335 Chapter 31: The Newborn at Risk -
Birth-Related Stressors Final Exam
Questions and Actual Answers.
1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained
amniotic fluid. The nurse knows this newborn might require which of the following?
1. Initial resuscitation
2. Vigorous stimulation at birth
3. Phototherapy immediately
4. An initial feeding of iron-enriched formula - Answer 1. Initial resuscitation
2) 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?
1. Begin chest compressions.
2. Begin direct tracheal suctioning.
3. Begin bag-and-mask ventilation.
4. Obtain a blood pressure reading. - Answer 3. Begin bag-and-mask ventilation.
3) Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to
resuscitate a newborn?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Nonreassuring fetal heart rate pattern/sustained bradycardia
2. Fetal scalp/capillary blood sample pH greater than 7.25
3. History of meconium in amniotic fluid
4. Prematurity
5. Significant intrapartum bleeding - Answer 1. Nonreassuring fetal heart rate
pattern/sustained bradycardia
3. History of meconium in amniotic fluid
4. Prematurity
5. Significant intrapartum bleeding
, 3. Urinary output
4. Adequate thermoregulation - Answer 1. The rise and fall of the chest
5) A nurse explains to new parents that their newborn has developed respiratory distress
syndrome (RDS). Which of the following signs and symptoms would not be characteristic of
RDS?
1. Grunting respirations
2. Nasal flaring
3. Respiratory rate of 40 during sleep
4. Chest retractions - Answer 3. Respiratory rate of 40 during sleep
6) A client 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 80. What does the nurse anticipate?
1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions.
2. Direct tracheal suctioning by specially trained personnel.
3. Preparation for the immediate use of positive pressure to expand the lungs.
4. Suctioning of the oropharynx when the newborn's head is delivered. - Answer 2. Direct
tracheal suctioning by specially trained personnel.
7) 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?
1. Meconium aspiration syndrome
2. Transient tachypnea of the newborn
3. Respiratory distress syndrome
4. Prematurity of the neonate - Answer 2. Transient tachypnea of the newborn
8) 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?
1. Decreased urine output
2. Pulmonary vascular resistance increases
3. Increased PCO2
Birth-Related Stressors Final Exam
Questions and Actual Answers.
1) The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained
amniotic fluid. The nurse knows this newborn might require which of the following?
1. Initial resuscitation
2. Vigorous stimulation at birth
3. Phototherapy immediately
4. An initial feeding of iron-enriched formula - Answer 1. Initial resuscitation
2) 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?
1. Begin chest compressions.
2. Begin direct tracheal suctioning.
3. Begin bag-and-mask ventilation.
4. Obtain a blood pressure reading. - Answer 3. Begin bag-and-mask ventilation.
3) Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to
resuscitate a newborn?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Nonreassuring fetal heart rate pattern/sustained bradycardia
2. Fetal scalp/capillary blood sample pH greater than 7.25
3. History of meconium in amniotic fluid
4. Prematurity
5. Significant intrapartum bleeding - Answer 1. Nonreassuring fetal heart rate
pattern/sustained bradycardia
3. History of meconium in amniotic fluid
4. Prematurity
5. Significant intrapartum bleeding
, 3. Urinary output
4. Adequate thermoregulation - Answer 1. The rise and fall of the chest
5) A nurse explains to new parents that their newborn has developed respiratory distress
syndrome (RDS). Which of the following signs and symptoms would not be characteristic of
RDS?
1. Grunting respirations
2. Nasal flaring
3. Respiratory rate of 40 during sleep
4. Chest retractions - Answer 3. Respiratory rate of 40 during sleep
6) A client 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 80. What does the nurse anticipate?
1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions.
2. Direct tracheal suctioning by specially trained personnel.
3. Preparation for the immediate use of positive pressure to expand the lungs.
4. Suctioning of the oropharynx when the newborn's head is delivered. - Answer 2. Direct
tracheal suctioning by specially trained personnel.
7) 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?
1. Meconium aspiration syndrome
2. Transient tachypnea of the newborn
3. Respiratory distress syndrome
4. Prematurity of the neonate - Answer 2. Transient tachypnea of the newborn
8) 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?
1. Decreased urine output
2. Pulmonary vascular resistance increases
3. Increased PCO2
