Test ch 9
14. Which is the most appropriate nursing action when intermittently gavage-feeding a preterm newborn? a. Allow formula to flow by gravity. b. Insert tube through nares rather than mouth. c. Avoid letting newborn suck on tube. d. Apply steady pressure to syringe to deliver formula to stomach in a timely manner.
A
1. The nurse needs to obtain blood for ongoing assessment of a high-risk newborn's progress. Which tests should the nurse monitor? (Select all that apply.) a. Blood glucose b. Complete blood count (CBC) c. Calcium d. Serum electrolytes e. Neonatal prothrombin time (PTT)
A C D
2. Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture? a. Negative scarf sign b. Asymmetric Moro reflex c. Swelling of fingers on affected side d. Paralysis of affected extremity and muscles
ANS: B A newborn with a broken clavicle may have no symptoms. The Moro reflex, which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities, will most likely be asymmetric. The scarf sign that is used to determine gestational age should not be performed if a broken clavicle is suspected. Swelling of fingers on affected side and paralysis of affected extremity and muscles are not indicative of a fractured clavicle.
50. Several types of seizures can occur in the newborn. Which is characteristic of clonic seizures? a. Apnea b. Tremors c. Rhythmic jerking movements d. Extensions of all four limbs
C
6. Nursing care of the newborn with oral candidiasis (thrush) includes: a. avoiding use of pacifier. b. removing characteristic white patches with a soft cloth. c. continuing medication for a prescribed number of days. d. applying medication to oral mucosa, being careful that none is ingested.
C
61. The commonly used Guthrie blood test is performed on newborns to diagnose: a. Down syndrome. b. isoimmunization. c. PKU. d. congenital hypothyroidism (CH).
C
8. The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. The nurse's response should be based on knowledge that: a. excision of the lesion will be necessary. b. injections of prednisone into the lesion will reduce it. c. no treatment is usually necessary because of the high rate of spontaneous involution. d. pulsed dye laser treatments will be necessary immediately to prevent permanent disability.
C
3. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? (Select all that apply.) a. Avoid stimulation. b. Decrease fluid intake. c. Expose all the newborn's skin. d. Monitor skin temperature closely. e. Reposition the newborn every 2 hours. f. Cover the newborn's eyes with eye shields or patches.
D E F
18. The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborn's diaper, the nurse observes the newborn's color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of: a. stress. b. subtle seizures. c. preterm behavior. d. onset of respiratory distress.
A
42. Which is the central factor responsible for respiratory distress syndrome? a. Deficient surfactant production b. Overproduction of surfactant c. Overdeveloped alveoli d. Absence of alveoli
A
48. Which is the most common cause of anemia in preterm newborns? a. Frequent blood sampling b. Respiratory distress syndrome c. Meconium aspiration syndrome d. Persistent pulmonary hypertension
A
7. A nurse is assessing a premature newborn. Which assessment findings are consistent with prematurity? (Select all that apply.) a. Abundant lanugo over the body b. Ear cartilage soft and pliable c. Flexed body posture d. Deep creases on the sole of the foot e. Skin is bright pink, smooth, and shiny.
A B E
4. A nurse is planning care for a premature newborn. Which interventions should the nurse implement for skin care? (Select all that apply.) a. Use cleaning agents with neutral pH. b. Rub skin during drying. c. Use adhesive remover solvent when removing tape. d. Avoid removing adhesives for at least 24 hours. e. Consider pectin barriers beneath adhesives.
A D E
15. A healthy, stable, preterm newborn will soon be discharged. The nurse should recommend which position for sleep? a. Prone b. Supine c. Side lying d. Position of comfort
B
7. Which is a bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth? a. Port-wine stain b. Juvenile melanoma c. Cavernous hemangioma d. Strawberry hemangioma
D
2. Which are clinical manifestations of postmaturity in the newborn? (Select all that apply.) a. Excessive lanugo b. Increased subcutaneous fat c. Absence of scalp hair d. Parchment-like skin e. Minimal vernix caseosa f. Long fingernails
D E F
20. A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of the newborn express apprehension and worry that the newborn may still be in danger. The nurse should recognize that this is: a. normal. b. a reason to postpone discharge. c. suggestive of maladaptation. d. suggestive of inadequate bonding.
A
29. The newborn with severe jaundice is at risk for developing: a. encephalopathy. b. bullous impetigo. c. respiratory distress. d. blood incompatibility.
