Maternal Child NCLEX Review Questions

Maternal Child NCLEX Review Questions And Actual Answers A 12-hour-old infant has hemolytic disease of the newborn. What is the most common complication of this disorder? A. respiratory failure B. Liver failure C. Jaundice D. Blindness - Answer: C Rationale: Hemolytic disease of the newborn is caused by incompatibility of maternal and fetal blood types. When the fetal Rh-positive antigens or anti-A or anti-B antigens cross into the maternal circulation, the mother produces anti-Rh, anti-A, or anti-B antibodies. When the maternal anti-Rh, anti-A, or anti-B antibodies cross into the fetal circulation, these antibodies attack the fetal RBCs. The RBC destruction results in release of excess bilirubin, which the fetal or newborn's immature liver cannot metabolize; the result is newborn jaundice. Respiratory failure, liver failure, and blindness are not common complications of hemolytic disease of the newborn when appropriate treatment is provided. A 48-hour-old infant who is being breast-fed is diagnosed with physiological jaundice and is prescribed phototherapy treatment. Which measure taken by the nurse would enhance bilirubin excretion? A. keeping the infant snugly wrapped B. placing the infant in a quite, darkened area C. providing the infant with additional oral fluids every 3 hours D. encouraging the mother to temporarily suspend breast-feeding her infant - Answer: C Rationale: Phototherapy can cause insensible water loss, thus it is important to assess for dehydration and provide fluids. Proper fluid balance will promote bilirubin excretion. Keeping the infant wrapped in the dark and suspending breast-feedings will not enhance the excretion of bilirubin. A neonate experiences meconium aspiration at the time of delivery and develops respiratory distress syndrome (RDS). Which nursing diagnosis would be most appropriate for an infant diagnosed with this disorder? A. Risk for Infection B. Risk for Aspiration C. Impaired Gas Exchange D. Dysfunctional Ventilatory Weaning Response - Answer: C Rationale: Impaired gas exchange is the most appropriate nursing diagnosis because meconium aspiration interferes with the exchange of O2 and CO2. Risk for infection is present but is not as high a priority as impaired gas exchange. Risk for aspiration has already occurred. Dysfunctional ventilatory weaning response may be appropriate i the newborn demonstrates difficulty with the ventilatory weaning process A neonate weights 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. The nurse should instruct the mother to: A. increase the amount of formula to prevent further dehydration and weight loss B. continue feeding on demand because the noted weight loss is within normal limits C. give additional feedings because the weight loss indicates inadequate caloric intake D. switch to a different formula because the current one is inadequate to maintain weight - Answer: B Rationale: Neonates tend to lose 5% -- 10% of their birth weight during the first few days after birth, mostly because of decreased, but acceptable, nutrition and extracellular fluid loss. Increasing formula volumes and feedings or changing the formula is not necessary in this situation. A new father observes his newborn infant receiving a vitamin K injection and asks the nurse, "Why did my son need a shot?" The nurse's response should be based on the understanding that infants: A. need vitamin K to stimulate liver maturation B. cannot get enough vitamin K from their feeeings C. have a sterile intestinal tract and cannot synthesize vitamin K D. are often born with hypokalemia, which responds to vitamin K therapy - Answer: C Rationale: