ATI Maternal Newborn Test 5 Exam Study Guide

ATI Chapter 27: Assessment and Management of Newborn Complications 1. A nurse is caring for a client who is at 42 weeks gestation and in labor. The client asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make? A. “Your baby will have excess body fat.” B. “Your baby will have flat areola without breast buds.” C. “Your baby’s heels will easily move to his ears.” D. “Your baby’s skin will have a leathery appearance.” Rationale: A. Excess body fat is seen in a newborn who is macrosomic. B. Flat areolas without breast buds are seen in a newborn who is preterm. C. Heels that are movable fully to the ears are seen in a newborn who is preterm. D. CORRECT: Leathery, cracked, and wrinkled skin is seen in a newborn who is postmature due to placental insufficiency. 2. A nurse is caring for an infant who has a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? A. Conjunctivitis B. Bronze skin discoloration C. Sunken fontanels D. Maculopapular skin rash Rationale: A. Conjunctivitis is an important finding, but it is not the priority. B. Bronze skin discoloration is an important finding, but it is not the priority. C. CORRECT: Using the safety and risk reduction framework, sunken fontanels is the priority finding. Infants receiving phototherapy are at risk for dehydration from loose stools due to increased bilirubin excretion. D. Maculopapular skin rash is an important finding, but it is not the priority. 3. A nurse is called to the birthing room to assist with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. Which of the following are expected findings in this newborn? (Select all that apply.) A. Lanugo B. Long nails C. Weak grasp reflex D. Translucent skin E. Plump face Rationale: A. CORRECT: Characteristics of a preterm newborn include the presence of abundant lanugo. B. Long nails are a finding in a newborn who is postmature. C. CORRECT: A weak grasp reflex is characteristic of a preterm newborn. D. CORRECT: Skin that is thin, smooth, shiny, and translucent is a finding in a preterm newborn. E. A plump face would be observed in a newborn who is macrosomic. 4. A nurse is caring for a newborn who is preterm and has respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn’s condition following administration of synthetic surfactant? A. Oxygen saturation B. Body temperature C. Serum bilirubin D. Heart rate Rationale: A. CORRECT: Surfactant stabilizes the alveoli and helps increase oxygen saturation. B. Surfactant administration has no direct effect on body temperature. C. Surfactant administration has no direct effect on bilirubin levels. D. Surfactant administration has no direct effect on heart rate. 5. A nurse is teaching a newly licensed nurse about neonatal abstinence syndrome. Which of the following statements by the newly licensed nurse indicate understanding of the teaching? A. “The newborn will have decreased muscle tone.” B. “The newborn will have a continuous high‑pitched cry.” C. “The newborn will sleep for 2 to 3 hours after a feeding.” D. “The newborn will have mild tremors when disturbed.” Rationale: A. Increased muscle tone is seen in a newborn who has neonatal abstinence syndrome. B. CORRECT: A continuous high‑pitched cry is often an indication of CNS disturbances in a newborn who has neonatal abstinence syndrome. C. A newborn who has neonatal abstinence syndrome can have sleep pattern disturbances and would have difficulty sleeping for 2 to 3 hr after feeding. D. A newborn who has neonatal abstinence syndrome often has moderate to severe tremors when undisturbed. Most newborns exhibit mild tremors when disturbed. Chapter 30: The Newborn at Risk: Conditions Present at Birth 1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn? A) Offer early feedings with formula or breast milk. B) Provide glucose water exclusively. C) Evaluate blood glucose levels at 12 hours after birth. D) Assess for hyperthermia. Answer: A Explanation: A) IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum). B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) Blood glucose determinations should be performed by heel stick hourly during the first 4 hours after birth and at 4-hour intervals until the risk period (about 48 hours) has passed. D) Hypothermia is a potential problem for the SGA newborn due to decreased brown fat stores and minimal subcutaneous tissues. Page Ref: 758 2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity? A) 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory B) 23-year-old of low socioeconomic status, unmarried C) 16-year-old who began prenatal care at 30 weeks D) 28-year-old with a history of gestational diabetes Answer: A Explanation: A) This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic. B) The main risk factor for this client is her low socioeconomic status. C) This client has two risk factors: young age and late onset of prenatal care. D) This client's only risk factor is the history of gestational diabetes. Page Ref: 754 3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart? A) Preterm appropriate for gestational age, symmetrical IUGR B) Term small for gestational age, symmetrical IUGR C) Preterm small for gestational age, asymmetrical IUGR D) Preterm appropriate for gestational age, asymmetrical IUGR Answer: C Explanation: A) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. B) Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. C) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR. D) The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is considered small for gestational age. Page Ref: 755 4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn? A) Monitor for feeding difficulties. B) Assess for facial paralysis. C) Monitor for signs of hyperglycemia. D) Maintain a warm environment. Answer: D Explanation: A) LGA, not SGA, newborns are more difficult to arouse to a quiet alert state, and can have feeding difficulties. B) LGA, not SGA, newborns often are prone to birth trauma such as facial paralysis, due to cephalopelvic disproportion. C) SGA newborns are more prone to hypoglycemia. D) Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss. Page Ref: 756 5) The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority? A) Obtain a blood calcium level. B) Take the newborn's temperature. C) Obtain a bilirubin level. D) Place a pulse oximeter on the newborn. Answer: A Explanation: A) Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant. B) Body temperature might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. C) Bilirubin level