Exam 3 NUR 404 | Questions, Answers and Rationales

Exam 3 NUR 404 | Questions, Answers and Rationales A nurse is assessing a premature newborn and notes an episode of apnea lasting 25 seconds, accompanied by bradycardia. What is the priority nursing intervention? A. Notify the physician immediately. B. Administer oxygen via nasal cannula. C. Provide gentle tactile stimulation to the infant. D. Place the infant in a prone position to facilitate breathing. Rationale: Tactile stimulation can often prompt the infant to breathe again. Which of the following statements about apnea in newborns is true? A. Apnea episodes in newborns are typically self-resolving without intervention. B. A full stomach can enhance the risk of apnea by applying pressure to the diaphragm. C. All newborns should be placed on respiratory support after an apneic episode. D. Apnea monitors are primarily used for detecting bradycardia in infants. Rationale: Many episodes may resolve spontaneously; however, monitoring and gentle stimulation are critical. A nurse is educating parents about managing apnea in their premature infant. Which instruction is most important to include? A. Allow the infant to sleep on their stomach to prevent apnea. B. Provide tactile stimulation only if the infant appears to be in distress. C. Maintain a neutral thermal environment to help prevent apnea episodes. D. Frequent feedings will help the infant gain weight and reduce apnea. Rationale: A neutral thermal environment is crucial for reducing fatigue and preventing apnea. When monitoring a newborn for apnea, which finding would indicate the need for immediate intervention? A. The infant is occasionally still for 15 seconds during sleep. B. The infant's heart rate drops to 80 beats per minute during an apneic episode. C. The infant demonstrates rhythmic breathing interspersed with short pauses. D. The infant exhibits a bluish tint to the lips during an apneic episode. Rationale: Assessing the infant is the first step in determining the need for further intervention. A nurse is caring for a newborn who has just been resuscitated. The infant exhibits signs of hypoglycemia. What is the most appropriate nursing action? A. Administer intravenous fluids with dextrose as prescribed. B. Encourage oral feeding immediately to boost blood sugar levels C. Monitor the infant's blood pressure closely for changes. D. Document the findings and continue to observe the infant. Rationale: Immediate treatment for hypoglycemia in a newborn typically includes intravenous dextrose to raise blood sugar levels effectively. Which assessment finding in a newborn would indicate a need for further evaluation of fluid status? A. Urine output of 3 mL/kg/hr. B. Urine specific gravity of 1.020. C. Pallor and tachycardia observed during assessment. D. Consistent feeding pattern with adequate weight gain. Rationale: Pallor and tachycardia can indicate hypovolemia and inadequate tissue perfusion, necessitating further evaluation of fluid status. A newborn presents with signs of tachypnea, decreased arterial blood pressure, and decreased tissue perfusion. What is the most likely underlying condition? A. Fetal blood loss due to placenta previa. B. Hypoglycemia from resuscitation efforts. C. Infection leading to sepsis. D. Congenital heart defect affecting circulation. Rationale: The symptoms described are consistent with hypovolemia, often resulting from fetal blood loss in conditions like placenta previa. A nurse is caring for a high-risk newborn who has just undergone resuscitation. Which intervention is most important to maintain the infant's temperature? A. Place the newborn under a radiant warmer B. Dress the infant in multiple layers of clothing. C. Allow the infant to acclimate to room temperature gradually. D. Frequently assess the infant's temperature every hour. Rationale: A radiant warmer provides a controlled environment to maintain the newborn's temperature, especially after resuscitation. A newborn is placed in an environment that is too cold. What physiological response can be expected in the infant? A. Increased metabolic rate and vasodilation. B. Decreased oxygen demand and respiratory rate. C. Increased metabolic rate and vasoconstriction of peripheral blood vessels. D. Decreased production of surfactant in the lungs. Rationale: In a cold environment, the newborn increases metabolism to generate heat, leading to vasoconstriction to conserve body heat. Which of the following statements made by a nursing student regarding thermoregulation in high-risk newborns indicates a need for further education? A. "Keeping the newborn in a neutral-temperature environment minimizes metabolic demand." B. "If the environment is too hot, the infant's metabolism