Chapter 24 Questions

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required? a) "Intravenous fluids are going to be needed so that the baby won't get dehydrated." b) "After this surgery is done tomorrow, my baby will be able to eat and drink." c) "They will be placing a tube in the stomach during surgery." d) "The baby will have tubes in the chest to drain chest fluids."

"After this surgery is done tomorrow, my baby will be able to eat and drink."

Four weeks before the birth of her already large child, the physician has told the pregnant woman that if the baby gets bigger and his lungs are ready, the physician would like to perform a cesarean to deliver the baby. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal delivery. What is an appropriate response by the nurse? a) "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress." b) "If the physician has recommended the procedure, it's likely that the benefits outweigh the risks." c) "The procedure isn't risky for the baby, but your healing takes longer and you'll have a scar." d) "Some women don't have any problem delivering large babies. You might want to get a second opinion."

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs, if that doesn't happen there's a higher risk of respiratory distress."

The nurse is doing teaching with the caregivers of an infant diagnosed with hypospadias. Which of the following statements made by the caregivers is accurate regarding hypospadias? a) "It is upsetting to me that he is in pain when he urinates." b) "We hadn't decided about circumcision, but he will have to be circumcised before they do the surgery." c) "At least he won't have to have surgery until he is almost ready to start school." d) "Being able to most likely correct this in one stage rather than several is reassuring."

"Being able to most likely correct this in one stage rather than several is reassuring."

In examining her newborn son, a mother becomes concerned that the frenulum, under his tongue, is too short. She points it out to the nurse. Which of the following should the nurse say in response to this mother's concern? a) "In most cases, a short frenulum does not cause problems and does not need to be corrected." b) "The child will most likely develop speech problems and will require speech therapy." c) "It is likely that the child will need to have surgery in the coming weeks to prevent developmental problems." d) "This condition can be corrected by passive stretching exercises of the tongue."

"In most cases, a short frenulum does not cause problems and does not need to be corrected."

A woman with a history of PKU tells the nurse that she has decided to try to become pregnant. Her serum phenylalanine level is 10 mg/dL. Which of the following is an appropriate response for the nurse to make? a) "It will be best if you cut back on vegetables and fruit before you become pregnant to get your serum phenylalanine level down under 8 mg." b) "It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg." c) "The baby won't be able to breast feed. You know breast feeding is really the best way to care for a newborn." d) "Think carefully about the decision. The child might be mentally retarded if she inherits your PKU, especially if your levels stay that high."

"It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

The nurse is working with a group of parents of children who have congenital heart disorders. Which of the following statements made by the parents would most likely be an indication the child is showing signs of congestive heart failure. a) "They say he has a heart murmur but it may go away." b) "She gets so tired when she is eating." c) "His chest measurement is the same as his head." d) "When I move her legs up toward her chest I hear a click."

"She gets so tired when she is eating."

A group of nursing students is discussing hydrocephalus. The students make the following statements related to the noncommunicating type of congenital hydrocephalus. Which statement is the most accurate? a) "There is defective absorption of cerebrospinal fluid." b) "There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord." c) "There is an opening between the ventricles and the spinal cord that usually closes at birth." d) "There is a decreased production of cerebrospinal fluid."

"There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord."

A group of nursing students is discussing hydrocephalus. The students make the following statements related to the noncommunicating type of congenital hydrocephalus. Which statement is the most accurate? a) "There is an opening between the ventricles and the spinal cord that usually closes at birth." b) "There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord." c) "There is a decreased production of cerebrospinal fluid." d) "There is defective absorption of cerebrospinal fluid."

"We can probably start feeding him with the bottle about a day after the surgery."

The nurse teaches the parents of a newborn with hyperbilirubinemia about home phototherapy using bilirubin lights. Which statement indicates that the teaching was successful? a) "We will turn him every ½ hour to make sure that his whole body is exposed." b) "We should see reddened areas on his skin, which mean the treatment is working." c) "We'll place the lights so that they are about 5 inches above our baby at all times." d) "We'll take off the patches on his eyes when we're feeding him so he can look at us."

"We'll take off the patches on his eyes when we're feeding him so he can look at us."

An infant was born with a severely deformed hand. He is now 6 months old. The nurse informs the parents that the orthopedic surgeon has recommended amputation of the hand and fitting of a prosthesis. The mother objects and tells the nurse that they would like to wait and see how the hand develops. Which of the following should the nurse say in response? a) "An alternative to amputation and prosthesis is administration of a new drug that can help regenerate the hand." b) "With a deformity such as this, the hand is highly unlikely to improve." c) "If we perform the amputation and you change your mind later, the hand can always be surgically reattached." d) "I agree. You should wait until your son is older and let him decide whether he would like to have it done."

"With a deformity such as this, the hand is highly unlikely to improve."

Which of the following instructions would the nurse include in the teaching plan for a mother of a substance-exposed newborn? a) "Let your newborn sleep in his stomach for naps but not at night." b) "Place your newborn on his side when you feed him." c) "Wrap him snugly in a blanket and gently rock him if he's fussy." d) "Avoid using a pacifier because it can damage his teeth in the future."

"Wrap him snugly in a blanket and gently rock him if he's fussy."

An older infant is scheduled to have a cleft palate repair. The mother asks if she will still be able to breastfeed the baby during the postoperative phase. What is the best response by the nurse? a) "You will not be able to breastfeed but immediately after, but you can pump and feed the child with a cup." b) "Yes, the surgery will not interfere with breastfeeding your child." c) "No, you will have to put the baby on regular formula." d) "Yes, you will be able to breastfeed but will have to interrupt the feedings frequently."

"You will not be able to breastfeed but immediately after, but you can pump and feed the child with a cup."