might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. D) Oxygen saturation might be necessary to monitor, but obtaining a blood calcium level takes priority for this newborn. Page Ref: 762 6) A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action? A) To recheck the blood sugar in 6 hours B) To begin an IV of 10% dextrose C) To feed the baby 1 ounce of formula D) To document the findings in the chart Answer: D Explanation: A) Blood glucose determinations should be performed on blood by heel stick hourly during the first 4 hours after birth, and subsequently at 4-hour intervals. B) A blood sugar reading of 47 mg/dL is considered normal for a neonate. No IV is needed. C) Feeding would be appropriate if the infant's blood sugar was below 45 mg/dL, but this infant's reading is 47. D) A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action. Page Ref: 762 7) The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn? A) Offer early feedings. B) Administer an intravenous infusion of glucose. C) Assess for hypercalcemia. D) Assess for hyperbilirubinemia immediately after birth. Answer: A Explanation: A) Newborns of diabetic mothers may benefit from early feedings, as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia. B) If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion of glucose will be necessary. C) The newborn should be assessed for hypocalcemia. D) Hyperbilirubinemia can occur 48 to 72 hours after birth. Page Ref: 764 8) The nurse caring for a post-term newborn would not perform what intervention? A) Providing warmth B) Frequently monitoring blood glucose C) Observing respiratory status D) Restricting breastfeeding Answer: D Explanation: A) Provision of warmth is an important intervention for post-term newborns. B) Frequent monitoring of blood glucose is an important intervention for post-term newborns. C) Observation of respiratory status is an important intervention for post-term newborns. D) Breastfeeding is an appropriate means of feeding for the post-term newborn. Page Ref: 764 9) The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best? A) "Babies can develop postmaturity syndrome, which refers to a number of complications that can occur after 42 weeks of pregnancy." B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid." C) "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens." D) "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger." Answer: A Explanation: A) The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome. B) Although this statement is partially true, meconium-stained amniotic fluid is not always present or the only complication of postmaturity syndrome. C) Although this statement is true, it is too vague. It is better to be specific and call postmaturity syndrome by its name. D) Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an issue. Page Ref: 764 10) The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response? A) "Most newborns are nose breathers." B) "The tube will elicit the sucking reflex." C) "A smaller catheter is preferred for feedings." D) "Most newborns are mouth breathers." Answer: A Explanation: A) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. B) The tube or gavage feeding method is used with preterm infants who lack or have a poorly coordinated suckswallow-breathing pattern. C) A small catheter is used for a nasogastric tube to minimize airway obstruction. D) Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers. Page Ref: 772 11) A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. The nurse explains to the parents that due to oxygen therapy, their infant is at a greater risk for which of the following? A) Visual impairment B) Hyperthermia C) Central cyanosis D) Sensitive gag reflex Answer: A Explanation: A) Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina, causing characteristic retinal changes known as retinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has become the norm. B) Hypothermia is more common in premature infants. C) Central cyanosis can be caused by decreased oxygen. D) An absent or decreased gag reflex is more common in premature infants. Page Ref: 774 12) A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU? Select all that apply. A) Schedule care throughout the day. B) Silence alarms quickly. C) Place a blanket over the top portion of the incubator. D) Do not offer a pacifier. E) Dim the lights. Answer: B, C, E Explanation: A) Nursing care should be planned to decrease the number of times the baby is disturbed. B) Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly. C) Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator. D) Pacifiers can be offered because they provide opportunities for nonnutritive sucking. E) Dimming the lights may encourage infants to open their eyes and be more responsive to their parents. Page Ref: 779 13) The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity? A) Cry is weak and feeble B) Clitoris and labia minora are prominent C) Strong sucking reflex D) Lanugo is plentiful Answer: C Explanation: A) Findings that indicate prematurity include a weak cry. B) Findings that indicate prematurity include a prominent clitoris and labia minora. C) Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn. D) Findings that indicate prematurity include lanugo that is plentiful and widely distributed. Page Ref: 766 14) The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statement(s) by the parents indicate that additional teaching is needed? Select all that apply. A) "Our baby will be in an incubator to keep him warm." B) "Breathing might be harder for our baby because he is early." C) "The growth of our baby will be faster than if he were term." D) "Tube feedings will be required because his stomach is small." E) "Because he came early, he will not produce urine for 2 days." Answer: C, D, E Explanation: A) Preterm infants have little subcutaneous fat, and have difficulty maintaining their body temperature. An incubator or warmer is used to keep the baby warm. B) Surfactant production might not be complete at 34 weeks, which leads to respiratory distress syndrome. The infant may become hypoxic, pulmonary blood flow may be inefficient, and the preterm newborn's available energy is depleted. C) Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity. D) Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to the infant's poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex. E) Although preterm babies have diminished kidney function due to incomplete development of the glomeruli they can produce urine. Preterm