted in feces; it should always be lower than the unconjugated bilirubin.

A term neonate is admitted to the neonatal intensive care unit. At birth, thick green amniotic fluid was noted. Which action is the priority? A) Apply oxygen after vigorous suctioning. B) Use vigorous orogastric suctioning. C) Apply continuous positive airway pressure. D) Continue assessment and evaluation for respiratory distress. E) Vigorously suction the nares.

D) Continue assessment and evaluation for respiratory distress. The standard prevention and treatment for meconium aspiration syndrome previously included vigorous suctioning of the mouth and nares. Previously infants have been given intubation and airway suctioning; routine tracheal suction is recommended only for depressed infants. Use of orogastric suctioning to prevent MAS is not supported by evidence from current studies. Guidelines suggest not stimulating infants born with meconium staining with vigorous sucking in order to avoid aspiration. Continued assessment and ongoing evaluation of the newborn for respiratory distress is the best option. CPAP would not be warranted.

The nurse is caring for a newborn with fetal alcohol syndrome. The nurse knows that the newborn will demonstrate: A) Jitteriness. B) lethargy. C) a large head circumference. D) hyperactivity. E) hyperglycemia.

D) hyperactivity. Newborns with fetal alcohol syndrome exhibit hyperactivity, a small height and head circumference, hypoglycemia, and irritability.