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have which of the following? a) A protruding sac that contains abdominal contents b) A membrane between the rectum and the anus c) An extremely large and rapidly growing head d) A partial to complete paralysis in the lower extremities

A partial to complete paralysis in the lower extremities

23. The priority assessment for the Rh-positive infant whose mother's indirect Coombs test was positive at 36 weeks is: a. skin color. b. temperature. c. respiratory rate. d. blood glucose level.

ANS: A An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor because of erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated with erythroblastosis fetalis. PTS: 1 DIF: Cognitive Level: Application REF: 657 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

10. Which intervention should make phototherapy most effective in reducing the indirect bilirubin in an affected newborn? a. Turn the infant every 2 hours. b. Place eye patches on the newborn. c. Wrap the infant in triple blankets to prevent cold stress. d. Increase the oral intake of water between and before feedings.

ANS: A Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed. It is important to increase oral feedings, but water should not necessarily be given, which would not reduce the bilirubin. PTS: 1 DIF: Cognitive Level: Application REF: 660 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

8. The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of: a. persistent pulmonary hypertension. b. bronchopulmonary dysplasia. c. transitory tachypnea of the newborn. d. left-to-right shunting of blood through the foramen ovale.

ANS: A Persistent pulmonary hypertension can result from the aspiration of meconium. Bronchopulmonary dysplasia is caused by the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is caused by delayed absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects. PTS: 1 DIF: Cognitive Level: Application REF: 655 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

16. While caring for a post-term infant, the nurse recognizes that the elevated hematocrit level most likely results from: a. hypoxia in utero. b. underproduction of red blood cells. c. increased breakdown of red blood cells. d. the normal expected shift from fetal hemoglobin to normal hemoglobin.

ANS: A While in utero, the infant who is hypoxic will compensate by producing more red blood cells. An elevated hematocrit results from an overproduction of red blood cells. It would be seen with a decreased breakdown of red blood cells and is not a normal shift from fetal hemoglobin to normal hemoglobin. PTS: 1 DIF: Cognitive Level: Analysis REF: 657 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

21. The nurse's immediate action after the birth of a post-term infant with meconium stained amniotic fluid is to: a. stimulate the infant to cry. b. suction the infant's airways. c. complete the 1- and 5-minute Apgars. d. vigorously dry the infant's head and trunk.

ANS: B Meconium in the upper airways may be pulled deep into the respiratory passages when the infant takes the first breath after birth. Stimulating the infant to cry may cause aspiration of meconium in the upper airways, completing the 1- and 5-minute Apgars would delay suctioning and allow initiation of respirations, and vigorously drying the infant would increase stimulation and crying. PTS: 1 DIF: Cognitive Level: Application REF: 653 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

15. The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice: a. usually results in kernicterus. b. appears during the first 24 hours of life. c. begins on the head and progresses down the body. d. results from the breakdown of excessive erythrocytes not needed after birth.

ANS: B Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is caused by a pathologic condition, such as Rh incompatibility. PTS: 1 DIF: Cognitive Level: Understanding REF: 673, 674 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula feedings or breastfeedings is to: a. prevent hyperglycemia. b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.

ANS: B Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infant's system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. The feedings stimulate bowel movements and emptying of the bilirubin from the bowel. PTS: 1 DIF: Cognitive Level: Application REF: 658 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

22. The nurse notes that the infant has been feeding poorly over the last 24 hours. She should immediately assess for other signs of: a. hyperglycemia. b. neonatal infection. c. hemolytic anemia. d. increased bilirubin levels.

ANS: B Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic anemia, and increased bilirubin levels are not associated with poor infant feeding. PTS: 1 DIF: Cognitive Level: Application REF: 662 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

5. Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority? a. Notify the clinician stat. b. Test for the blood glucose level. c. Start an intravenous line with D5W. d. Document the event in the nurses' notes.

ANS: B These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present. PTS: 1 DIF: Cognitive Level: Application REF: 670 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

9. The nurse present at the birth is reporting to the nurse who will be caring for the neonate after birth. Which information should be included for an infant who had thick meconium in the amniotic fluid? a. The parents spent an hour bonding with the baby after birth. b. An IV was started immediately after birth to treat dehydration. c. There was no meconium below the vocal cords when they were visualized. d. The infant needed vigorous stimulation immediately after birth to initiate crying.

ANS: C A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Bonding after birth is an expected occurrence. There is no relationship between dehydration and meconium fluid. Vigorous stimulation in the presence of meconium fluid is contraindicated to prevent aspiration. PTS: 1 DIF: Cognitive Level: Understanding REF: 653 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

18. While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth? a. Risk for infection related to release of meconium b. Risk for injury related to high-risk birth interventions, such as amino infusion c. Risk for aspiration related to retained secretions d. Risk for thermoregulation because of high-risk labor status

ANS: C Because the fetus has already passed meconium in utero, the labor and birth take on a high-risk management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, so airway abnormalities take precedence in terms of nursing diagnosis and medical management. PTS: 1 DIF: Cognitive Level: Application REF: 653 OBJ: Nursing Process Step: Nursing Diagnosis MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

7. Transitory tachypnea of the newborn (TTN) is thought to occur as a result of: a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal birth associated with meconium-stained fluid.

ANS: C Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant causes respiratory distress syndrome. A slow vaginal birth will help prevent TTN. PTS: 1 DIF: Cognitive Level: Understanding REF: 653 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

4. An infant with severe meconium aspiration syndrome is not responding to conventional treatment. Which method of treatment may be available at a level III facility for use with this infant? a. Insertion of an endotracheal tube b. Respiratory support with a ventilator c. Extracorporeal membrane oxygenation d. Insertion of a laryngoscope and suctioning of the trachea

ANS: C Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infant's lungs to rest and recover. An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth, before the infant takes the first breath. PTS: 1 DIF: Cognitive Level: Understanding REF: 653 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

11. A mother with diabetes has done some reading about the effects of her condition on a newborn. Which statement shows a misunderstanding that should be clarified by the nurse? a. "The red appearance of my baby's skin is due to an excessive number of red blood cells." b. "My baby will be watched closely for signs of low blood sugar, especially during the early days after birth." c. "My baby's pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy." d. "Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be."

ANS: C Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. High hematocrit values in neonates of diabetic mothers cause them to have a have a ruddy look. Neonates of diabetic mothers are prone to hypoglycemia. It is correct that some women with diabetes have very small babies because of poor blood flow through the placenta. PTS: 1 DIF: Cognitive Level: Analysis REF: 665 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

6. Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome? a. A 35-week-gestation male baby born vaginally to a mother addicted to heroin b. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes c. A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes d. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension

ANS: C Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia. PTS: 1 DIF: Cognitive Level: Analysis REF: 651, 652 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

13. When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find: a. cyanosis. b. diuresis. c. signs of pulmonary congestion. d. increased oxygenation of the tissues.

ANS: C Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this type of cardiac defect. PTS: 1 DIF: Cognitive Level: Analysis REF: 673 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

2. Which defect is present with tetralogy of Fallot? a. Patent ductus arteriosus b. Coarctation of the aorta c. Hypertrophy of the right ventricle d. Transposition of the great arteries

ANS: C Tetralogy of Fallot has four characteristics—ventricular septal defect, positioning of the aorta over the defect, pulmonary stenosis, and hypertrophy of the right ventricle. Patent ductus arteriosus is a result of the failure of the ductus arteriosus to close after birth. Blood flow is impeded, though this constricted area of the aorta is not a characteristic of tetralogy of Fallot. In transposition of the great arteries, the positions of the aorta and pulmonary artery are reversed. PTS: 1 DIF: Cognitive Level: Understanding REF: 674 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

17. Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea (TTN). The parents are notified and become anxious because they have no idea what this means in terms of medical condition. The best action that the nurse can take at this time is to: a. refer them to the neonatologist for more information. b. tell them not to worry because their infant will be monitored closely by trained staff. c. explain to them that this often occurs following a birth but it will most likely resolve in the next 24 to 48 hours. d. tell them that they will be able to come and see their baby, which will help make them feel better.

ANS: C The clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition. The RN should be able to provide information to clarify the parents' concern. Telling someone not to worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction with the newborn and parents may help ease anxiety but does not address the parents' knowledge deficit. PTS: 1 DIF: Cognitive Level: Analysis REF: 664 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

19. Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant? a. Direct Coombs test based on maternal blood sample b. Indirect Coombs test based on infant cord blood sample c. Infant bilirubin level d. Maternal blood type

ANS: C The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infant's bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice. PTS: 1 DIF: Cognitive Level: Analysis REF: 657 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

24. The nurse should be alert to a blood group incompatibility if: a. both mother and infant are O-positive. b. mother is A-positive and infant is A-negative. c. mother is O-positive and infant is B-negative. d. mother is B-positive and infant is O-negative.

ANS: D Blood group incompatibilities occur because O-positive mothers have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists. The mother with blood group B does not have any antibodies to group O. PTS: 1 DIF: Cognitive Level: Analysis REF: 657 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

1. The infant of a diabetic mother is hypoglycemic. Which type of feeding should be instituted first? a. Glucose water b. D5W intravenously c. Formula via nasogastric tube d. Small amount of glucose water followed by formula or breast milk

ANS: D Glucose followed by formula or breast milk is metabolized more slowly and results in longer normal glucose levels. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines would be a later choice if the hypoglycemia continues. Formula results in longer normal glucose levels but would be administered via bottle, not by tube feeding. PTS: 1 DIF: Cognitive Level: Application REF: 659 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

12. Newborns whose mothers are substance abusers frequently have which behaviors? a. Hypothermia, decreased muscle tone, and weak sucking reflex b. Excessive sleep, weak cry, and diminished grasp reflex c. Circumoral cyanosis, hyperactive Babinski reflex, and constipation d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

ANS: D Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. They will have hyperactive muscle tone, a high-pitched cry, and diarrhea, not constipation. PTS: 1 DIF: Cognitive Level: Understanding REF: 667 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

20. Which of the following lab values indicates that an infant may have polycythemia? a. Hb 18 g/dL, Hct 50% b. Hb 25/dL, Hct 55% c. Hb 20/dL, Hct 65% d. Hb 30 g/dL, Hct 70%

ANS: D The presence of polycythemia in an infant is characterized by a hemoglobin level greater than 22 g/dL and a hematocrit value greater than 65%. PTS: 1 DIF: Cognitive Level: Application REF: 665 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

14. In an infant with cyanotic cardiac anomaly, the nurse should expect to see: a. feedings taken eagerly. b. a consistent and rapid weight gain. c. a decrease in the heart rate with activity. d. little to no improvement in color with oxygen administration.

ANS: D With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity. PTS: 1 DIF: Cognitive Level: Application REF: 665 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

When providing care to a newborn with necrotizing enterocolitis (NEC), which of the following would the nurse need to report immediately? a) Stools negative for blood b) Abdomen appearing red and shiny c) Decrease in abdominal girth d) Bowel sounds in all four quadrants

Abdomen appearing red and shiny

When examining a newborn for developmental hip dysplasia, which of the following motions would the newborn's hip be unable to accomplish? a) Extension b) Abduction c) Adduction d) Rotation

Abduction

A nurse is caring for a newborn with transient tachypnea. Which is the priority nursing intervention? a) Administer IV fluids; gavage feedings b) Perform gentle suctioning c) Monitor for signs of hypotonia d) Maintain adequate hydration

Administer IV fluids; gavage feedings

Which of the following would the nurse expect to be included in the plan of care for an infant of a diabetic mother who has a serum calcium level of 6.2 mg/dL? a) Administration of calcium gluconate b) Infusions of intravenous glucose c) Initiation of phototherapy d) Initiation of oral feedings

Administration of calcium gluconate

A nursing instructor is teaching about newborn congenital disorders and realizes that the student needs further instruction upon making which of the following statements? a) All congenital disorders can be diagnosed at birth. b) Congenital defects may be caused by genetic or environmental factors. c) Hydrocephalus may not be diagnosed until after a few weeks or months of life. d) Hydrocephalus may be recognized at birth.

All congenital disorders can be diagnosed at birth.

One of the clinical manifestations seen in the child with hydrocephalus is which of the following? a) A partial to complete paralysis in the lower extremities b) An extremely large and rapidly growing head c) A membrane between the rectum and the anus d) Aprotruding sac that contains abdominal contents

An extremely large and rapidly growing head

After delivery, an infant experiences meconium aspiration. What does the nurse anticipate the physician ordering prophylactically to prevent pneumonia? a) Intubation b) Antibiotics c) Inhaled surfactant d) Suction of the oropharynx

Antibiotics

The nurse is caring for a newborn diagnosed with congenital talipes equinovarus. Which of the following treatments would the nurse most likely expect for this newborn? a) Placing the child in special shoes b) Doing passive range of motion c) Application of a cast d) Putting the child in Bryant's traction

Application of a cast

Immediately after delivery, the nurse is caring for a newborn with a myeolomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage? a) Cover the sac with petroleum jelly and a dry sterile dressing. b) Apply a sterile dressing moistened in a warm sterile saline solution. c) Cover the sac with a water-soluble lubricant and a dry sterile dressing. d) Allow the sac to dry out to "toughen" it.

Apply a sterile dressing moistened in a warm sterile saline solution.

In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of which of the following? a) Cerebrospinal fluid b) Circulatory blood flow c) Lymphatic system d) Genitourinary tract

Cerebrospinal fluid

Periventricular hemorrhage is suspected in a newborn of 30 weeks' gestation. The nurse would anticipate preparing the newborn for which of the following to confirm the diagnosis? a) Cranial ultrasound b) Blood glucose level c) Chest x-ray d) Arterial blood gases

Cranial ultrasound

Nursing assessment of the infant should include what important information that might indicate heart failure? a) Blood glucose level b) Color of hands and feet c) Diminished peripheral pulses d) Capillary refill time

Diminished peripheral pulses

A nurse is caring for a newborn with asphyxia. What nursing management is involved when treating a newborn with asphyxia? a) Administer surfactant as ordere b) Ensure effective resuscitation measures c) Ensure adequate tissue perfusion d) Administer IV fluids

Ensure effective resuscitation measures

A woman with hydramnios has just given birth. The nurse recognizes that the infant must be assessed for which of the following conditions? a) Torticollis b) Esophageal atresia c) Talipes d) Ankyloglossia

Esophageal atresia

The nurse is assessing a newborn suspected of having meconium aspiration syndrome. What sign or symptom would be most suggestive of this condition? a) Intermittent tachypnea b) Expiratory grunting c) Bile-stained emesis d) High-pitched shrill cry

Expiratory grunting

Since the inclusion of calcium in prenatal vitamins and all cereal and grain products, the incidence of neural tube disorders has fallen dramatically in the United States. a) True b) False

False

You care for a child born with a tracheoesophageal fistula. Which finding during pregnancy would have caused you to suspect this might be present? a) Oligohydramnios b) Bleeding at 32 weeks of pregnancy c) A difficult second stage of labor d) Hydramnios

Hydramnios

For which of the following would you commonly assess in an infant following surgery for a myelomeningocele? a) Dehydration b) Cerebrovascular accident c) Hydrocephalus d) Urinary tract infection

Hydrocephalus

In addition to newborns of diabetic mothers being at risk for hypoglycemia, these newborns are also at risk for which of the following? a) Hypermagnesemia b) Hypobilirubinemia c) Hypocalcemia d) Hyperkalemia

Hypocalcemia

A newborn has not passed any stools in the first 24 hours after birth, and his abdomen is becoming distended. The nurse recognizes that which of the following conditions could explain such findings? a) Imperforate anus b) Esophageal atresia c) Ankyloglossia d) Cleft palate

Imperforate anus

Over the course of an eight hour shift of postoperative care for a child who has had ventriculoatrial shunt placement, the nurse notes that the child's cry has become increasingly shrill and the child has projectile vomiting. The nurse would notify the physician immediately because of the possibility that the child might be experiencing a) A sudden increase in pain b) Increased intracranial pressure c) Infection at the surgical site d) Rejection of the shunt

Increased intracranial pressure

The nurse who is caring for newborn Andrew notices that although he has seemed healthy at 18 hours of age, Andrew's abdomen is now distended. By 24 hours he has passed no stool. The nurse will a) Inform the caregivers that Andrew might need surgery b) Schedule radiography to diagnose the problem c) Inform the physician of the findings d) Attempt to take a rectal temperature

Inform the physician of the findings

A pre-term newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanelle, cyanosis, and increased head circumference. These signs indicate the newborn most likely has which of the following complications? a) Cold stress b) Intraventricular hemorrhage (IVH) c) Respiratory distress syndrome d) Retinopathy of prematurity (ROP)