infants usually have some urine output during the first 24 hours of life. Page Ref: 766 15) The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? A) The new nurse holds the infant after giving a gavage feeding. B) The new nurse provides skin-to-skin care. C) The new nurse provides care when the baby is awake. D) The new nurse gives the feeding with room-temperature formula. Answer: D Explanation: A) If the infant cannot be held during a feeding, she should be held after feedings for comfort. B) Skin-to-skin (kangaroo) care has become the norm in NICUs across the United States and is defined as the practice of holding infants skin to skin next to their parents. C) Preterm babies spend more time in sleep cycles; it is best to not interrupt sleep when possible. D) Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature. Page Ref: 766 16) Benefits of skin-to-skin care as a developmental intervention include which of the following? Select all that apply. A) Routine discharge B) Stabilization of vital signs C) Increased periods of awake-alert state D) Decline in episodes of apnea and bradycardia E) Increased growth parameters Answer: B, D, E Explanation: A) Early discharge is a benefit of skin-to-skin care as a developmental intervention. B) Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention. C) Increased periods of quiet sleep is a benefit of skin-to-skin care as a developmental intervention. D) A decline in episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention. E) Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention. Page Ref: 780 17) In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following? Select all that apply. A) Volume of urine output B) Weight C) Blood pH D) Head circumference E) Bowel sounds Answer: A, B Explanation: A) In order to assess hydration status, volume of urine output must be evaluated. B) In order to assess hydration status, the infant's weight must be evaluated. C) Blood pH is not an indicator of hydration. D) Head circumference is not an indicator of hydration. E) Bowel sounds are not an indicator of hydration. Page Ref: 777 18) The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority? A) Tissue Integrity, Impaired B) Infection, Risk for C) Gas Exchange, Impaired D) Family Processes, Dysfunctional Answer: C Explanation: A) Tissue Integrity, Impaired is related to fragile capillary network in the germinal matrix, but not the highest priority. B) Infection, Risk for is related to lack of passive immunity and immature immune defenses due to preterm birth, but is not the highest priority. C) Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production, and has the highest priority. D) Family Processes, Dysfunctional is related to anger or guilt at having given birth to a premature baby and is a psychosocial need, and is therefore a lower priority than are physiologic needs. Page Ref: 756 19) The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include? A) Specially prepared formulas B) Cataract problems C) Low glucose concentrations D) Administration of thyroid medication Answer: A Explanation: A) An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Phenyl-Free 1 and Phenex-1, are available. B) Cataracts are associated with infants who have galactosemia. C) Low glucose concentrations are not an indication an inborn error of metabolism. D) Thyroid medication is given to infants with congenital hypothyroidism. Page Ref: 801 20) The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following? A) Omphalocele B) Gastroschisis C) Diaphragmatic hernia D) Myelomeningocele Answer: D Explanation: A) Omphalocele is a herniation of abdominal contents into the base of the umbilical cord. Hydrocephalus is not associated with an omphalocele. B) Gastroschisis is a full-thickness defect of the abdominal wall that results in the abdominal organs being located on the outside of the body. Hydrocephalus is not associated with a gastroschisis. C) Diaphragmatic hernia is a portion of the intestines in the thoracic cavity due to an abnormal opening in diaphragm, occurring commonly on the left side. Hydrocephalus is not associated with a diaphragmatic hernia. D) Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in the thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on his or her abdomen or side and restrained to prevent pressure and trauma to the sac. Hydrocephalus is often present with this condition. Page Ref: 786 21) During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following? A) Place the newborn in a prone position. B) Limit feedings to three a day to decrease diarrhea. C) Place the infant supine and operate a home apnea-monitoring system. D) Wean the newborn off the pacifier. Answer: C Explanation: A) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. B) Small, frequent feedings are recommended. C) Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented. D) A pacifier may be offered to provide nonnutritive sucking. Page Ref: 795 22) The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse? A) Occasional watery stools B) Spitting up after feeding C) Jitteriness and irritability D) Nasal stuffiness Answer: C Explanation: A) An occasional watery stool can be associated with the normal newborn. B) Spitting up after some feedings can be associated with the normal newborn. C) Jitteriness and irritability can be an indicator of drug withdrawal. D) Nasal stuffiness can be associated with the normal newborn. Page Ref: 795 23) Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required? A) "Our baby's heart murmur is from this syndrome." B) "He might be a fussy baby because of this." C) "His face looks like it does due to this problem." D) "Cuddling and rocking will help him stay calm." Answer: D Explanation: A) Valvular and septal defects are common in babies with FAS. B) FAS babies can be irritable and hyperactive in childhood. C) Facial characteristics of the FAS child include short palpebral fissures, epicanthal folds, broad nasal bridge, flattened midface, short upturned or beaklike nose, micrognathia (abnormally small lower jaw) or hypoplastic maxilla, thin upper lip or vermilion border, and smooth philtrum (groove on upper lip). D) The FASD baby is most comfortable in a quiet, minimally stimulating environment. Page Ref: 791 24) The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn? Select all that apply. A) Hyperirritability B) Decreased muscle tone C) Exaggerated reflexes D) Low pitched cry E) Transient tachypnea Answer: A, C, E Explanation: A) Newborns born to drug-addicted mothers exhibit hyperirritability. B) Newborns born to drug-addicted mothers show increased, not decreased, muscle tone. C) Newborns born to drug-addicted mothers exhibit exaggerated reflexes. D) Newborns born to drug-addicted mothers exhibit a high-pitched, not a low-pitched, cry. E) Newborns born to drug-addicted mothers exhibit transient tachypnea. Page Ref: 793 25) In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include? A) Allow extra time with feedings. B) Assign different personnel to the newborn each day. C) Place the newborn in a well-lit room. D) Monitor for hyperthermia. Answer: A Explanation: A) Newborns with fetal alcohol syndrome have feeding problems. Because of their feeding problems, these infants require extra time and patience during feedings B) It is important to provide consistency in the staff working with the baby and parents and to keep personnel and visitors to a minimum at any one time. C) The FASD baby is most comfortable in a quiet, minimally stimulating environment. D) Nursing care of the FASD newborn is aimed at avoiding heat loss. Page Ref: 791 26) The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize? Select all that apply. A) Use proper hand-washing technique. B) Provide three feedings per day. C) Place soiled diapers in a sealed plastic bag. D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change. E) Take the temperature rectally. Answer: A, C, D Explanation: A) The nurse should instruct the parents on proper hand-washing technique. B) Small, frequent meals are recommended. C) The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed, and disposed of daily. D) The nurse should instruct parents that the diaper-changing areas should be cleaned with a 1:10 dilution of household bleach after each diaper change. E) Taking rectal temperatures is to be avoided because it could stimulate diarrhea. Page Ref: 799 27) A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant? A) Test with an HIV serologic test at 8 months. B) Begin prophylactic AZT (Zidovudine) administration. C) Provide 4 to 5 large feedings throughout the day. D) Encourage the mother to breastfeed the child. Answer: B Explanation: A) Currently available HIV serologic tests (enzyme-linked immunosorbent assay [ELISA] and (Western blot test) cannot distinguish between maternal and infant antibodies; therefore, they are inappropriate for infants up to 18 months of age. B) For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon after birth as possible and continuing for 6 weeks. C) Nutrition is essential because failure to thrive and weight loss are common. Small, frequent feedings and food supplementation are helpful. D) Breastfeeding should be avoided with an HIV-positive mother, as transmission of the HIV virus to the newborn in breast milk is well documented. Page Ref: 799 28) An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include? A) Do not add food supplements to the baby's diet. B) Place soiled diapers in a sealed plastic bag. C) Wash soiled linens in cool water with bleach. D) Shield the baby's eyes from bright lights. Answer: B Explanation: A) Small, frequent feedings are recommended, as well as food supplementation as necessary to support weight gain. B) The nurse should instruct the parents about proper hand-washing techniques, proper disposal of soiled diapers, and the importance of wearing gloves when diapering. C) Soiled linens should be washed in hot, sudsy water with bleach. D) Shielding the baby's eyes from bright lights would be recommended for a preterm infant, not an infant with HIV Page Ref: 800 29) Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of birth that include which of the following? Select all that apply. A) Swollen glands B) Hard stools C) Smaller than average spleen and liver D) Rhinorrhea E) Interstitial pneumonia Answer: A, D, E Explanation: A) Signs that may be seen in the early infancy period include swollen glands. B) Signs that may be seen in the early infancy period include recurrent gastrointestinal (GI) problems that include diarrhea. C) Signs that may be seen in the early infancy period include enlarged spleen and liver. D) Signs that may be seen in the early infancy period include rhinorrhea. E) Signs that may be seen in the early infancy period include interstitial pneumonia. Page Ref: 798 30) The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect? A) Apical heart rate of 140 beats per minute B) Respiratory rate of 40 C) Temperature of 36.5°C D) Visible, blue discoloration of the skin Answer: D Explanation: A) An apical heart rate of 140 is a normal assessment finding for newborns. B) A respiratory rate of 40 is a normal assessment finding for newborns. C) Temperature of 36.5°C is a normal assessment finding for newborns. D) Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased oxygen saturation levels and is a common manifestation of a cardiac defect. Page Ref: 787 31) The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best? A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body." B) "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder." C) "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart." D) "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal." Answer: A Explanation: A) Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy. The severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. B) This describes coarctation of the aorta and is characterized by a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. C) This describes complete transposition of great vessels and is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery from the left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. D) This describes hypoplastic left heart syndrome which is the underdevelopment of the left side of the heart including aortic valve atresia, severe mitral valve stenosis, and small left ventricle. Page Ref: 78 32) The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective? A) "This condition occurs more frequently among Japanese people." B) "We must be very careful to avoid most proteins to prevent brain damage." C) "Carbohydrates can cause our baby to develop cataracts and liver damage." D) "Our baby's thyroid gland isn't functioning properly." Answer: B Explanation: A) Japanese people have a very low rate of PKU disease; it is most common among northern Europeans. B) PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain tissue leads to progressive, irreversible intellectual disability. C) Galactosemia is a carbohydrate metabolism disease. D) Congenital hypothyroidism is the disorder of low thyroid function at birth. Page Ref: 801 33) The nurse is observed conducting the following measurement. For what will this measurement be used? A) Determine fetal length B) Gauge stomach contents C) Placement of gavage tube D) Estimate chest circumference Answer: C Explanation: C) When measuring gavage tube length, measure the distance from the tip of the ear to the nose to the midpoint between the xiphoid process and the umbilicus, and mark the point with a small piece of paper tape to ensure there is enough tubing to enter the stomach. Page Ref: 771 34) The nurse is caring for a newborn with the following anomaly. What actions should the nurse take when caring for this infant? Select all that apply. 1. Burp frequently 2. Assess patency of nare 3. Assist with parental coping 4. Clean the area with sterile water 5. Feed with a special nipple and bottle Answer: 1, 3, 4, 5 Explanation: The infant has a cleft lip. The nurse should feed with a special nipple and bottle, burp frequently, clean the cleft with sterile water to prevent crusting on cleft before repair, and support parental coping. Assessing patency of nares would be appropriate for choanal atresia. Page Ref: 782 35) The nurse is preparing teaching material for the parents of a newborn with tracheoesophageal fistula. Where on the diagram should the nurse identify the location of this disorder? A) A B) B C) C D) D Answer: C Explanation: C) In a tracheoesophageal fistula, the lower esophageal segment connects to the lower trachea, with the upper esophageal segment ending blindly. Page Ref: 783 36) The nurse is preparing teaching material for the parents of a newborn. For which health problem should the nurse select the following diagram to be used for teaching? A) Gastroschisis B) Omphalocele C) Diaphragmatic hernia D) Prune belly syndrome Answer: C Explanation: C) In a diaphragmatic hernia, a portion of the intestines enters the thoracic cavity through an abnormal opening in the diaphragm. This most commonly occurs on the left side. An omphalocele is the herniation of abdominal contents into the base of the umbilical cord. Gastroschisis is a full-thickness defect in the abdominal wall that allows viscera outside the body to the right of an intact umbilical cord. Prune belly syndrome is the congenital absence of one or more layers of abdominal muscles. Page Ref: 784 37) An infant is diagnosed with an atrial-septal defect. When teaching the parents of this infant about the disorder, which diagram should the nurse use? B) C) D) Answer: A Explanation: A) Patent ductus arteriosus is a vascular connection that, during fetal life, bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. After birth, blood shunts through the ductus from the aorta to the pulmonary artery (left-to-right shunting). Coarctation of the aorta is characterized by a narrowed aortic lumen. The lesion produces an obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure and workload, minimizing systemic circulation of blood. In tetralogy of Fallot, the severity of symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect, and the degree to which the aorta overrides the septal defect. Complete transposition of great vessels is an embryologic defect caused by a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery from the left ventricle resulting in a parallel circulatory system. An abnormal communication between the two circulations must be present to sustain life. Page Ref: 788 38) The nurse is preparing to gavage-feed a preterm infant. Put the steps in the order in which the nurse should provide this feeding. 1. Check pH of the gastric aspirate 2. Elevate the syringe 6-8 inches above the infant's head 3. Measure from the tip of the nose to the earlobe to the xiphoid process 4. Clear the tubing with 2-3 mL of air 5. Lubricate the tube by dipping it into sterile water Answer: 3, 5, 1, 2, 4 Explanation: Measurement occurs before inserting the tube into the infant. Lubricating the tube helps with passage into the infant. After passage, the pH of gastric contents is determined. The syringe is elevated above the infant's head for the feeding. At the end of the feeding the tube is cleared with 2-3 mL of air. A) Page Ref: 771 Chapter 31: The Newborn at Risk: Birth-Related Stressors 1) 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? A) Initial resuscitation B) Vigorous stimulation at birth C) Phototherapy immediately D) An initial feeding of iron-enriched formula Answer: A Explanation: A) 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. B) Stimulation at birth should be avoided to minimize respiratory movements. C) Phototherapy is not required immediately. D) Mild or chronic anemia in an infant may be treated adequately with iron supplements alone or with iron-fortified formulas. Page Ref: 822 2) 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? A) Begin chest compressions. B) Begin direct tracheal suctioning. C) Begin bag-and-mask ventilation. D) Obtain a blood pressure reading. Answer: C Explanation: A) Chest compressions are not initiated until the heart rate is less than 60 and respirations have been established. B) Direct tracheal suctioning would be appropriate if there were meconium-stained fluid. There is no information about the amniotic fluid in the question. C) Most newborns can be effectively resuscitated by bag-and-mask ventilation. D) Blood pressure is insignificant during resuscitation efforts. This infant needs respirations established. Page Ref: 809 3) During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations? A) The rise and fall of the chest B) Sudden wakefulness C) Urinary output D) Adequate thermoregulation Answer: A Explanation: A) With proper resuscitation, chest movement is observed for proper ventilation. Pressure should be adequate to move the chest wall. B) Sudden wakefulness is not associated with effectiveness of bag-and-mask ventilations. C) Urinary output is not associated with effectiveness of bag-and-mask ventilations. D) Adequate thermoregulation is not associated with effectiveness of bag-and-mask ventilations. Page Ref: 808 4) 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? A) Grunting respirations B) Nasal flaring C) Respiratory rate of 40 during sleep D) Chest retractions Answer: C Explanation: A) Grunting with respirations is a characteristic of RDS. B) Nasal flaring is a characteristic of RDS. C) A respiratory rate of 40 during sleep is normal. D) Significant chest retractions are characteristic of RDS. Page Ref: 815 5) 