Mother/Baby HESIs 23 & 24
The nurse takes into consideration that the effect PKU has on the infant's development will depend primarily upon which factor? - Blood phenylalanine levels in utero - Excessive levels of epinephrine at birth - Diagnosis within the first 2 days after birth - Adherence to a corrective diet instituted early
- adherence to a corrective diet instituted early
At 42 weeks' gestation a client gives birth to an 8 lb 5 oz (3771 g) newborn. On examining the infant, what does the nurse expect to observe? Select all that apply. - Long nails - Wrinkled skin - Edematous skin - Abundant body hair - Obvious blood vessels in the skin
- long nails - wrinkled skin
The nurse is assigned to care for an infant in the newborn nursery who was born 4 hours ago. Maternal substance abuse is strongly suspected. Which symptoms are seen in neonates demonstrating signs of drug withdrawal? Select all that apply. - Tachypnea - Relaxed muscle tone - Exaggerated Moro reflex - Prolonged, high-pitched cry - Restlessness and excessive activity - Strong sucking and swallowing reflex
- tachypnea - exaggerated Moro reflex - prolonged, high-pitched cry - restlessness and excessive activity
Typical signs of neonatal abstinence syndrome related to opioid withdrawal usually begin within 24 hours after birth. What characteristics should the nurse anticipate in the infant of a suspected or known opioid abuser? Select all that apply. - Tremors - Dehydration - Hyperactivity - Muscle hypotonicity - Prolonged sleep periods
- tremors - hyperactivity
A neonate born at 35 weeks' gestation has Apgar scores of 8 and 9. At 4 hours of age the newborn begins to experience respiratory distress, has a below-normal temperature in a warm environment, and has a low blood glucose level. What problem does the nurse suspect? - Hypoglycemia - Bacterial sepsis - Cocaine withdrawal - Meconium aspiration
bacterial sepsis
The nurse must meet the hydration needs of a preterm infant. What should the nurse consider carefully regarding the preterm infant's kidney function? - Large amounts of urine are excreted - It is the same as in a full-term newborn - Urine is concentrated, with an increased specific gravity - Acid-base and electrolyte balance are adequately maintained
large amounts of urine are excreted
A newborn is admitted to the nursery and classified as small for gestational age (SGA). What is the priority nursing intervention for this infant? - Testing the infant's stools for occult blood - Monitoring the infant's blood glucose level - Placing the infant in the Trendelenburg position - Comparing the infant's head circumference and chest circumference
monitoring the infant's blood glucose level
A newborn is diagnosed as having neonatal abstinence syndrome (NAS) after exhibiting jitteriness, irritability, and a shrill cry. What is the priority nursing care? - Administering an opioid antagonist - Limiting fluid intake to inhibit vomiting - Assessing for age-appropriate developmental level - Reducing environmental stimuli to promote relaxation
reducing environmental stimuli to promote relaxation
Because preterm infants are at risk for respiratory distress syndrome, immediate nursing intervention is required when a preterm infant exhibits what sign? - Supraventricular retractions - Tachycardia of 160 beats/min - Respirations of 50-60 breaths/min - Neonatal Infant Pain Scale (NIPS) score of 3
supraventricular retractions