Intraventricular hemorrhage (IVH)

While the nurse is weighing and measuring a toddler during his annual checkup, the toddler's mother mentions that she is thinking of having another child. The toddler is small in stature and seems mildly developmentally delayed. His eyelid folds are short and his nose is flat. What do the toddler's characteristics suggest is the best advice the nurse can give this mother about pregnancy? a) It's a good idea to stop drinking alcohol 3 months before trying to get pregnant b) It's important to keep insulin levels controlled during pregnancy c) It would be good to stop smoking before getting pregnant d) It's important to add iron and vitamin B supplements to your diet

It's a good idea to stop drinking alcohol 3 months before trying to get pregnant

Which of the following is a common finding in the child who has a ventricular septal defect? a) Bounding pulse b) Delayed growth and development c) Fatigue and dyspnea d) Loud, harsh murmur

Loud, harsh murmur

Which of the following is a common finding in the child who has a ventricular septal defect? a) Delayed growth and development b) Loud, harsh murmur c) Bounding pulse d) Fatigue and dyspnea

Loud, harsh murmur

In the infant born with a cleft lip and a cleft palate, the highest priority of the nurse is related to which of the following? a) Maintaining the nutritional needs if the infant b) Promoting coping skills in the family caregivers c) Reducing family anxiety related to the treatment d) Managing the pain level of the infant

Maintaining the nutritional needs if the infant

A nurse is caring for a newborn whose chest x-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. The nurse should prepare for the management of which dangerous conditions when providing care to this newborn? a) Choanal atresia b) Diaphragmatic hernia c) Pneumonia d) Meconium aspiration syndrome

Meconium aspiration syndrome

The hereditary defect known as Phenylketonuria (PKU) will cause which of the following if left untreated? a) Strangulated intestine b) Congenital heart defects c) Increased intracranial pressure d) Mental retardation

Mental retardation

It would be best to place an infant with a myelomeningocele in which position prior to surgery? a) Supine with the head elevated b) On the stomach (prone) c) Semi-Fowler's in an infant chair d) On the left side with the head dependent

On the stomach (prone)

The nurse is assessing for developmental dysplasia of the hip in the newborn. The dislocated hip elicits a characteristic clunk as the femoral head slides over the posterior rim of the acetabulum and the dislocation feels reduced. Which maneuver did the nurse perform? a) Pavlik b) Gower c) Barlow d) Ortolani

Ortolani

The nurse is changing the diaper on a newborn and notices that there is a musty smell to the infant's urine. This finding is a characteristic sign of which of the following disorders? a) Turner syndrome b) Phenylketonuria c) Congenital hypothyroidism d) Galactosemia

Phenylketonuria

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration? a) Place a wedge under the child's crib. b) Place the child on the abdomen. c) Place the child on the back. d) Position the child on the side.

Position the child on the side.

A nurse is assigned to care for a newborn with esophageal atresia. What priority preoperative nursing care is the priority for this newborn? a) Prevent aspiration by elevating the head of the bed and insert an NG tube to low suction b) Administer antibiotics and total parenteral nutrition as ordered c) Provide NG feedings only d) Document the amount and color of esophageal drainage

Prevent aspiration by elevating the head of the bed and insert an NG tube to low suction

The nurse cares for a newborn with a congenital cardiac anomaly. What component of nursing care is the priority for the newborn? a) Accompany the newborn to all radiologic examinations b) Teach the parents to take pulse and blood pressure measurements c) Prevent pain as much as possible d) Maintain oxygen saturation at 95% or above

Prevent pain as much as possible

A nurse is working with a child who has spina bifida. The highest priority nursing goal for this child would be which of the following? a) Providing caregiver teaching b) Reducing family anxiety c) Promoting comfort measures d) Preventing infection

Preventing infection

An infant born is suspected of having persistent pulmonary hypertension of the newborn (PPHM). What intervention implemented by the nurse would be most beneficial in treating this client? a) Provide oxygen by oxygen hood or ventilator b) Encourage the parents to hold the infant for bonding c) Administer anticonvulsants as ordered d) Place the infant in a cool environment to prevent overheating

Provide oxygen by oxygen hood or ventilator

In the pre-term newborn, which of the following body systems are the most critical complications related to? a) Integumentary b) Immune c) Respiratory d) Digestive

Respiratory

In caring for the child with esophageal atresia the nurse recognizes the highest concern for this child is the possibility of which of the following? a) Respiratory distress b) Cardiac anomalies c) Excess bleeding d) Feeding difficulty

Respiratory distress

An infant has just been born with a cleft lip and palate. The birthing room suddenly becomes very quiet, and the birth team seem somber. The physician is busy examining the newborn, but the mother is obviously aware that something is not right. Which of the following should the nurse do? a) Say to the parents, "I'm very sorry. There appears to be a problem with your son. The doctor will be over shortly to talk to you about it." b) Say to the parents, "Your son has been born with a cleft lip and palate. This condition is highly treatable by surgery, however, and he is otherwise in excellent health." c) Wait until the physician has finished examining the baby, and allow her to tell the parents. d) When the physician has finished examining the baby, take the baby over to the mother and let her hold him and bond with him before discussing the condition.

Say to the parents, "Your son has been born with a cleft lip and palate. This condition is highly treatable by surgery, however, and he is otherwise in excellent health."

When assessing a newborn, the nurse determines that the newborn is most likely experiencing respiratory distress syndrome (RDS) based on which of the following? a) Peripheral cyanosis b) Slightly diminished breath sounds c) See-saw respirations d) Respiratory distress occurring by 6 hours of age

See-saw respirations

The parents of an infant with congenital club foot question the nurse about what the treatment will be to address this problem. What initial treatment plan would the nurse explain to the parents? a) Serial casting b) Application of bilateral braces c) Initiation of physical therapy d) Immediate surgery to straighten the ankle

Serial casting

What treatment can the nurse anticipate assisting with for a newborn with congenital talipes equinovarus? a) Serial casting b) Open reduction with internal fixation c) Pavlik harness d) Closed reduction

Serial casting

A nurse is caring for a newborn with jaundice undergoing phototherapy. What intervention is appropriate when caring for the newborn? a) Shield the newborn's eyes b) Expose the newborn's skin minimally c) Discourage feeding the newborn d) Discontinue therapy if stools are loose, green, and frequent

Shield the newborn's eyes

A nurse is performing a newborn assessment and notices a small dimple on the sacral area. The infant has a normal neurological assessment and moves all extremities well. What does the nurse suspect that the dimple indicates? a) Spina bifida with menigocele b) Spina bifida occulta c) A normal spinal closure d) Spina bifida with myelomeningocele

Spina bifida occulta

After teaching a group of students about the physiologic jaundice in breast-fed and bottle-fed newborns, the instructor determines that the teaching was successful when the students state which of the following? a) Jaundice associated with bottle feeding occurs in two distinct patterns. b) Peak bilirubin levels occur earlier for bottle-fed newborns than for breast-fed newborns. c) The decline in bilirubin levels occurs more quickly in bottle-fed newborns. d) Breast-fed newborns tend to have more frequent bowel movements.

The decline in bilirubin levels occurs more quickly in bottle-fed newborns.

The nurse is caring for a newborn with retinopathy of prematurity (ROP). Which of the following is the best explanation of this disorder? a) The infant has a degenerative disease of the retina b) The infant's lungs are immature and deficient in surfactant c) The infant has bleeding into the ventricles of the brain d) The infant's liver is unable to manage the bilirubin produced by hemolysis

The infant has a degenerative disease of the retina

The nurse is caring for a newborn with hyaline membrane disease. Which of the following is the best explanation of this disorder? a) The infant's lungs are immature and deficient in surfactant b) The infant's liver is unable to manage the bilirubin produced by hemolysis c) The infant has bleeding into the ventricles of the brain d) The infant has a degenerative disease of the retina

The infant's lungs are immature and deficient in surfactant

The nurse is caring for a newborn with retinopathy of prematurity (ROP). Which of the following is the best explanation of this disorder? a) The infant has bleeding into the ventricles of the brain b) The infant's liver is unable to manage the bilirubin produced by hemolysis c) The infant's lungs are immature and deficient in surfactant d) The infant has a degenerative disease of the retina

The infant's lungs are immature and deficient in surfactant

A nurse is assigned to care for a newborn with hyperbilirubinemia. The newborn is relatively large in size and shows signs of listlessness. What would have most likely happened to have caused these conditions to occur in the infant? a) The infant's mother must have had a long labor. b) The infant's mother probably used alcohol. c) The infant's mother probably had diabetes. d) The infant may have experienced birth trauma.

The infant's mother probably had diabetes.

A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects? a) The umbilical cord comes out of middle of the defect b) The intestines appear reddened and swollen and have no sac around them c) The abdominal contents are contained within a thin, transparent sac d) The skin over the abdomen is wrinkled and looks like a prune

The intestines appear reddened and swollen and have no sac around them

The nurse is caring for a newborn who was small for gestational age and has been determined to have the condition intrauterine growth restriction (IUGR). Which of the following factors would most likely have contributed to this condition? a) The mother of this newborn smoked until 4 years ago b) The mother of this newborn has been pregnant 3 previous times c) The mother of this newborn has a history of abnormal blood glucose levels d) The mother of this newborn was on a food stamp program during pregnancy

The mother of this newborn has a history of abnormal blood glucose levels

The nurse is caring for a newborn of a substance abusing mother who is withdrawing from alcohol. Which of the following would the nurse likely see in this newborn? a) The newborn has a large head circumference b) The newborn is lethargic and sleepy c) The newborn is hyperactive and irritable d) The newborn is above average birth weight

The newborn is hyperactive and irritable

The nurse is caring for a newborn with hemolytic disease of the newborn who is receiving phototherapy. Which of the following nursing interventions would be most appropriate for the nurse to do? a) The nurse dresses the newborn in a lightweight gown at night b) The nurse leaves the light off for one hour 6 times a day c) The nurse turns the newborn every 3 or 4 hours d) The nurse removes and changes the eye patches every hour

The nurse turns the newborn every 3 or 4 hours

The nurse is reinforcing discharge teaching with the mother of an infant who is being discharged prior to having a required blood test done. The nurse explains to this mother that she needs to bring the newborn back to check the infant's phenylalanine level. Which of the following is most accurate related to this blood test? a) It is common to perform this test after the newborn is five days old. b) The test is done after the newborn has ingested protein. c) If the test is not done the newborn could be mentally retarded. d) The test is done by drawing blood from the infant's umbilical cord.

The test is done after the newborn has ingested protein.

