Deck 34: The Newborn at Risk: Birth-Related Stressors

Question 1

A patient in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of

A) Delivery of the neonate on its side with head up, to facilitate drainage of secretions.
B) Direct tracheal suctioning by specially trained personnel.
C) Preparation for the immediate use of positive pressure to expand the lungs.
D) Suctioning of the oropharynx when the newborn's head is delivered.
80) The nurse anticipates:

Answer 1

Direct tracheal suctioning by specially trained personnel.

Question 2

The patient with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. The best response by the nurse is:

A) "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization."
B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells."
C) "The red blood cells of your baby are breaking down because you both have type O blood."
D) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

Answer 2

"Your body has made antibodies against the baby's blood that are destroying her red blood cells."

Question 3

The nurse assesses a 12-hour-old newborn's serum bilirubin level and finds it to be 14 mg/dl. What nursing intervention would be included in the plan of care for this newborn?

A) Continue to observe.
B) Begin phototherapy.
C) Begin blood exchange transfusion.
D) Stop breastfeeding.

Answer 3

Begin phototherapy.

Question 4

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention?

A) Eyes are covered, no clothing on, diaper in place.
B) Axillary temperature
C) Infant removed from the isolette for breastfeeding
D) Loose bowel movement
99)7°F

Question 5

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require:

A) Initial resuscitation.
B) Vigorous stimulation at birth.
C) Phototherapy immediately.
D) An initial feeding of iron-enriched formula.

Question 6

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care?

A) Urine-specific gravity is assessed each voiding.
B) Eye coverings are left off to help keep the baby calm.
C) Temperature is checked every 6 hours.
D) The infant is taken out of the isolette for diaper changes.

Question 7

The nurse is caring for a newborn with jaundice. The parents why the newborn is not under phototherapy lights. The nurse explains that the fiber optic blanket is beneficial because:

A) Lights can stay on all the time.
B) The eyes do not need to be covered.
C) The lights will need to be removed for feedings.
D) Newborns do not get overheated.
E) Weight loss is not a complication of this system.

Question 8

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, the nursing instructor tells the students to:

A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood.
B) Use a previous puncture site.
C) Cool the heel prior to obtaining blood.
D) Use a sterile needle and aspirate.

Question 9

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?

A) Vasoconstriction and pallor
B) Blood glucose level of 45
C) Room-temperature IV running
D) Positioned under radiant warmer

Question 10

During newborn resuscitation, the nurse evaluates the effectiveness of bag-and-mask ventilations by:

A) The rise and fall of the chest.
B) Sudden wakefulness.
C) Urinary output.
D) Adequate thermoregulation.

Question 11

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment?

A) Decreased urine output
B) Pulmonary vascular resistance increases.
C) Increased PCO2
D) Increased urination

Question 12

Which nursing intervention is appropriate in the management of the preterm infant with hypothermia?

A) Warm the baby rapidly to reverse the hypothermia.
B) Monitor skin temperature every 2 hours to determine whether the infant's temperature is increasing.
C) Keep IV fluids at room temperature.
D) Initiate efforts to maintain the newborn in a neutral thermal environment.
E) Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

Question 13

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dl to 16.6 mg/dl in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn?

A) Continue to observe.
B) Begin phototherapy.
C) Begin blood exchange transfusion.
D) Stop breastfeeding.

Question 14

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn?

A) Jitteriness
B) Sucking on fingers
C) Lusty cry
D) Axillary temperature of 98°F

Question 15

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition?

A) Meconium aspiration syndrome
B) Transient tachypnea of the newborn
C) Respiratory distress syndrome
D) Prematurity of the neonate

Question 16

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Note; Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text:

A) Jaundice present within the first 24 hours of life
B) Appearance of jaundice symptoms after 24 hours of life
C) Yellowish coloration of the sclera of the eyes
D) Cephalhematoma or excessive bruising
E) Cyanosis

Question 17

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). The nurse bases this assessment on all of the following data except:

A) Grunting respirations.
B) Nasal flaring.
C) Respiratory rate of 40 during sleep.
D) Chest retractions.

Question 18

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?

A) Begin chest compressions.
B) Deep-suction the airways.
C) Begin bag-and-mask ventilation.
D) Obtain a blood pressure reading.

Question 19

When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate?

A) Hypoxia
B) Respiratory alkalosis
C) Metabolic acidosis
D) Massive atelectasis
E) Pulmonary edema

Question 20

A newborn is receiving phototherapy. Which intervention by the nurse would be most important?

A) Measurement of head circumference
B) Encouraging the mother to stop breastfeeding
C) Stool guaiac testing
D) Assessment of hydration status

Question 21

Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement?

A) Obtain skin cultures.
B) Restrict parental visits.
C) Evaluate bilirubin levels.
D) Administer oxygen as ordered.
E) Observe for signs of hypoglycemia.

Question 22

The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected?

A) "If I had taken better care of myself, this wouldn't have happened."
B) "I've been sleeping very well since I had the baby."
C) "This is probably the doctor's fault."
D) "If I hadn't seen our baby's birth, I wouldn't believe she is ours."

Question 23

The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is:

A) "Your newborn likes to be touched."
B) "Stroking the newborn will help with stimulation."
C) "Visits must be scheduled between feedings."
D) "Your baby loves her pink blanket."

Question 24

Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy?

A) Cover the newborn's eyes at all times, even when not under the lights.
B) Close the newborn's eyelids before applying eye patches.
C) Inspect the eyes each shift for conjunctivitis, drainage, and corneal abrasions.
D) Keep the baby swaddled in a blanket to prevent heat loss.
E) Reposition the baby every 2 hours.

Question 25

The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy?

A) The newborn maintains a normal temperature.
B) Bilirubin level of 14 mg/dl
C) Decreased reflexes
D) Skin blanching yellow

Question 26

One day after giving birth vaginally, a patient develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. The expected care for her neonate includes:

A) Meticulous hand washing and antibiotic eye ointment administration.
B) Intravenous acyclovir (Zovirax) and contact precautions.
C) Cultures of blood and CSF and serial chest x-rays every 12 hours.
D) Parental rooming-in and four intramuscular injections of penicillin.

Question 27

The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment?

A) Hemoglobin
B) Hematocrit
C) Reticulocyte count
D) Direct Coombs' test
E) Cord serum OgM

Question 28

The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best?

A) "I'll bring you to your baby and then leave so you can have some privacy."
B) "Your baby is on a ventilator with 50% oxygen, and has an umbilical line."
C) "I am so sorry this has all happened. I know how stressful this can be."
D) "Your baby is working hard to breathe and lying quite still, and has an IV."

Question 29

The nurse assesses that a newborn's skin has a ruddy appearance and the peripheral pulses are decreased. The nurse suspects polycythemia. Which lab report might indicate that the newborn has polycythemia?

A) Central venous hematocrit level greater than 65%
B) Bilirubin level of 6 mg/dl
C) Venous hemoglobin level lower than 12 g/dl
D) Blood glucose level of 44 mg/dl

Question 30

The nurse is caring for a 41-weeks'-gestation infant born yesterday. The newborn's hematocrit is 75%. The best action by the nurse based on this finding is to:

A) Inform the parents that their baby has an abnormal lab value.
B) Call the physician and report the hematocrit level.
C) Notify the blood bank that a transfusion will be required.
D) Increase breastfeeding frequency, and supplement between feedings.

Question 31

Which findings would the nurse expect when assessing a newborn infected with syphilis?

A) Rhinitis
B) Fissures on mouth corners
C) Red rash around anus
D) Lethargy
E) Large for gestational age

Question 32

The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother:

A) Has a history of obsessive-compulsive disorder (OCD).
B) Has chlamydia.
C) Has delivered six other children by cesarean section.
D) Has a urinary tract infection (UTI).