A
32. A blood sample for measurement of bilirubin is required from a newborn receiving phototherapy. In what environment should this blood sample be drawn? a. While phototherapy lights are turned off b. While newborn remains under phototherapy lights c. When newborn is covered with a blanket d. When newborn has been off phototherapy for 30 to 60 minutes
A
35. Hemolytic disease is suspected in a mother's second newborn. Which factor is important in understanding how this could develop? a. The mother's first child was Rh positive. b. The mother is Rh positive. c. Both parents have type O blood. d. RhIG (RhoGAM) was given to the mother during her first pregnancy.
A
37. To prevent Rh isoimmunization, RhIG (RhoGAM) is administered to all: a. Rh-negative women who deliver an Rh-positive newborn. b. Rh-positive women who deliver an Rh-negative newborn. c. Rh-negative newborns whose mothers are Rh positive. d. Rh-positive fathers before conception of second newborn when first newborn was Rh positive.
A
41. The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of hypocalcemia. Which intervention is the most appropriate during the acute phase? a. Allow newborn to sleep with pacifier to decrease stimuli. b. Keep newborn awake to monitor central nervous system changes. c. Encourage parents to hold and feed newborn to facilitate attachment during illness. d. Awaken newborn periodically to assess level of consciousness.
A
44. The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of respiratory distress syndrome. The nurse should recognize that, because of the mechanical ventilation, there is an increased risk of: a. alveolar rupture. b. meconium aspiration. c. transient tachypnea. d. retractions and nasal flaring.
A
45. The nurse is caring for a newborn with respiratory distress syndrome. The newborn has an endotracheal tube. Which statement describes nursing considerations related to suctioning? a. Suctioning should not be carried out routinely. b. Newborn should be in Trendelenburg position for suctioning. c. Routine suctioning, usually every 15 minutes, is necessary. d. Frequent suctioning is necessary to maintain patency of bronchi.
A
46. A premature newborn requires oxygen and mechanical ventilation. Which complications should the nurse assess for? a. Bronchopulmonary dysplasia, pneumothorax b. Anemia, necrotizing enterocolitis c. Cerebral palsy, persistent patent ductus d. Congestive heart failure, cerebral edema
A
53. The nurse is caring for a newborn whose mother is diabetic. Which clinical manifestations should the nurse expect to see? a. Hypoglycemic, large for gestational age b. Hyperglycemic, large for gestational age c. Hypoglycemic, small for gestational age d. Hyperglycemic, small for gestational age
A
63. Which is an important nursing consideration in the care of the newborn with PKU? a. Suggest ways to make formula more palatable. b. Teach proper administration of phenylalanine hydroxylase. c. Encourage the breastfeeding mother to adhere to low-phenylalanine diet. d. Give reassurance that dietary restrictions are a temporary inconvenience.
A
6. A nurse is admitting a premature newborn to the NICU. Which interventions should the nurse implement to prevent retinopathy? (Select all that apply.) a. Place on pulse oximetry. b. Decrease exposure to bright, direct lighting. c. Place on a cardiac monitor. d. Cover eyes with an eye shield at night. e. Use supplemental oxygen only when needed.
A B E
1. Which is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery? a. Caput succedaneum b. Hydrocephalus c. Cephalhematoma d. Subdural hematoma
ANS: A A vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery is the definition of a caput succedaneum. The swelling consists of serum and/or blood accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It would not be visible on the scalp.
16. Which intervention should the nurse implement to maintain the skin integrity of the premature newborn? a. Cleanse skin with a gentle alkaline-based soap and water. b. Cleanse skin with a neutral pH solution only when necessary. c. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution. d. Avoid cleaning skin.
B
26. Which statement best describes the clinical manifestations of the preterm newborn? a. Head is proportionately small in relation to the body. b. Sucking reflex is absent, weak, or ineffectual. c. Thermostability is well established. d. Extremities remain in attitude of flexion.
B
3. The parents of a newborn ask the nurse what caused the baby's facial nerve paralysis. The nurse's response is based on knowledge that this is caused by a(n): a. genetic defect. b. birth injury. c. spinal cord injury. d. inborn error of metabolism.
B
33. The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching? a. "I should change the baby's position many times during the day." b. "I can dress the baby in lightweight clothing while under phototherapy." c. "I should be sure that the baby's eyelids are closed before applying patches." d. "I can take the patches off the baby during feedings and other caregiving activities."
B
36. When should the nurse expect jaundice to be present in a newborn with hemolytic disease? a. At birth b. During first 24 hours after birth c. 24 to 48 hours after birth d. 48 to 72 hours after birth
B
38. The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be? a. Notify practitioner. b. Stop the transfusion. c. Administer calcium gluconate. d. Monitor vital signs electronically.