The nurse is caring for a newborn who has transient tachypnea of the newborn. In discussing the contributing factors for this disorder which of the following statements is most accurate? a) This disorder is associated with fetal distress during labor b) This disorder is often seen in newborns born by cesarean delivery c) This disorder usually occurs when the mother has a history of hypertension d) This disorder may be seen with advanced gestational age

This disorder is often seen in newborns born by cesarean delivery

A meconium plug is an extremely hard portion of meconium that has completely blocked the intestinal lumen, causing bowel obstruction. a) True b) False

True

In working with the child or family of a child with a congenital disorder, the most effective nursing intervention for this child or family would be for the nurse to a) Keep the family informed about new and effective treatments b) Use reflective listening and offer nonjudgmental support c) Help the child to understand his or her limitations d) Model good medical practices for the child's family

Use reflective listening and offer nonjudgmental support

In working with the child or family of a child with a congenital disorder, the most effective nursing intervention for this child or family would be for the nurse to a) Model good medical practices for the child's family b) Keep the family informed about new and effective treatments c) Help the child to understand his or her limitations d) Use reflective listening and offer nonjudgmental support

Use reflective listening and offer nonjudgmental support

Following birth the newborn's independent circulatory system is established. If there is an abnormal opening between the chambers in the heart, which of the following cardiac defects may occur? a) Patent ductus arteriosus b) Transposition of the great vessels c) Coarctation of the aorta d) Ventricular septal defect

Ventricular septal defect

A procedure used in the treatment of the child with hydrocephalus is to surgically insert a shunt that drains cerebrospinal fluid into a chamber in the heart. This type of shunt procedure is referred to as which of the following? a) Ventricular septal b) Ventriculoatrial c) Atrial septal d) Ventriculoperitoneal

Ventriculoatrial

An infant develops hydrocephalus at 2 weeks of age. Which of the following would you expect to assess? a) Hypothermia in the late afternoon b) White sclera showing above the pupils c) A soft, fretful cry d) Excessive thirst

White sclera showing above the pupils

While caring for a post term infant, the nurse recognizes that the elevated hematocrit level most likely results from a. hypoxia in utero b. underproduction of red blood cells c. increased breakdown of red blood cells d. the normal expected shift from fetal hemoglobin to normal hemoglobin

a. hypoxia in utero rationale: While in utero, the infant who is hypoxic will compensate by producing more red blood cells.

The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of a. persistent pulmonary hypertension b. bronchopulmonary dysplasia c. transitory tachypnea of the newborn d. left to right shunting of blood through the foramen ovale.

a. persistent pulmonary hypertension rationale: persistent pulmonary hypertension can result from the aspiration of meconium.

The priority assessment for the Rh-positive infant whose mothers indirect Coombs test was positive at 36 weeks is a. skin color b. temperature c. respiratory rate d. blood glucose level

a. skin color rationale: An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells and exhibit skin pallor because of erythroblastosis fetalis.

Which intervention should make phototherapy most effective in reducing the indirect bilirubin in an affected newborn. a. Turn the infant every 2 hours b. place eye patches on the newborn c. wrap the infant in triple blankets to prevent cold stress d. increase the oral intake of water between and before feedings.

a. turn the infant every 2 hours. rationale: exposure of all parts of the skin increases the effectiveness of phototherapy.

The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice a. usually results in kernicterus b. appears during the first 24 hours of life c. begins on the head and progresses down the body d. results from the breakdown of excessive erythrocytes not needed after birht.

b. appears during the first 24 hours of life rationale: non-physiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life.

The nurse notes that the infant has been feeding poorly over the last 24 hours. She should immediately assess for other signs of a. hyperglycemia b. neonatal infection c. hemolytic anemia d. increased bilirubin levels.

b. neonatal infection rationale: signs of neonatal infection (Sepsis) in the newborn are subtle. Temp instability, respiratory problems, and changes in feeding habits may be common.

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula feedings or breastfeeding is to a. prevent hyperglycemia b. provide fluids and protein. c. decrease gastrointestinal motility d. prevent rapid emptying of the bilirubin from the bowel.

b. prevent fluids and protein. rationale: proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infants system

The nurses immediate action after the birth of a post term infant with meconium stained amniotic fluid is to a. stimulate the infant to cry b. suction the infants airways c. complete the 1- and 5-minute Apgar d. vigorously dry the infants head and trunk

b. suction the infants airways rationale: meconium in the upper airways may be pulled deep into the respiratory passages when the infant takes the first breath after birth.

Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high pitched cry. Which nursing action has top priority a. Notify the clinician stat b. test for the blood glucose level c. start an IV with D5W d. document the event in the nurses notes.

b. test for the blood glucose level rationale: these symptoms are signs of hypoglycemia in the newborn.

Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome a. A 35 week gestation male baby born vaginally to a mother addicted to heroin b. A 35 week gestation female baby born vaginally 72 hours after the rupture of membranes c. A 36 week gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes d. A 35 week gestation female born vaginally to a mother who has pregnancy induced hypertension

c. A 36 week gestation male baby born by cesarean birth to a mother with insulin dependent diabetes. rationale: infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome.

Transitory tachypnea of the newborn (TTN) is thought to occur as a result of a. a lack of surfactant b. hypoinflation of the lungs c. delayed absorption of fetal lung fluid d. a slow vaginal birth associated with meconium-stained fluid

c. delayed absorption of fetal lung fluid rationale: delayed absorption of fetal lung fluid is thought to be the reason for TTN

Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the NICU for closer observation, with a diagnosis of transient tachypnea (TTN). The parents are notified and become anxious because they have no idea what this means in terms of medical condition. The best action that the nurse can take at this time is to a. refer them to the neonatologist for more information b. tell them not to worry because their infant will be monitored closely by trained staff c. explain to them that this often occurs following a birth but it will most likely resolve in the next 24 to 48 hours. d. Tell them that they will be able to come and see their baby, which will help make them feel better.

c. explain to them that this often occurs following a birth but it will most likely resolve in the next 24 to 48 hours. rationale: the clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition.

