Deck 24: High-Risk Newborn: Acquired and Congenital Conditions

Question 1

The nurse present at the birth is reporting to the nurse who will be caring for the neonate after the delivery. Prior to birth there was meconium present in the amniotic fluid. The infant presented with depressed respirations and weak muscle tone. Which information should be included in the report for this infant?

A) The parents spent an hour bonding with the baby after birth.
B) An IV was started immediately after birth to treat dehydration.
C) The infant required warmed humidified oxygen.
D) The infant was placed skin to skin with the mother.

Answer 1

The infant required warmed humidified oxygen.

Question 2

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) inadequate absorption of fetal lung fluid.
D) a delayed vaginal birth associated with meconium-stained fluid.

Answer 2

inadequate absorption of fetal lung fluid.

Question 3

Infection can be transmitted to the neonate from mother during the pregnancy or birth or from the mother, family members, visitors, or agency staff after birth. Which viral infections are most likely to be transmitted during the birth process? (Select all that apply.)

A) Hepatitis B
B) Rubella
C) Herpes
D) Varicella Zoster
E) Cytomegalovirus

Answer 3

Hepatitis B
Herpes
Cytomegalovirus

Question 4

Which intervention will increase the effectiveness 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.

Question 5

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 of the neonate (TTN). The parents are notified and become anxious because they have no understanding of what this means for their infant. The best action that the nurse can take at this time is to

A) refer them to the neonatologist for more information.
B) reassure them not to worry. The infant will be monitored closely by trained staff.
C) explain to them that this often occurs following a birth and 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 calm their anxiety.

Question 6

Which of the following lab values indicates that an infant may have polycythemia?

A) Hct 50%
B) Hct 55%
C) Hct 62%
D) Hct 70%

Question 7

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.

Question 8

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.

Question 9

The difference between nonphysiologic jaundice (pathologic jaundice) and physiologic jaundice is that nonphysiologic jaundice

A) may result 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.

Question 10

Newborns whose mothers are substance abusers frequently exhibit which of the following 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

Question 11

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.

Question 12

The drug-exposed infant often presents with irritability, frantic crying, and is difficult to console. Which nursing measures can be used to prevent this behavior in this high-risk infant? (Select all that apply.)

A) Keep the room well lit.
B) Swaddle the infant.
C) Rock slowly and gently.
D) Coo softly and gently.
E) Avoid pacifier use.

Question 13

The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. If breastfeeding must be supplemented, formula should be used instead of water. The purpose of this plan is to

A) prevent hyperglycemia.
B) provide fluids and protein.
C) decrease gastrointestinal motility.
D) prevent rapid emptying of the bilirubin from the bowel.

Question 14

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

Question 15

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 congestive heart failure.
D) increased oxygenation of the tissues.

Question 16

Which newborn should the nurse recognize as being at the greatest 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.

Question 17

The priority assessment for the Rh-negative 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.

Question 18

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

Question 19

The nurse notes that the infant has been feeding poorly over the last 24 hours. The nurse should immediately assess for other signs of

A) hyperglycemia.
B) neonatal infection.
C) hemolytic anemia.
D) increased bilirubin levels.

Question 20

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 D10W.
D) Document the event in the nurses' notes.