decreases to cool the body." C. "Prolonged cold exposure can lead to metabolic acidosis due to anaerobic glycolysis." D. "High temperatures prevent the ductus arteriosus from remaining open." Rationale: High temperatures can increase metabolic demand, not prevent the ductus arteriosus from remaining open; it's the hypoxia and low PO2 that may keep it open. A high-risk newborn is experiencing hypoxia due to respiratory difficulty. Which compensatory mechanism is the infant likely to exhibit? A. Peripheral vasodilation to increase blood flow. B. Increased cardiac output to enhance oxygen delivery. C. Shunting of blood away from peripheral tissues toward vital organs. D. Decreased respiratory rate to conserve energy. Rationale: To prioritize oxygen delivery to essential body functions, the body shunts blood to the central torso, reducing perfusion to peripheral tissues. A nurse is assessing a high-risk newborn who has been in a cold environment for an extended period. Which laboratory finding would most likely indicate the consequence of prolonged cold exposure? A. Elevated PO2 levels and decreased PCO2 levels. B. Increased arterial blood pH and decreased bicarbonate levels. C. Decreased PO2 levels and increased lactic acid in the blood. D. Normal blood glucose levels and elevated respiratory rate. Rationale: Prolonged cold exposure leads to increased metabolism and anaerobic glycolysis, resulting in hypoxia (lowered PO2) and lactic acid accumulation. A nurse is caring for a newborn who experienced severe asphyxia at birth and is currently receiving intravenous fluids. What is the most appropriate nursing action if the infant's respiratory rate remains rapid and ineffective for sucking? A. Encourage oral feedings with breast milk. B. Initiate gavage feedings using expressed breast milk. C. Delay all feeding until respiratory status improves. D. Consult a dietitian for specialized nutritional needs. Rationale: Gavage feedings can provide necessary nutrition when the infant cannot suck effectively due to respiratory distress. A premature neonate is showing signs of hunger, such as rooting and sucking motions. Which feeding method should the nurse prioritize to provide optimal nutrition? A. Formula feeding through a bottle. B. Gavage feeding with expressed breast milk. C. Total parenteral nutrition (TPN). D. Gastrostomy tube feeding. Rationale: Breast milk offers immune protection and optimal nutrients, making it the best choice for premature infants, especially in a gavage feeding situation. What is a key benefit of offering oral stimulation, such as a pacifier, to a neonate receiving gavage or gastrostomy feedings? A. It decreases the need for intravenous fluids. B. It helps the infant develop proper sucking reflexes. C. It ensures adequate caloric intake. D. It prevents the risk of aspiration during feeding. Rationale: Oral stimulation promotes the development of the sucking reflex, which can aid in transitioning to oral feedings later. Which of the following statements regarding the feeding of premature neonates is accurate? A. Premature neonates do not require breast milk since formula is nutritionally superior. B. Gavage feeding should only be used for infants who are unable to suck due to congenital anomalies. C. Expressed breast milk can be utilized in gavage feeding to provide optimal nutrition. D. Oral stimulation is unnecessary for infants who are being fed via gastrostomy tube. Rationale: Using expressed breast milk in gavage feeding offers the nutritional benefits of breast milk to premature infants. A nurse is educating a new mother about the feeding practices for her premature infant. Which statement by the mother indicates a need for further teaching? A. "I should look for signs of hunger like rooting and sucking motions." B. "It's best to introduce bottle feeding as soon as possible to encourage sucking." C. "I can use my expressed breast milk for my baby's gavage feedings." D. "Gavage feeding will help my baby get the nutrition needed until they can suck effectively." Rationale: Premature infants may need to continue gavage feedings until they are stable enough to suck effectively; immediate bottle feeding may not be appropriate. A nurse is assessing a premature neonate who has just undergone resuscitation. The nurse notes that the infant has not voided within the first 24 hours. Which of the following statements best explains the significance of this finding? A. The infant's lack of voiding indicates that the kidneys are likely not being perfused adequately. B. Most premature neonates will void later than term infants due to immature renal function. C. A delay in voiding is typical for all neonates and does not require further assessment. D. The absence of