Chapter 17
1. 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
\2. 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
\3. 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
\4. 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
\5. 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
\6. 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
\7. 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.
3. Infants are within saturation limits about 75% of the time.
1. 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
\2. 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
\3. 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
\4. 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
\5. 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
\6. 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
\7. 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.
3. Infants are within saturation limits about 75% of the time.