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? A) Delivery of the neonate on its side with head up, to facilitate drainage of secretions. B) Direct tracheal suctioning by specially trained personnel. C) Preparation for the immediate use of positive pressure to expand the lungs. D) Suctioning of the oropharynx when the newborn's head is delivered. Answer: B Explanation: A) The newborn is not delivered on its side. B) 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. C) Positive pressure is not used to expand the lungs. D) Current evidence does not support intrapartum oropharyngeal and nasopharyngeal suctioning as they do not prevent or alter the course of MAS. Page Ref: 808 6) 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? A) Meconium aspiration syndrome B) Transient tachypnea of the newborn C) Respiratory distress syndrome D) Prematurity of the neonate Answer: B Explanation: A) There was no meconium in the amniotic fluid, which rules out meconium aspiration syndrome. B) The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn. C) The infant is not premature and therefore is not likely to be experiencing respiratory distress syndrome. D) The infant is not premature. Page Ref: 816 7) 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? A) Decreased urine output B) Pulmonary vascular resistance increases C) Increased PCO2 D) Increased urination Answer: D Explanation: A) Increased urination, not decreased urine output, could be an indication that the newborn's condition is improving. B) Pulmonary vascular resistance increases with hypoxia. C) Increased PCO2 results from alveolar hypoventilation. D) 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. Page Ref: 815 8) Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn? A) Jitteriness B) Sucking on fingers C) Lusty cry D) Axillary temperature of 98°F Answer: A Explanation: A) Jitteriness of the newborn is associated with hypoglycemia. Aggressive treatment is recommended after a single low blood glucose value if the infant shows this symptom. B) Sucking on the fingers is a normal finding. C) A lusty cry is a normal finding. D) An axillary temperature of 98°F is a normal finding. Page Ref: 828 9) A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, what does the nursing instructor tell the student do? A) Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood. B) Use a previous puncture site. C) Cool the heel prior to obtaining blood. D) Use a sterile needle and aspirate. Answer: A Explanation: A) The site should be cleaned by rubbing vigorously with a 70% isopropyl alcohol swab. The friction produces local heat, which aids vasodilation. B) A microlancet is used to make the puncture in an unpunctured site. C) The heel should not be cooled. D) A microlancet, not a needle, is used to make the puncture. Page Ref: 829 10) The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention? A) Increased skin temperature and respirations B) Blood glucose level of 45 C) Room-temperature IV running D) Positioned under radiant warmer Answer: C Explanation: A) Decreased skin temperature and decreased respirations are signs and symptoms of cold stress. B) A blood glucose level of 45 is an adequate blood sugar in a neonate. A level lower than 40 indicates the infant is hypoglycemic. C) IV fluids should be warmed prior to administration and the newborn can be wrapped in a chemically activated warming mattress immediately following birth to decrease the postnatal fall in temperature that normally occurs. D) Radiant warmers are used to gradually increase the neonate's temperature. Page Ref: 827 11) The nurse is caring for a newborn with jaundice. The parents question why the newborn is not under phototherapy lights. The nurse explains that the fiber-optic blanket is beneficial because of which of the following? Select all that apply. A) Lights can stay on all the time. B) The eyes do not need to be covered. C) The lights will need to be removed for feedings. D) Newborns do not get overheated. E) Weight loss is not a complication of this system. Answer: A, B, D, E Explanation: A) With the fiber-optic blanket, the light stays on at all times. B) The eyes do not have to be covered with a fiber optic blanket. C) With the fiber-optic blanket, the light stays on at all times, and the newborn is accessible for care, feeding, and diaper changes. D) With the fiber-optic blanket, greater surface area is exposed and there are no thermoregulation issues. E) Fluid and weight loss are not complications of fiber-optic blankets Page Ref: 835 12) The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention? A) Eyes are covered, no clothing on, diaper in place B) Axillary temperature 99.7°F C) Infant removed from the isolette for breastfeeding D) Loose bowel movement Answer: B Explanation: A) Eye coverings are used because it is not known if phototherapy injures delicate eye structures, particularly the retina. Because the tissue absorbs the light, best results are obtained when there is maximum skin surface exposure. B) Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7°F-98.6°F. Vital signs should be monitored every 4 hours with axillary temperatures. C) Breastfeeding should continue during phototherapy; removing the infant for feedings repositions the infant to prevent pressure areas. D) Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. Page Ref: 835 13) The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation? Select all that apply. A) Physiologic jaundice occurs after 24 hours of age. B) Pathologic jaundice occurs after 24 hours of age. C) Phototherapy increases serum bilirubin levels. D) The need for phototherapy depends on the bilirubin level and age of the infant. E) Kernicterus causes irreversible neurological damage. Answer: A, E Explanation: A) Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life, and appears after 24 hours of life. B) Diagnosis of pathologic jaundice is given to newborns who exhibit jaundice within the first 24 hours of life. C) Phototherapy decreases serum bilirubin levels. D) The decision to start phototherapy is based on two factors: gestational age and age in hours. E) Kernicterus refers to the deposition of unconjugated bilirubin in the basal ganglia of the brain and to permanent neurologic sequelae of untreated hyperbilirubinemia. Page Ref: 831 14) The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn? A) Continue to observe B) Begin phototherapy C) Begin blood exchange transfusion D) Stop breastfeeding Answer: B Explanation: A) Continued observation is only appropriate with normal findings. B) Neonatal