urine output suggests that the infant is dehydrated and needs intravenous fluids. Rationale: In immature neonates, especially those who have experienced resuscitation, a lack of urine output may signal inadequate blood pressure and renal perfusion, which is important to assess for improving conditions. A nurse is monitoring a premature neonate after a resuscitation attempt. The infant has not voided within the first 36 hours. What should the nurse do next? A. Increase the fluid intake to promote urine output. B. Document the finding and continue to monitor the infant. C. Notify the healthcare provider about the lack of urine output. D. Prepare to initiate dialysis due to renal failure. Rationale: A lack of urine output for 36 hours in a premature neonate is concerning and warrants immediate notification to the healthcare provider for further assessment and potential intervention. A nurse is assessing a newborn immediately after birth. The infant weighs 2,200 grams and is 35 weeks gestational age. How should the nurse classify this infant? A. Appropriate for gestational age (AGA) B. Small for gestational age (SGA) C. Low birth weight (LBW) D. Large for gestational age (LGA) Rationale: The infant weighs less than the 10th percentile for gestational age, classifying them as SGA. Additionally, they are LBW since they weigh less than 2,500 grams. A nurse notes that a newborn is classified as large for gestational age (LGA). Which of the following potential risks should the nurse monitor for in this infant? A. Increased risk of respiratory distress syndrome. B. Higher likelihood of hypoglycemia after birth C. Greater risk of hyperbilirubinemia. D. Higher incidence of congenital anomalies. Rationale: LGA infants are at increased risk for hypoglycemia due to the increased insulin production stimulated by their larger size. Which of the following newborns is classified as appropriate for gestational age (AGA)? A. A newborn weighing 2,800 grams at 39 weeks gestation. B. A newborn weighing 2,400 grams at 34 weeks gestation. C. A newborn weighing 3,200 grams at 42 weeks gestation. D. A newborn weighing 1,800 grams at 30 weeks gestation. Rationale: Newborns between the 10th and 90th percentiles for weight at their gestational age are classified as AGA. The first newborn falls within this range. A preterm infant has been diagnosed with normochromic, normocytic anemia. Which of the following interventions is most important for the nurse to include in the care plan? A. Monitor the infant for signs of respiratory distress. B. Assess for adequate nutritional intake, particularly vitamin E. C. Schedule frequent blood transfusions to increase red blood cell count D. Encourage early introduction of solid foods to enhance iron intake. Rationale: Monitoring for adequate vitamin E intake is crucial because it protects red blood cells from oxidative damage, thus helping to prevent anemia. What is the most appropriate nursing intervention to help prevent the development of anemia in a preterm infant immediately after birth? A. Administer an iron supplement as prescribed. B. Initiate phototherapy to reduce bilirubin levels. C. Delay cord clamping for a brief period. D. Increase the infant's fluid intake to improve hydration. Rationale: Delaying cord clamping allows for additional blood flow from the placenta to the infant, which can help increase blood volume and reduce the risk of anemia. Which laboratory finding would the nurse expect to see in a preterm infant diagnosed with normochromic, normocytic anemia? A. Decreased reticulocyte count and elevated hematocrit. B. Normal hemoglobin concentration and increased white blood cell count C. Normal red blood cell morphology with low hemoglobin levels. D. Microcytic red blood cells with low serum ferritin. Rationale: Normochromic, normocytic anemia is characterized by normal-sized red blood cells but decreased numbers and low hemoglobin levels. A nurse is explaining the mechanism of action of phototherapy for the treatment of hyperbilirubinemia in a premature neonate. Which explanation is most accurate? A. Phototherapy increases serum albumin levels, enhancing bilirubin binding. B. Phototherapy converts indirect bilirubin into a form that can be excreted without conjugation. C. Phototherapy directly destroys red blood cells to lower bilirubin production. D. Phototherapy stimulates the liver to produce more bilirubin-conjugating enzymes. Rationale: Phototherapy changes indirect bilirubin into water-soluble isomers that can be excreted in urine and bile without needing conjugation. Which statement about the management of indirect hyperbilirubinemia in premature infants is most accurate? A. Phototherapy is only necessary when bilirubin levels exceed 20 