Ricci Chapter 24 - Test Bank - 4th Edition || 100% Accurate
Solutions.
1. A newborn with severe meconium aspiration syndrome (MAS) is not responding to
conventional treatment. Which measure would the nurse anticipate as possibly necessary for this
newborn?
A. extracorporeal membrane oxygenation (ECMO)
B. respiratory support with a ventilator
C. insertion of a laryngoscope for deep suctioning
D. replacement of an endotracheal tube via X-ray Correct Answer: A
Rationale: If conventional measures are ineffective, then the nurse would need to prepare the
newborn for ECMO. Hyperoxygenation, ventilatory support, and direct tracheal suctioning are
typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO
would be the next step.
2. A nurse is providing care to a newborn. The nurse suspects that the newborn is developing
sepsis based on which assessment finding?
A. increased urinary output
B. interest in feeding
C. temperature instability
D. wakefulness Correct Answer: C
Rationale: Manifestations of sepsis are typically nonspecific and may include hypothermia
(temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy.
3. A nurse is providing care to a newborn who is receiving phototherapy. Which action would
the nurse most likely include in the plan of care?
A. keeping the newborn in the supine position
B. covering the newborn's eyes while under the bililights
C. ensuring that the newborn is covered or clothed
D. reducing the amount of fluid intake to 8 ounces daily Correct Answer: B
Rationale: During phototherapy, the newborn's eyes are covered to protect them from the lights.
The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept
undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid
intake is increased to allow for added fluid, protein, and calories.
4. A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The
nurse understands that the newborn most likely acquired this infection from which cause?
A. improper hand washing
B. contaminated formula
C. nonsterile catheter insertion
D. mother's birth canal Correct Answer: D
Rationale: Most often, a newborn develops a group B streptococcus infection during the birthing
process when the newborn comes into contact with an infected birth canal. Improper hand
washing, contaminated formula, and nonsterile catheter insertion would most likely lead to a
late-onset infection, which typically occurs in the nursery due to horizontal transmission.
, 5. Which action would be most appropriate for the nurse to take when a newborn has an
unexpected anomaly at birth?
A. Show the newborn to the parents as soon as possible while explaining the defect.
B. Remove the newborn from the birthing area immediately.
C. Inform the parents that there is nothing wrong at the moment.
D. Tell the parents that the newborn must go to the nursery immediately. Correct Answer: A
Rationale: When an anomaly is identified at or after birth, parents need to be informed promptly
and given a realistic appraisal of the severity of the condition, the prognosis, and treatment
options so that they can participate in all decisions concerning their child. Removing the
newborn from the area or telling them that the newborn needs to go to the nursery immediately is
inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is
wrong is inappropriate because it violates their right to know.
6. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea
based on the understanding that this type of feeding is necessary because:
A. lactase enzymatic activity is not adequate.
B. oxygen demands need to be reduced.
C. renal solute lead must be considered.
D. hyperbilirubinemia is likely to develop. Correct Answer: B
Rationale: For the newborn with transient tachypnea, the newborn's respiratory rate is high,
increasing the oxygen demand. Thus, measures are initiated to reduce this demand. Gavage
feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are
not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is
not increased.
7. Which information would the nurse include when teaching a new mother about the difference
between pathologic and physiologic jaundice?
A. Physiologic jaundice results in kernicterus.
B. Pathologic jaundice appears within 24 hours after birth.
C. Both are treated with exchange transfusions of maternal O- blood.
D. Physiologic jaundice requires transfer to the NICU. Correct Answer: B
Rationale: Pathologic jaundice appears within 24 hours after birth whereas physiologic jaundice
commonly appears around the third or fourth days of life. Kernicterus is more commonly
associated with pathologic jaundice. An exchange transfusion is used only if the total serum
bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's
blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic
jaundice often is treated at home.
8. A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for
the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse
determines that additional teaching is needed when the mother identifies which action as
appropriate for her newborn?
A. wrapping the newborn snugly in a blanket
B. waking the newborn every hour
C. checking the newborn's fontanels
D. offering a pacifier Correct Answer: B
Solutions.
1. A newborn with severe meconium aspiration syndrome (MAS) is not responding to
conventional treatment. Which measure would the nurse anticipate as possibly necessary for this
newborn?
A. extracorporeal membrane oxygenation (ECMO)
B. respiratory support with a ventilator
C. insertion of a laryngoscope for deep suctioning
D. replacement of an endotracheal tube via X-ray Correct Answer: A
Rationale: If conventional measures are ineffective, then the nurse would need to prepare the
newborn for ECMO. Hyperoxygenation, ventilatory support, and direct tracheal suctioning are
typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO
would be the next step.
2. A nurse is providing care to a newborn. The nurse suspects that the newborn is developing
sepsis based on which assessment finding?
A. increased urinary output
B. interest in feeding
C. temperature instability
D. wakefulness Correct Answer: C
Rationale: Manifestations of sepsis are typically nonspecific and may include hypothermia
(temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy.
3. A nurse is providing care to a newborn who is receiving phototherapy. Which action would
the nurse most likely include in the plan of care?
A. keeping the newborn in the supine position
B. covering the newborn's eyes while under the bililights
C. ensuring that the newborn is covered or clothed
D. reducing the amount of fluid intake to 8 ounces daily Correct Answer: B
Rationale: During phototherapy, the newborn's eyes are covered to protect them from the lights.
The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept
undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid
intake is increased to allow for added fluid, protein, and calories.
4. A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The
nurse understands that the newborn most likely acquired this infection from which cause?
A. improper hand washing
B. contaminated formula
C. nonsterile catheter insertion
D. mother's birth canal Correct Answer: D
Rationale: Most often, a newborn develops a group B streptococcus infection during the birthing
process when the newborn comes into contact with an infected birth canal. Improper hand
washing, contaminated formula, and nonsterile catheter insertion would most likely lead to a
late-onset infection, which typically occurs in the nursery due to horizontal transmission.
, 5. Which action would be most appropriate for the nurse to take when a newborn has an
unexpected anomaly at birth?
A. Show the newborn to the parents as soon as possible while explaining the defect.
B. Remove the newborn from the birthing area immediately.
C. Inform the parents that there is nothing wrong at the moment.
D. Tell the parents that the newborn must go to the nursery immediately. Correct Answer: A
Rationale: When an anomaly is identified at or after birth, parents need to be informed promptly
and given a realistic appraisal of the severity of the condition, the prognosis, and treatment
options so that they can participate in all decisions concerning their child. Removing the
newborn from the area or telling them that the newborn needs to go to the nursery immediately is
inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is
wrong is inappropriate because it violates their right to know.
6. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea
based on the understanding that this type of feeding is necessary because:
A. lactase enzymatic activity is not adequate.
B. oxygen demands need to be reduced.
C. renal solute lead must be considered.
D. hyperbilirubinemia is likely to develop. Correct Answer: B
Rationale: For the newborn with transient tachypnea, the newborn's respiratory rate is high,
increasing the oxygen demand. Thus, measures are initiated to reduce this demand. Gavage
feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are
not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is
not increased.
7. Which information would the nurse include when teaching a new mother about the difference
between pathologic and physiologic jaundice?
A. Physiologic jaundice results in kernicterus.
B. Pathologic jaundice appears within 24 hours after birth.
C. Both are treated with exchange transfusions of maternal O- blood.
D. Physiologic jaundice requires transfer to the NICU. Correct Answer: B
Rationale: Pathologic jaundice appears within 24 hours after birth whereas physiologic jaundice
commonly appears around the third or fourth days of life. Kernicterus is more commonly
associated with pathologic jaundice. An exchange transfusion is used only if the total serum
bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's
blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic
jaundice often is treated at home.
8. A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for
the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse
determines that additional teaching is needed when the mother identifies which action as
appropriate for her newborn?
A. wrapping the newborn snugly in a blanket
B. waking the newborn every hour
C. checking the newborn's fontanels
D. offering a pacifier Correct Answer: B