An infant with severe meconium aspiration syndrome is not responding to conventional treatment. Which method of treatment may be available at a level III facility for use with this infant. a. insertion of an endotracheal tube b. respiratory support with a ventilator c. extracorporeal membrane oxygenation d. insertion of a laryngoscope and suctioning of the trachea.

c. extracorpeal membrane oxygenation rationale: extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infants lungs to rest and recover.

Which defect is present with tetralogy of Fallot a. Patent ductus arteriosus b. Coarctation of the aorta c. Hypertrophy of the right ventricle d. Transposition of the great arteries.

c. hypertrophy of the right ventricle rationale: tetralogy of Fallot has four characteristics- ventricular septal defect, positioning stenosis, and hypertrophy of the right ventricle.

Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant. a. Direct Coombs test based on maternal blood sample b. indirect Coombs test based on infant cord blood sample c. infant bilirubin level d. maternal blood type.

c. infant bilirubin level rationale: the direct coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples.

A mother with diabetes has done some reading about the effects of her condition on a newborn. Which statement shows a misunderstanding that should be clarified by the nurse a. The red appearance of my babys skin is due to an excessive number of red blood cells. b. My baby will be watched closely for signs of low blood sugar, especially during the early days after birth c. My babys pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy. d. Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be.

c. my babys pancreas may not produce insulin because the cells became smaller than normal during pregnancy. rationale: infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need.

While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth. a. Risk for infection related to release of meconium b. risk for injury related to high risk birth interventions, such as amino infusion c. risk for aspiration related to retained secretions d. risk for thermoregulation because of high risk labor status.

c. risk for aspiration related to retained secretions. rationale: because the fetus has already passed meconium in utero, the labor and birth take on a high risk management perspective.

When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find a. cyanosis b. diuresis c. signs of pulmonary congestion d. increased oxygenation of the tissues.

c. signs of pulmonary congestion rationale: mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion.

The nurse present at the birth reporting to the nurse who will be caring for the neonate after birth. Which information should be included for an infant who had thick meconium in the amniotic fluid. a. The parents spent an hour bonding with the baby after birth b. An IV was started immediately after birth to treat dehydration c. There was no meconium below the vocal cords when they were visualized. d. the infant needed vigorous stimulation immediately after birth to initiate crying.

c. there was no meconium below the vocal cords when they were visualized. rationale: a laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome.

which of the following lab values indicates that an infant may have polycythemia a. Hb 18 g/dL, Hct 50% b. Hb 25/dL, Hct 55% c. Hb 20/dL, Hct 65% d. Hb 30 g/dL, Hct 70%

d. Hb 30 g/dL, Hct 70% rationale: the presence of polycythemia in an infant is characterized by a hemoglobin level greater than 22 and a hematocrit value greater than 65%

Newborns whose mothers are substance abusers frequently have which behaviors. a. Hypothermia, decreased muscle tone, and weak sucking reflex b. excessive sleep, weak cry, and diminished grasp reflex c. circumoral cyanosis, hyperactive Babinski reflex, and constipation d. Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding.

d. decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding. rationale: Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors.

In an infant with cyanotic cardiac anomaly, the nurse should expect to see a. feedings taken eagerly b. a consistent and rapid weight gain c. a decrease in the heart rate with activity. d. little to no improvement in color with oxygen administration

d. little to no improvement in color with oxygen administration rationale: with a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen.

The nurse should be alert to a blood group incompatibility if a. both mother and infant are O-positive b. mother is A positive and infant is A-negative c. mother is O positive and infant is B negative d. mother is B positive and infant is O negative.

d. mother is B positive and infant is O negative. rationale: blood group incompatibilities occur because O-positive mothers have natural antibodies to type A or B blood.

The infant of a diabetic mother is hypoglycemic. Which type of feeding should be instituted first a. glucose water b. D5W intravenously c. Formula via NG tube d. Small amount of glucose water followed by formula or breast milk

d. small amount of glucose water and followed by formula or breast milk.

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance, and that cleft palate is diagnosed in which of the following ways? a) ultrasound b) X-ray c) blood work d) feeling the palate with a gloved finger or using a tongue blade

feeling the palate with a gloved finger or using a tongue blade

When planning preoperative care for a newborn with a cleft lip and palate, a major need for which you would plan interventions is a) visual stimulation. b) prevention of pneumonia. c) nutrition. d) prevention of oral infection.

nutrition

What are the causes of retinopathy of the preterm newborn? Select all that apply. a) Assistive ventilation with high oxygen content b) Insufficient oxygenation in an Isolette c) Shock d) Alkalosis e) Fragility of blood vessels in the eyes in response to changes on oxygenation.

• Assistive ventilation with high oxygen content • Fragility of blood vessels in the eyes in response to changes on oxygenation. • Shock

A mother brings her 1-month-old daughter in for a visit to the doctor's office and mentions that her daughter tends to tilt her head to one side and rotates her chin to the opposite side. The nurse explains that this is a condition called torticollis and explains the interventions that are commonly used to correct this condition. Which of the following should she mention to the mother? (Select all that apply.) a) Administering botulism injections b) Feeding the child in such a way as to cause her to look toward the affected shoulder c) Placing a mobile on the child's crib on the affected side d) Applying an ice pack to the shoulder on the affected side 15 minutes daily e) Speaking to the child from the unaffected side f) Performing passive stretching exercises

• Performing passive stretching exercises • Feeding the child in such a way as to cause her to look toward the affected shoulder • Placing a mobile on the child's crib on the affected side

A woman who has a history of cocaine abuse gives birth to a newborn. Which of the following would the nurse expect to assess in the newborn? Select all that apply. a) Prolonged periods of sleeping b) Inconsolable c) Flaccid positioning d) Poor sucking e) Piercing cry

• Piercing cry • Poor sucking • Inconsolable