High Risk Neonatal Nursing
Care with complete verified
solutions
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
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.
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
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
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.
, 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
The nurse will observe the neonate for respiratory status, apnea,
bradycardia, oxygenation, and feeding tolerance. The neonate needs to
exhibit cardiorespiratory regulation before oral feedings are started. This
is the most essential condition for oral feedings.
The NICU nurse encourages the mother of a premature neonate to bring
breast milk to the unit for enteral feedings to her baby. For which reason
does the nurse make this suggestion?
1. The baby will be more likely to breastfeed later.
2. The mother will feel more involved with the baby.
3. The neonate will gain weight faster on breast milk.
4. Breast milk helps prevent necrotizing enterocolitis
ANS 4
It is a known fact that babies fed on breast milk are less likely to develop
necrotizing enterocolitis.
The nurse is providing care for a premature neonate born at 28 weeks
gestation who is experiencing respiratory distress syndrome (RDS). Which
assessment finding indicates to the nurse that the neonate's respiratory
status is deteriorating?
1. Pao2 is 48 and Paco2 is 55 mm Hg on 90% oxygen.
2. Respiratory rate is 58 breaths per minute.
3. Breath sounds on auscultation are decreased.
4. Heart rate is 162 beats per minute
ANS 1
A sign that the neonate's respiratory status is deteriorating is if increased
oxygen levels fail to maintain a Pao2 and Paco2 within normal limits. The
normal range of Pao2 is 60 to 70 mm Hg and the normal range of Paco2 is
35 to 45 mm Hg. The neonate is unable to maintain a normal range on 90%
oxygen, which is a sign of deterioration.
The nurses in a NICU are concerned about the appropriate levels of oxygen
therapy during the care of premature neonates. The nurses referenced an
article by Newman (2014) titled, "Oxygen Saturation Limits and Evidence
supporting the Targets." On which evidence-based conclusion will the
nurses develop guidelines?
1. Oxygen saturation limits of 85% to 89% are effective.
2. Oxygen saturation rates of 91% to 95% are effective.
Care with complete verified
solutions
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
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.
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
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
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.
, 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
The nurse will observe the neonate for respiratory status, apnea,
bradycardia, oxygenation, and feeding tolerance. The neonate needs to
exhibit cardiorespiratory regulation before oral feedings are started. This
is the most essential condition for oral feedings.
The NICU nurse encourages the mother of a premature neonate to bring
breast milk to the unit for enteral feedings to her baby. For which reason
does the nurse make this suggestion?
1. The baby will be more likely to breastfeed later.
2. The mother will feel more involved with the baby.
3. The neonate will gain weight faster on breast milk.
4. Breast milk helps prevent necrotizing enterocolitis
ANS 4
It is a known fact that babies fed on breast milk are less likely to develop
necrotizing enterocolitis.
The nurse is providing care for a premature neonate born at 28 weeks
gestation who is experiencing respiratory distress syndrome (RDS). Which
assessment finding indicates to the nurse that the neonate's respiratory
status is deteriorating?
1. Pao2 is 48 and Paco2 is 55 mm Hg on 90% oxygen.
2. Respiratory rate is 58 breaths per minute.
3. Breath sounds on auscultation are decreased.
4. Heart rate is 162 beats per minute
ANS 1
A sign that the neonate's respiratory status is deteriorating is if increased
oxygen levels fail to maintain a Pao2 and Paco2 within normal limits. The
normal range of Pao2 is 60 to 70 mm Hg and the normal range of Paco2 is
35 to 45 mm Hg. The neonate is unable to maintain a normal range on 90%
oxygen, which is a sign of deterioration.
The nurses in a NICU are concerned about the appropriate levels of oxygen
therapy during the care of premature neonates. The nurses referenced an
article by Newman (2014) titled, "Oxygen Saturation Limits and Evidence
supporting the Targets." On which evidence-based conclusion will the
nurses develop guidelines?
1. Oxygen saturation limits of 85% to 89% are effective.
2. Oxygen saturation rates of 91% to 95% are effective.