hyperbilirubinemia must be considered pathologic if the serum bilirubin concentration is rising by more than 0.2 mg/dL per hour. If the newborn is over 24 hours old, which is past the time where an increase in bilirubin would result from pathologic causes, phototherapy may be the treatment of choice to prevent the possible complications of kernicterus. C) If a newborn has hemolysis with an unconjugated bilirubin level of 14 mg/dL, weighs less than 2500 g (birth weight), and is 24 hours old or less, an exchange transfusion may be the best management. This newborn is 36-hours-old. D) The newborn may continue to breastfeed. Page Ref: 832 15) The client with blood type O Rh-negative has given birth to an infant with blood type O Rhpositive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. What is the best response by the nurse? A) "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization." B) "Your body has made antibodies against the baby's blood that are destroying her red blood cells." C) "The red blood cells of your baby are breaking down because you both have type O blood." D) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed." Answer: B Explanation: A) Although this statement is true, the term "alloimmunization" is not likely to be understood by the client. It is better to explain what is happening using more understandable terminology. B) This explanation is accurate and easy for the client to understand. Newborns of Rh-negative and O blood type mothers are carefully assessed for blood type status, appearance of jaundice, and levels of serum bilirubin. C) Mother and baby's both having type O blood is not a problem. ABO incompatibility occurs if mother is O and baby is A or B. D) The infant's liver is indeed too immature to eliminate red blood cells, but the hemolysis from the maternal antibodies is the cause of the jaundice. Page Ref: 831 16) Which of the following are considered risk factors for development of severe hyperbilirubinemia? Select all that apply. A) Northern European descent B) Previous sibling received phototherapy C) Gestational age 27 to 30 weeks D) Exclusive breastfeeding E) Infection Answer: B, D, E Explanation: A) East Asian or Mediterranean descent is considered a risk factor for development of severe hyperbilirubinemia. B) Previous sibling received phototherapy is considered a risk factor for development of severe hyperbilirubinemia. C) Gestational age 35 to 36 weeks (late preterm gestational age) is considered a risk factor for development of severe hyperbilirubinemia. D) Exclusive breastfeeding, particularly if nursing is not going well and excessive weight loss is experienced, is considered a risk factor for development of severe hyperbilirubinemia. E) Infection is considered a risk factor for development of severe hyperbilirubinemia. Page Ref: 832 17) A newborn is receiving phototherapy. Which intervention by the nurse would be most important? A) Measurement of head circumference B) Encouraging the mother to stop breastfeeding C) Stool blood testing D) Assessment of hydration status Answer: D Explanation: A) Phototherapy does not affect head circumference. B) Breastfeeding most likely can be continued. C) The stools do not need to be tested for blood. D) Infants undergoing phototherapy treatment have increased water loss and loose stools as a result of bilirubin excretion. This increases their risk of dehydration. Page Ref: 835 18) The nurse is observing a student nurse who is caring for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care? A) Urine specific gravity is assessed at each voiding. B) Eye coverings are left off to help keep the baby calm. C) Temperature is checked every 6 hours. D) The infant is taken out of the isolette for diaper changes Answer: A Explanation: A) This action is correct. Specific gravity provides one measure of urine concentration. Highly concentrated urine is associated with a dehydrated state. Weight loss is also a sign of developing dehydration in the newborn. B) Eyes should be covered at all times. C) Six hours is too long. Vital signs should be monitored every 4 hours with axillary temperatures. D) The isolette helps the infant maintain his or her temperature while undressed. The diaper should be changed while the infant is under the lights in the isolette, as care activities should be clustered. Page Ref: 846 19) The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy? A) The newborn maintains a normal temperature B) An increase of serum bilirubin levels C) Weight loss D) Skin blanching yellow Answer: A Explanation: A) Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy. The isolette helps the infant maintain his or her temperature while undressed. B) Phototherapy is a primary intervention that is used for the prevention of hyperbilirubinemia, to halt bilirubin levels from climbing dangerously high. C) Weight loss is a sign of developing dehydration in the newborn. The newborn should be weighed daily. D) Yellowing in the skin should disappear with effective phototherapy. Page Ref: 835 20) The nurse is assessing the newborn for symptoms of anemia. If the blood loss is acute, the baby may exhibit which of the following signs of shock? Select all that apply. A) Increased pulse B) High blood pressure C) Tachycardia D) Bradycardia E) Capillary filling time greater than 3 seconds Answer: C, E Explanation: A) Decreased pulse would be a sign of shock. B) Low blood pressure would be a sign of shock. C) Tachycardia would be a sign of shock. D) Tachycardia, not bradycardia, would be a sign of shock. E) Capillary filling time greater than 3 seconds would be a sign of shock. Page Ref: 840 21) Mild or chronic anemia in an infant may be treated adequately by which of the following? A) Transfusions with O-negative or typed and cross-matched packed red cells B) Iron supplements or iron-fortified formulas C) Steroid therapy D) Antibiotics or antivirals Answer: B Explanation: A) Severe cases of anemia are treated with transfusions with O-negative or typed and crossmatched packed red cells. B) Mild or chronic anemia in an infant may be treated adequately with iron supplements or ironfortified formulas. C) Management of anemia of prematurity includes treating the causative factor (e.g., antibiotics or antivirals used for infection or steroid therapy for disorders of erythrocyte production). D) Management of anemia of prematurity includes treating the causative factor (e.g., antibiotics or antivirals used for infection or steroid therapy for disorders of erythrocyte production). Page