B
39. Which is the primary treatment for hypoglycemia in newborns with feeding intolerance? a. Oral glucose feedings b. Intravenous (IV) infusion of glucose c. Short-term insulin therapy d. Feedings (formula or breast milk) at least every 2 hours
B
4. A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is: a. easily treated. b. benign and transient. c. usually not contagious. d. usually not disfiguring.
B
51. Newborns are highly susceptible to infection as a result of: a. excessive levels of immunoglobulin A (IgA) and immunoglobulin M (IgM). b. diminished nonspecific and specific immunity. c. increased humoral immunity. d. overwhelming anti-inflammatory response.
B
54. The nurse is caring for a newborn who was born 24 hours ago to a mother who received no prenatal care. The newborn is a poor feeder but sucks avidly on his hands. Clinical manifestations also include loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating. Which should the nurse suspect? a. Seizure disorder b. Narcotic withdrawal c. Placental insufficiency d. Meconium aspiration syndrome
B
60. Phenylketonuria (PKU) is a genetic disease that results in the body's inability to correctly metabolize: a. glucose. b. phenylalanine. c. phenylketones. d. thyroxine.
B
9. Which term refers to a newborn born before completion of week 37 of gestation, regardless of birth weight? a. Postterm b. Premature c. Low birth weight d. Small for gestational age
B
8. A nurse is reviewing acid-base laboratory data on a newborn admitted to the NICU for meconium aspiration. Which laboratory values should the nurse report to the physician? (Select all that apply.) a. pH: 7.35 b. PCO2 : 49 c. HCO3-: 30 d. PaO2: 96
B C
5. A nurse is assessing a premature newborn for the possibility of necrotizing enterocolitis (NEC). Which assessment findings should the nurse expect to find if NEC is confirmed? (Select all that apply.) a. Minimal gastric residual b. Abdominal distention c. Apnea d. Urinary output at 2 ml/kg/hr e. Unstable temperature
B C E
11. The nurse is caring for a very low-birth-weight (VLBW) newborn with a peripheral intravenous infusion. Which statement describes nursing considerations regarding infiltration? a. Infiltration occurs infrequently because VLBW newborns are inactive. b. Continuous infusion pumps stop automatically when infiltration occurs. c. Hypertonic solutions can cause severe tissue damage if infiltration occurs. d. Infusion site should be checked for infiltration at least once per 8-hour shift.
C
17. Which is an important nursing action related to the use of tape and/or adhesives on premature newborns? a. Avoid using tape and adhesives until skin is more mature. b. Use solvents to remove tape and adhesives instead of pulling on skin. c. Remove adhesives with warm water or mineral oil. d. Use scissors carefully to remove tape instead of pulling tape off.
C
23. The nurse is planning care for a low-birth-weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation? a. Place in Trendelenburg position periodically. b. Suction at least every 2 to 3 hours. c. Maintain neutral thermal environment. d. Hyperextend neck with nose pointing to ceiling.
C
24. A preterm newborn has been receiving orogastric feedings of breast milk. The nurse initiates nipple feedings, but the newborn tires easily and has weak sucking and swallowing reflexes. The most appropriate nursing intervention is to: a. encourage mother to breastfeed. b. try nipple-feeding preterm newborn formula. c. resume orogastric feedings of breast milk. d. resume orogastric feedings of formula.
C
27. Physiologic jaundice in a newborn can be caused by: a. fetal-maternal blood incompatibility. b. destruction of red blood cells as a result of antibody reaction. c. liver's inability to bind bilirubin adequately for excretion. d. immature kidneys' inability to hydrolyze and excrete bilirubin.
C
28. When should the nurse expect breastfeeding-associated jaundice to first appear in a normal newborn? a. 0 to 12 hours b. 12 to 24 hours c. 2 to 4 days d. 4 to 5 days
C
30. Early clinical manifestations of bilirubin encephalopathy in the newborn include: a. mental retardation. b. absence of stooling. c. lethargy or irritability. d. increased or decreased temperature.
C
31. A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn? a. Buttocks b. Tip of nose and sclera c. Sclera, conjunctiva, and oral mucosa d. Palms of hands and soles of feet
C
34. The nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy. Which is an appropriate nursing intervention for this newborn? a. Apply lotion as prescribed to moisturize skin. b. Maintain nothing-by-mouth (NPO) status to prevent nausea and vomiting. c. Monitor temperature to prevent hypothermia or hyperthermia. d. Keep eye patches on for at least 8 to 12 of every 24 hours.
C
40. Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry? a. Monitor blood pressure closely. b. Obtain urine sample to detect glycosuria. c. Obtain serum glucose and serum calcium levels. d. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
C
49. A newborn is diagnosed with retinopathy of prematurity. The nurse should know that: a. blindness cannot be prevented. b. no treatment is currently available. c. cryotherapy and laser therapy are effective treatments. d. long-term administration of oxygen will be necessary.
C
5. What is oral candidiasis (thrush) in the newborn? a. Bacterial infection that is life threatening in the neonatal period b. Bacterial infection of mucous membranes that responds readily to treatment c. Yeastlike fungal infection of mucous membranes that is relatively common d. Benign disorder that is transmitted from mother to newborn during the birth process only
C
56. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage? a. Trisomy b. Monosomy c. Translocation d. Nondisjunction
C
10. Which refers to a newborn whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts? a. Postterm b. Postmature c. Low birth weight d. Small for gestational age
D
12. The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action? a. Elevate feet 15 degrees. b. Place socks on newborn. c. Wrap feet loosely in prewarmed blanket. d. Report findings immediately to the practitioner.
D
13. The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn: a. achieves a weight of at least 3 pounds. b. indicates an interest in breastfeeding. c. does not require supplemental oxygen. d. has adequate sucking and swallowing reflexes.
D
19. When is the best time for the neonatal intensive care unit (NICU) nurse to initiate an individualized stimulation program for the preterm newborn? a. As soon as possible after newborn is born b. As soon as parent is available to provide stimulation c. When newborn is over 38 weeks of gestation d. When developmental organization and stability are sufficient
D
21. The nurse is planning care for a family expecting their newborn to die. The nurse's interventions should be based on which statement? a. Tangible remembrances of the newborn (e.g., lock of hair, picture) prolong grief. b. Photographs of newborns should not be taken after the death has occurred. c. Funerals are not recommended because mother is still recovering from childbirth. d. Parents should be encouraged to name their newborn if they have not done so already.
D
22. The nurse has been caring for a newborn who just died. The parents are present but say they are "afraid" to hold the dead newborn. Which is the most appropriate nursing intervention? a. Tell them there is nothing to fear. b. Insist that they hold newborn "one last time." c. Respect their wishes and release body to morgue. d. Keep newborn's body available for a few hours in case they change their minds.
D
25. The parents of a newborn who has just died decide they want to hold their deceased infant. The most appropriate nursing intervention at this time is to: a. explain gently that this is no longer possible. b. encourage parents to accept the loss of their newborn. c. offer to take a photograph of their newborn because they cannot hold newborn. d. get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased infant.
D
43. A preterm newborn of 36 weeks of gestation is admitted to the NICU. Approximately 2 hours after birth, the newborn begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. Which is important for the nurse to recognize? a. This is a normal finding. b. This is not significant unless cyanosis is present. c. Improvement should occur within 24 hours. d. Further evaluation is needed.
D
47. Meconium aspiration syndrome is caused by: a. hypoglycemia. b. carbon dioxide retention. c. bowel obstruction with meconium. d. aspiration of meconium in utero or at birth.
D
52. Which is most descriptive of the clinical manifestations observed in neonatal sepsis? a. Seizures and sunken fontanels b. Sudden hyperthermia and profuse sweating c. Decreased urinary output and frequent stools d. Nonspecific physical signs with hypothermia
D
55. Which should the nurse anticipate in the newborn whose mother used cocaine during pregnancy? a. Seizures b. Hyperglycemia c. Cardiac and respiratory problems d. Neurobehavioral depression or excitability
D
57. Trisomy 13, trisomy 18, and trisomy 21 have which in common? a. Viability is rare. b. They are considered deletion syndromes. c. Diagnosis is difficult, time-consuming, and expensive. d. Diagnosis can be made early, based on physical characteristics.
D
58. Which is characteristic of newborns whose mothers smoked during pregnancy? a. Large for gestational age b. Preterm, but size appropriate for gestational age c. Growth retardation in weight only d. Growth retardation in weight, length, and head circumference
D
59. Which is an important nursing consideration in preventing the complications of congenital hypothyroidism (CH)? a. Assess for family history of CH. b. Assess mother for signs of hypothyroidism. c. Be certain appropriate screening is done prenatally. d. Be certain appropriate screening is done on newborn.
D
62. The screening test for PKU is most reliable if the blood sample is: a. from cord blood. b. taken 14 days after birth. c. taken before oral feedings are initiated. d. fresh blood from the heel.
D
