Answers)
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 correct answers Answer: 1
Explanation: 1. The presence of meconium in the amniotic fluid indicates that the fetus may be
suffering from asphyxia. Meconium-stained newborns or newborns who have aspirated
particulate meconium often have respiratory depression at birth and require resuscitation to
establish adequate respiratory effort.
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. correct answers Answer: 3
Explanation: 3. Most newborns can be effectively resuscitated by bag-and-mask ventilation.
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 correct answers Answer: 1, 3, 4, 5
Explanation: 1. Nonreassuring fetal heart rate pattern/sustained bradycardia would be considered
a potential need to resuscitate a newborn.
3. History of meconium in amniotic fluid would be considered a potential need to resuscitate a
newborn.
4. Prematurity would be considered a potential need to resuscitate a newborn.
5. Significant intrapartum bleeding would be considered a potential need to resuscitate a
newborn.
During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask
ventilations?
1. The rise and fall of the chest
2. Sudden wakefulness
3. Urinary output
4. Adequate thermoregulation correct answers Answer: 1
, Explanation: 1. With proper resuscitation, chest movement is observed for proper ventilation.
Pressure should be adequate to move the chest wall.
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 correct answers Answer: 3
Explanation: 3. A respiratory rate of 40 during sleep is normal.
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. correct answers Answer:
2
Explanation: 2. If the infant has absent or depressed respirations, heart rate less than 100
beats/min, or poor muscle tone, direct tracheal suctioning by specially trained personnel is
recommended.
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 correct answers Answer: 2
Explanation: 2. The infant is term and was born by cesarean, and is most likely experiencing
transient tachypnea of the newborn.
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
4. Increased urination correct answers Answer: 4
Explanation: 4. In babies with respiratory distress syndrome (RDS) who are on ventilators,
increased urination/diuresis may be an early clue that the baby's condition is improving.
When planning care for the premature newborn diagnosed with respiratory distress syndrome,
which potential complications would the nurse anticipate?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.