Chapter 17 - High-Risk
Neonatal Nursing Care
questions and answers
2025
The nurse in NICU is assessing a neonate delivered at 32 weeks gestation.
Which pathophysiological manifestation is the nurse's greatest concern?
1. Absent or weak reflexes
2. Presence of a heart murmur
3. Apnea 20 seconds or longer
4. Low hemoglobin lab level
ANS: 3
1 This is incorrect. Absent or weak reflexes are expected in a premature
neonate because of neurologic immaturity.
2 This is incorrect. In a premature neonate, the presence of a heart
murmur is related to a patent ductus arteriosus. This finding is indicative
of circulation status; however, it is still not the nurse's greatest concern.
3 This is correct. Apnea for 20 seconds or longer is the nurse's greatest
concern. Even though this is expected in premature neonates, the nurse
will still focus on ABCs.
4 This is incorrect. Anemia is not unexpected in a premature neonate.
While this finding is a concern because of a reduction in the blood's ability
to carry sufficient oxygen, the greatest concern is still breathing issues.
The labor and delivery nurse is present for the delivery of a premature
neonate. Which action by the nurse is most important?
1. Stabilize and transfer neonate to NICU.
2. Review pregnancy history for risk factors.
3. Maintain fluid and electrolyte balance.
4. Provide a neutral temperature environment.
ANS: 4
1 This is incorrect. The premature neonate will need to be stabilized and
moved to NICU for specialized care; however, this is not the nurse's most
important action at the immediate time of birth.
, 2 This is incorrect. Review of the mother's pregnancy history in order to
identify risk factors related to prematurity is not an immediate concern.
3 This is incorrect. The nurse in NICU is likely to be involved in maintaining
fluid and electrolyte balance.
4 This is correct. When attending a premature birth, the most important
nursing action is to provide a neutral temperature environment (NTE). The
premature neonate is at risk for increased loss of heat because of
diminished amounts of subcutaneous fat. The nurse needs to take
measures to prevent cold stress, which can be fatal.
The nurse is providing care for a premature neonate in the NICU nursery.
The neonate is diagnosed with bronchopulmonary dysplasia (BPD) and
patent ductus arteriosus (PDA). Which specific intervention does the nurse
expect for this neonate?
1. Monitor of hemoglobin and hematocrit levels.
2. Obtain blood glucose levels.
3. Maintain fluid restrictions.
4. Administer enteral feedings.
ANS: 3
1 This is incorrect. Monitoring hemoglobin and hematocrit levels is an
expected intervention for premature neonates.
2 This is incorrect. Obtaining blood glucose levels is an expected
intervention for premature neonates.
3 This is correct. Maintaining fluid restrictions is specific for this neonate
due to bronchopulmonary dysplasia (BPD) and patent ductus arteriosus
(PDA). Fluid restrictions are appropriate for premature neonates with BPD,
PDA, or other complications that can lead to pulmonary edema.
4 This is incorrect. Administering enteral feedings is an expected
intervention for premature neonates.
A mother of a premature neonate in NICU asks the nurse when her baby
will begin getting oral feedings. The nurse is aware that multiple
conditions are desired. Which condition is most essential?
1. The neonate demonstrates proper feeding actions.
2. The neonate exhibits cardiorespiratory regulation.
3. The neonate is able to demonstrate hunger cues.
4. The neonate is able to maintain a quiet alert state
ANS: 2
1 This is incorrect. A premature neonate needs to be able to suck,
swallow, and breathe before oral feedings can be initiated. However, this
is not the most essential condition.
2 This is correct. The nurse will observe the neonate for respiratory
status, apnea, bradycardia, oxygenation, and feeding tolerance. The
Neonatal Nursing Care
questions and answers
2025
The nurse in NICU is assessing a neonate delivered at 32 weeks gestation.
Which pathophysiological manifestation is the nurse's greatest concern?
1. Absent or weak reflexes
2. Presence of a heart murmur
3. Apnea 20 seconds or longer
4. Low hemoglobin lab level
ANS: 3
1 This is incorrect. Absent or weak reflexes are expected in a premature
neonate because of neurologic immaturity.
2 This is incorrect. In a premature neonate, the presence of a heart
murmur is related to a patent ductus arteriosus. This finding is indicative
of circulation status; however, it is still not the nurse's greatest concern.
3 This is correct. Apnea for 20 seconds or longer is the nurse's greatest
concern. Even though this is expected in premature neonates, the nurse
will still focus on ABCs.
4 This is incorrect. Anemia is not unexpected in a premature neonate.
While this finding is a concern because of a reduction in the blood's ability
to carry sufficient oxygen, the greatest concern is still breathing issues.
The labor and delivery nurse is present for the delivery of a premature
neonate. Which action by the nurse is most important?
1. Stabilize and transfer neonate to NICU.
2. Review pregnancy history for risk factors.
3. Maintain fluid and electrolyte balance.
4. Provide a neutral temperature environment.
ANS: 4
1 This is incorrect. The premature neonate will need to be stabilized and
moved to NICU for specialized care; however, this is not the nurse's most
important action at the immediate time of birth.
, 2 This is incorrect. Review of the mother's pregnancy history in order to
identify risk factors related to prematurity is not an immediate concern.
3 This is incorrect. The nurse in NICU is likely to be involved in maintaining
fluid and electrolyte balance.
4 This is correct. When attending a premature birth, the most important
nursing action is to provide a neutral temperature environment (NTE). The
premature neonate is at risk for increased loss of heat because of
diminished amounts of subcutaneous fat. The nurse needs to take
measures to prevent cold stress, which can be fatal.
The nurse is providing care for a premature neonate in the NICU nursery.
The neonate is diagnosed with bronchopulmonary dysplasia (BPD) and
patent ductus arteriosus (PDA). Which specific intervention does the nurse
expect for this neonate?
1. Monitor of hemoglobin and hematocrit levels.
2. Obtain blood glucose levels.
3. Maintain fluid restrictions.
4. Administer enteral feedings.
ANS: 3
1 This is incorrect. Monitoring hemoglobin and hematocrit levels is an
expected intervention for premature neonates.
2 This is incorrect. Obtaining blood glucose levels is an expected
intervention for premature neonates.
3 This is correct. Maintaining fluid restrictions is specific for this neonate
due to bronchopulmonary dysplasia (BPD) and patent ductus arteriosus
(PDA). Fluid restrictions are appropriate for premature neonates with BPD,
PDA, or other complications that can lead to pulmonary edema.
4 This is incorrect. Administering enteral feedings is an expected
intervention for premature neonates.
A mother of a premature neonate in NICU asks the nurse when her baby
will begin getting oral feedings. The nurse is aware that multiple
conditions are desired. Which condition is most essential?
1. The neonate demonstrates proper feeding actions.
2. The neonate exhibits cardiorespiratory regulation.
3. The neonate is able to demonstrate hunger cues.
4. The neonate is able to maintain a quiet alert state
ANS: 2
1 This is incorrect. A premature neonate needs to be able to suck,
swallow, and breathe before oral feedings can be initiated. However, this
is not the most essential condition.
2 This is correct. The nurse will observe the neonate for respiratory
status, apnea, bradycardia, oxygenation, and feeding tolerance. The