mg/dL B. Premature neonates typically require higher bilirubin levels for ABE to develop. C. Exchange transfusion is indicated if phototherapy fails to reduce bilirubin levels effectively. D. Breastfeeding should be discontinued to prevent elevated bilirubin levels. Rationale: If phototherapy does not adequately lower bilirubin levels, exchange transfusion may be necessary to prevent complications such as ABE. A nurse is caring for a small-for-gestational-age (SGA) infant who has been identified as being below the 10th percentile for birth weight. Which of the following are potential complications associated with SGA infants? (Select all that apply.) A. Hyperbilirubinemia B. Hypoglycemia C. Increased risk of respiratory distress syndrome D. Prolonged acrocyanosis E. High hematocrit levels Rationale: SGA infants can experience several complications, including hyperbilirubinemia due to polycythemia, hypoglycemia from inadequate nutrient stores, prolonged acrocyanosis due to poor perfusion, and high hematocrit levels related to increased red blood cell production. While SGA infants can be at risk for respiratory issues, this is not specifically a direct complication of being SGA compared to the other listed options. During a health education session, a nurse explains the risks associated with small-for-gestational-age (SGA) infants. Which complication should the nurse emphasize as being particularly common in SGA infants? A. Hypothermia B. Hyperbilirubinemia C. Congenital anomalies D. Neonatal infections Rationale: SGA infants are at risk for hyperbilirubinemia, often due to high hematocrit levels from polycythemia, which is a common complication associated with SGA status. A healthcare provider is assessing a newborn identified as small-for-gestational-age (SGA). What is the most critical assessment the nurse should perform on this infant? A. Measurement of head circumference B. Assessment of blood glucose levels C. Monitoring of respiratory rate D. Evaluation of temperature stability Rationale: Hypoglycemia is a common complication in SGA infants due to limited glycogen stores, making blood glucose assessment critical for their care. A nurse is caring for a small-for-gestational-age (SGA) infant with acrocyanosis. What is the most appropriate nursing intervention for this condition? A. Increase ambient temperature to warm the infant. B. Place the infant under a bilirubin light. C. Administer intravenous fluids. D. Perform heel stick for blood glucose monitoring. Rationale: Prolonged acrocyanosis in SGA infants can be due to poor perfusion or hypothermia, so warming the infant can help improve peripheral circulation A nurse is reviewing the pathophysiology of respiratory distress syndrome (RDS). Which statement best describes the role of surfactant in the lungs? A. Surfactant prevents the formation of pneumonia in neonates. B. Surfactant is produced in the liver and transported to the lungs. C. Surfactant reduces surface tension in the alveoli, preventing their collapse. D. Surfactant increases lung fluid levels to enhance gas exchange. Rationale: Surfactant is a phospholipid that decreases surface tension in the alveoli, allowing them to remain open during expiration. The other statements are incorrect regarding the role and origin of surfactant. During a routine assessment, a nurse observes that a newborn with RDS exhibits seesaw respirations. What does this finding indicate? A. Increased lung compliance B. Severe respiratory distress and impaired gas exchange C. Normal respiratory pattern for a newborn D. Adequate surfactant production Rationale: Seesaw respirations indicate significant respiratory distress, where the chest and abdomen move in opposition due to difficulty in breathing, suggesting impaired gas exchange. This is not a normal pattern for a newborn. A nurse is monitoring a newborn diagnosed with RDS. Which of the following findings would be most concerning and indicative of worsening respiratory status? A. Increased oxygen saturation levels B. Periods of apnea followed by bradycardia C. Presence of fine rales upon auscultation D. Occasional nasal flaring Rationale: Periods of apnea combined with bradycardia are serious signs of deteriorating respiratory status in a newborn with RDS. While the other findings may indicate distress, they are less critical than apnea and bradycardia. A nurse is caring for a premature infant diagnosed with respiratory distress syndrome (RDS) who has just received a surfactant replacement therapy via an endotracheal tube. Which of the following nursing interventions should the nurse prioritize to ensure the effectiveness of the surfactant and the infant's respiratory status? (Select all that apply.) A. Position the infant with the head of the incubator elevated. B. Suction the airway immediately after surfactant administration to clear secretions. C. Monitor the infant's oxygen saturation and adjust oxygen therapy as needed. D. Maintain the infant in a flat position to promote lung expansion. E. Avoid suctioning the infant's airway for as long as safely possible post-administration. Rationale: Elevating the head of the incubator helps the surfactant reach the lower lung areas. Monitoring oxygen saturation is crucial to ensure adequate oxygenation, and avoiding suctioning after administration helps retain the surfactant in the lungs. Suctioning immediately after surfactant administration (B) is inappropriate, and maintaining a flat position (D) does not support optimal lung function in this context. A nurse is educating a new parent about the administration of surfactant therapy for their newborn with RDS. Which statement made by the parent indicates a need for further teaching? A. "Surfactant helps keep the alveoli open by reducing surface tension." B. "My baby will be positioned flat on their back during the procedure." C. "This therapy will help improve my baby's breathing and oxygen levels." D. "We may need to monitor my baby for signs of complications after the treatment." Rationale: Positioning the infant flat on their back is incorrect; the infant should be positioned with the head elevated after surfactant administration to improve its effectiveness. The other statements accurately describe the purpose and monitoring associated with surfactant therapy. After administering surfactant to a newborn with RDS, the nurse observes that the infant's respiratory rate has increased and oxygen saturation levels are fluctuating. Which of the following interventions should the nurse implement? (Select all that apply.) A. Increase the oxygen flow rate to improve saturation levels. B. Assess for signs of pneumothorax, such as asymmetrical chest movement C. Continue to monitor respiratory status closely and document findings. D. Place the infant in a supine position to facilitate lung expansion. E. Prepare for possible re-intubation if the infant's condition worsens. Rationale: Assessing for signs of pneumothorax (B) is critical, especially after surfactant administration, and ongoing monitoring (C) is essential to document changes in status. Preparing for re-intubation (E) may be necessary if the infant's condition deteriorates. Increasing the oxygen flow rate (A) may not be effective without assessing the underlying cause of the fluctuations, and placing the infant supine (D) is not advisable; the infant should be in an elevated position to facilitate better lung function. A premature infant receiving ventilation support following surfactant therapy has an inspiratory/expiratory (I/E) ratio of 1:2. What concern should the nurse have regarding this ventilation strategy? A. It provides adequate time for gas exchange B. It may lead to increased risk of air trapping in the lungs. C. It requires higher pressures that could cause lung injury. D. It is appropriate for infants with compliant lungs. Rationale: An I/E ratio of 1:2 may require higher pressures for adequate ventilation, increasing the risk of lung injury or pneumothorax, especially in infants with stiff, noncompliant lungs. The other options do not address the concerns associated with this ventilation strategy. A nurse is assessing a newborn who is suspected to have transient tachypnea of the newborn (TTN). Which of the following findings would most likely support this diagnosis? A. Apnea and bradycardia episodes B. Nasal flaring and mild retractions C. Cyanotic mucous membranes D. Absent breath sounds on auscultation Rationale: Nasal flaring and mild retractions are common findings in TTN, reflecting increased respiratory effort. The other options indicate more severe distress or different conditions. A chest X-ray is performed on a newborn diagnosed with TTN. Which of the following findings is the nurse likely to observe? A. Hyperinflation of the lungs with a clear pleural space B. Consolidation in the right lower lobe C. Fluid in the lung fields with hyperexpansion D. Ground-glass opacities throughout both lungs Rationale: A chest X-ray in TTN typically shows fluid in the lungs along with hyperexpansion due to retained alveolar fluid. The other options are more indicative of other respiratory conditions. A nurse is educating parents about transient tachypnea of the newborn (TTN). Which statement by the parents indicates a need for further teaching? A. "TTN usually resolves within 36 hours after birth." B. "Our baby might have some difficulty feeding due to rapid breathing." C. "This condition is caused by a lack of mature surfactant production." D. "TTN is a serious condition that requires immediate intervention." Rationale: TTN is generally self-limiting and resolves with supportive care; it is not classified as a serious condition requiring immediate intervention. The other statements accurately reflect the nature and characteristics of TTN. A nurse monitors a newborn with TTN who exhibits a rapid respiratory rate. What is the most critical nursing action the nurse should take to ensure the infant's safety? A. Administer supplemental oxygen immediately. B. Assess the infant's ability to suck and breathe simultaneously. C. Position the infant flat to facilitate lung expansion. D. Schedule a follow-up chest X-ray within 24 hours. Rationale: Since TTN can make feeding difficult due to the rapid respiratory rate, assessing the infant's ability to suck and breathe is critical. While supplemental oxygen may be necessary, the immediate priority is to evaluate feeding safety. Positioning flat (C) is incorrect; infants should be elevated. Follow-up X-rays (D) are not routinely required. During the assessment of a newborn suspected of having meconium aspiration syndrome, the nurse notes the following findings: tachypnea, retractions, and coarse bronchial sounds on auscultation. What is the priority nursing intervention? A. Initiate positive-pressure ventilation. B. Administer oxygen therapy. C. Prepare for a chest X-ray. D. Place the newborn in a supine position. Rationale: Given the severe respiratory distress indicated by tachypnea and retractions, initiating positive-pressure ventilation is the immediate priority. While oxygen therapy (B) may be necessary, it is secondary to ensuring adequate ventilation. A chest X-ray (C) is not the immediate intervention, and a supine position (D) is not optimal for respiratory distress management. A mother is being educated about the risks associated with meconium-stained amniotic fluid. Which statement by the mother indicates a correct understanding of the risks? A. "My baby may need antibiotics to prevent pneumonia." B. "Meconium can only cause problems if it's inhaled after birth." C. "This condition will resolve on its own without any interventions." D. "Increased pulmonary resistance can cause my baby's heart to work harder." Rationale: Antibiotics may be necessary to prevent pneumonia in newborns who have aspirated meconium. The other statements are inaccurate; meconium can cause issues if aspirated in utero or at birth (B), not all cases resolve without intervention (C), and increased pulmonary resistance can indeed affect cardiac function (D). A nurse is providing care for a high-risk newborn during resuscitation at birth. Which of the following actions should the nurse take to support the parents effectively? A. Encourage the parents to leave the resuscitation area to minimize their distress. B. Explain each step of the resuscitation process to the parents as it occurs. C. Advise the parents to refrain from touching the newborn until the situation stabilizes. D. Limit the parents' visitation to once a day to allow the staff to focus on the neonate's care. Rationale: Keeping parents informed during resuscitation helps them understand the situation and feel involved in their newborn's care. Encouraging parents to leave (A) is not supportive, as they should be present if possible. Advising them not to touch the newborn (C) may hinder bonding, and limiting visitation (D) is contrary to fostering a connection with their infant. The nurse is educating new parents about Sudden Infant Death Syndrome (SIDS) and its risk factors. Which of the following statements made by the parents indicate a need for further teaching? (Select all that apply.) A. "We should always place our baby to sleep on their back to reduce the risk of SIDS." B. "It's okay to let our baby sleep on soft bedding as long as we check on them frequently." C. "Breastfeeding may help lower the risk of SIDS for our infant." D. "We should avoid exposing our baby to secondhand smoke, as it can increase the risk." E. "Having our baby sleep in the same bed with us is safe if we're careful." Rationale: B is correct because soft bedding increases the risk of SIDS, and checking frequently does not eliminate this risk. E is correct because bed-sharing is not recommended; while room-sharing without bed-sharing is safer, bed-sharing poses additional risks. A is a correct statement promoting safe sleep practices. C correctly highlights the protective benefits of breastfeeding against SIDS. D is also correct as avoiding secondhand smoke is crucial in reducing SIDS risk. A nurse is providing education to parents of a newborn about reducing the risk of SIDS. Which of the following strategies should the nurse include in the teaching? (Select all that apply.) A. "Place your baby to sleep on their stomach to promote better digestion." B. "Use a firm mattress and avoid soft bedding in the crib." C. "Encourage room-sharing without bed-sharing." D. "Offer a pacifier at nap and bedtime to help reduce SIDS risk." E. "Ensure your baby sleeps in a well-ventilated room to avoid overheating." Rationale: B is correct as a firm mattress and avoiding soft bedding are key recommendations for safe sleep. C is correct because room-sharing without bed-sharing is advised. D is correct; offering a pacifier has been shown to reduce the risk of SIDS. E is also correct; good ventilation helps prevent overheating. A is incorrect as sleeping on the stomach increases the risk of SIDS. During a health education session, a nurse outlines the potential contributing factors to SIDS. Which of the following factors should the nurse include? (Select all that apply.) A. Exposure to secondhand smoke. B. Sleeping in a car seat for long periods. C. Viral respiratory infections. D. Regular pediatric visits and immunizations. E. Distorted familial breathing patterns Rationale: A is correct; exposure to secondhand smoke increases the risk of SIDS. B is correct; prolonged sleeping in a car seat can increase risk. C is correct as viral respiratory infections can be contributing factors. E is correct because distorted familial breathing patterns can also be a risk. D is incorrect; while regular pediatric visits and immunizations are essential for overall health, they do not directly contribute to SIDS risk. The nurse is discussing risk factors associated with SIDS with a group of new parents. Which of the following factors should the nurse identify as increasing the risk for SIDS? (Select all that apply.) A. Infants of adolescent mothers. B. Infants who are exclusively breastfed. C. Infants with a family history of SIDS. D. Infants who sleep with a pacifier. E. Infants who are preterm or low birth weight. Rationale: A is correct; infants of adolescent mothers are at higher risk for SIDS. C is correct because a family history of SIDS increases the risk. E is correct; preterm or low birth weight infants are more vulnerable to SIDS. B is incorrect as breastfeeding is protective against SIDS. D is incorrect because using a pacifier is associated with a reduced risk of SIDS. A nurse is providing education to parents of an infant who has experienced an apparent life-threatening event (ALTE). Which of the following statements made by the parents indicate a need for further teaching? (Select all that apply.) A. "We should only worry if our baby experiences a color change without any other symptoms. B. "It's important for us to monitor our baby's breathing and heart rate with the apnea monitor." C. "If the monitor alarms, we should immediately start mouth-to-mouth resuscitation." D. "We can benefit from community support to help us manage the stress of monitoring our baby." E. "As long as the apnea lasts less than 20 seconds, we don't need to do anything." Rationale: A is correct because parents should be aware that a color change can occur with other symptoms, and all symptoms should be taken seriously. C is correct; while mouth-to-mouth resuscitation may be necessary in some cases, parents should follow specific guidelines and assess the situation before initiating resuscitation. E is correct; any apnea lasting 20 seconds or longer requires attention and potential intervention. B is a correct statement emphasizing the importance of monitoring. D is also correct, as community support can provide reassurance and guidance for parents. A newborn is diagnosed with tracheoesophageal fistula (TEF) and esophageal atresia (EA). Which of the following findings would the nurse expect to observe in this infant? (Select all that apply.) A. Difficulty breathing and cyanosis during feeding B. Excessive drooling and inability to handle secretions C. Normal feeding patterns with no signs of distress D. Presence of a blind pouch upon imaging studies E. Choking or coughing during feeding attempts Rationale: A is correct; infants with TEF and EA often exhibit respiratory distress during feeding due to aspiration. B is correct; excessive drooling is common due to the inability to swallow secretions properly. C is incorrect; normal feeding patterns would not be expected due to the anatomical anomalies. D is correct; imaging may reveal a blind pouch in the upper esophagus. E is correct; choking or coughing during feeding is a hallmark sign of these conditions due to aspiration. A nurse is assessing a newborn suspected of having esophageal atresia (EA) and tracheoesophageal fistula (TEF). Which of the following assessments would be most critical for the nurse to perform? A. Measure the infant's weight to assess nutritional status. B. Assess for signs of respiratory distress during feeding. C. Monitor for jaundice as a potential complication D. Evaluate the infant's ability to suck and swallow effectively. Rationale: A is important but not the priority in the acute setting. B is correct; assessing for respiratory distress during feeding is critical due to the risk of aspiration. C, while important for overall assessment, is less directly related to EA and TEF. D is also relevant but secondary to monitoring for respiratory distress, as airway management is the priority. A newborn diagnosed with tracheoesophageal fistula (TEF) is admitted to the neonatal unit. Which nursing intervention should be the highest priority? A. Initiate oral feedings using a specialized nipple. B. Maintain the infant in an elevated position to reduce aspiration risk C. Schedule a chest X-ray to confirm the diagnosis. D. Teach the parents about potential long-term feeding difficulties. Rationale: Maintaining an elevated position is critical to reduce the risk of aspiration and respiratory distress in infants with TEF. During a feeding session, a nurse observes a newborn with tracheoesophageal fistula aspirate formula. What is the nurse's immediate priority action? A. Administer supplemental oxygen to the infant. B. Position the infant upright and provide suction as needed. C. Notify the healthcare provider about the incident. D. Continue the feeding to assess tolerance. Rationale: The immediate priority is to ensure the infant's airway is clear and to position them upright to reduce the risk of further aspiration. A nurse is caring for a newborn with a confirmed diagnosis of tracheoesophageal fistula (TEF). Which of the following should the nurse monitor most closely? A. Nutritional intake through oral feedings. B. Signs of respiratory distress during feedings. C. Daily weight to assess growth progress. D. The infant's ability to maintain a normal body temperature. Rationale: Monitoring for respiratory distress during feedings is critical due to the high risk of aspiration in infants with TEF. A nurse is educating the parents of a toddler diagnosed with an umbilical hernia. Which statement by the parents indicates a need for further teaching? A. "We should keep the area clean and dry to prevent infection." B. "Using a belly band will help reduce the hernia." C. "Surgery is usually recommended if the hernia is larger than 2 cm." D. "We will sponge bathe our child until the dressing is removed." Rationale: Using a belly band is not recommended as it can lead to bowel strangulation. This indicates a need for further teaching. The nurse is assessing a child with an umbilical hernia. Which finding would require immediate intervention? A. The hernia bulges when the child coughs. B. The child has not had a bowel movement in two days. C. The hernia is tender to the touch and has changed color. D. The hernia is reducible when the child is lying down. Rationale: Tenderness and color change of the hernia may indicate bowel strangulation, which is a surgical emergency requiring immediate intervention. After umbilical hernia repair surgery, the nurse instructs the parents on postoperative care. Which instruction is essential for preventing complications? A. "Allow your child to engage in normal activities as soon as they feel comfortable." B. "Keep the dressing dry and intact until the follow-up appointment." C. "Change the dressing daily to monitor for signs of infection." D. "Encourage your child to play outside to prevent constipation." Rationale: Keeping the dressing dry and intact is crucial to prevent infection and ensure proper healing. A neonate is diagnosed with omphalocele. During the initial assessment, which finding is most characteristic of this condition? A. The presence of a dark, necrotic sac covering the protruded organs B. A protrusion of abdominal contents covered by a thin, transparent membrane. C. An umbilical hernia with no associated sac. D. Visible intestinal loops with signs of peritonitis. Rationale: An omphalocele is characterized by the protrusion of abdominal contents through the abdominal wall, typically covered by a thin, transparent membrane. This is a key distinguishing feature of the condition. When planning care for a newborn with an omphalocele, which of the following interventions should the nurse prioritize? A. Immediate surgical intervention to correct the defect. B. Protecting the protruding organs with a sterile, moist dressing. C. Initiating oral feedings to prevent hypoglycemia. D. Providing education to the parents about home care post-surgery. Rationale: Protecting the protruding organs with a sterile, moist dressing is crucial to