Ref: 840 22) What indications would lead the nurse to suspect sepsis in a newborn? A) Respiratory distress syndrome developing 48 hours after birth B) Temperature drops from 97.4°F to 97.0 2°F hours after 2 hours of warming. C) Irritability and flushing of the skin at 8 hours of age D) Bradycardia and tachypnea developing when the infant is 36 hours old Answer: B Explanation: A) The infant may deteriorate rapidly in the first 12 to 24 hours after birth if β-hemolytic streptococcal infection is present. B) Temperature instability is often seen with sepsis. Fever is rare in a newborn. C) Irritability or lethargy with pallor after the first 24 hours might indicate sepsis, and the skin is cool and clammy. D) Tachycardia and periods of apnea are seen with sepsis. Page Ref: 845 23) Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement? Select all that apply. A) Obtain skin cultures. B) Restrict parental visits. C) Evaluate bilirubin levels. D) Administer oxygen as ordered. E) Observe for signs of hypoglycemia. Answer: A, C, D, E Explanation: A) The nurse will assist in obtaining skin cultures. Skin cultures are taken of any lesions or drainage from lesions or reddened areas. B) Restricting parental visits has not been shown to have any effect on the rate of infection and may be harmful to the newborn's psychologic development. C) The nurse will observe for hyperbilirubinemia, anemia, and hemorrhagic symptoms. D) The nurse will administer oxygen as ordered. E) The nurse will observe for signs of hypoglycemia. Page Ref: 846 24) The nurse will be bringing the parents of a neonate with sepsis to the neonatal intensive care nursery for the first time. Which statement is best? A) "I'll bring you to your baby and then leave so you can have some privacy." B) "Your baby is on a ventilator with 50% oxygen, and has an umbilical line." C) "I am so sorry this has all happened. I know how stressful this can be." D) "Your baby is working hard to breathe and lying quite still, and has an IV." Answer: D Explanation: A) When bringing parents to see their ill newborn for the first time, it is important to prepare them for what they will see. Bringing parents without preparation is inappropriate. B) Although this statement describes the treatment the baby is receiving, it is worded in medical jargon that will not be understood by most parents. The nurse should describe the equipment being used for the at-risk newborn and its purpose before entering the unit. C) This response focuses on the nurse. Avoid saying "I know how you feel," because it is impossible for the nurse to actually know how clients feel. D) This answer is best because it explains what the parents will see in terminology that they will understand. A trusting relationship is essential for collaborative efforts in caring for the infant. The nurse should respond therapeutically to relate to the parents on a one-to-one basis. Page Ref: 849 25) The nurse is planning care for four infants who were born on this shift. The infant who will require the most detailed assessment is the one whose mother has which of the following? A) A history of obsessive-compulsive disorder (OCD) B) Chlamydia C) Delivered six other children by cesarean section D) A urinary tract infection (UTI) Answer: B Explanation: A) Obsessive-compulsive disorder (OCD) is not a risk factor for the infant. B) Infants born to mothers with chlamydia infections are at risk for neonatal pneumonia and conjunctivitis, and require close observation of the respiratory status and eyes. C) Having multiple siblings, regardless of how they were delivered, is not a risk factor for the infant. D) An infant whose mother has an untreated urinary tract infection might have been exposed to pathogens, but it is not known whether the mother in this question is on antibiotics. Page Ref: 843 26) One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate? A) Meticulous hand washing and antibiotic eye ointment administration. B) Intravenous acyclovir (Zovirax) and contact precautions. C) Cultures of blood and CSF and serial chest x-rays every 12 hours. D) Parental rooming-in and four intramuscular injections of penicillin. Answer: B Explanation: A) Although meticulous hand washing by staff and parents is important, antibiotic eye ointment is used for conjunctivitis of gonorrhea or chlamydia. B) Administering intravenous acyclovir (Zovirax) and contact precautions are appropriate measures for an infant at risk for developing herpes simplex 2 infection. C) Cultures of blood and CSF cultures are appropriate, but chest X-rays are not indicated. Chest X-rays are obtained if the neonate is thought to have group B strep pneumonia. D) Parental rooming-in is encouraged, but penicillin does not treat viral illness. Page Ref: 842 27) The parents of a preterm newborn wish to visit their baby in the NICU. A statement by the nurse that would not support the parents as they visit their newborn is which of the following? A) "Your newborn likes to be touched." B) "Stroking the newborn will help with stimulation." C) "Visits must be scheduled between feedings." D) "Your baby loves her pink blanket." Answer: C Explanation: A) Statements that encourage the parents to touch the newborn will help them bond with their child. B) Statements that encourage the parents to stroke the newborn will help them bond with their child and provide stimulation. C) The nurse should always encourage parents to visit and get to know their newborn, even in the NICU. Nurses foster the development of a safe, trusting environment by viewing the parents as essential caregivers, not as visitors or nuisances in the unit. D) Comments that personalize the baby will tell the parents their baby is unique and special. Page Ref: 849 28) The special care nursery nurse is working with parents of a 3-day-old infant who was born with myelomeningocele and has developed an infection. Which statement from the mother is unexpected? A) "If I had taken better care of myself, this wouldn't have happened." B) "I've been sleeping very well since I had the baby." C) "This is probably the doctor's fault." D) "If I hadn't seen our baby's birth, I wouldn't believe she is ours." Answer: B Explanation: A) Some parents may feel guilty about their baby's condition and think they have caused the problem. B) A sick infant is a source of great anxiety for parents. This response is from the mother would be unexpected. C) Parents express grief as shock and disbelief, denial of reality, anger toward self and others, guilt, blame, and concern for the future. D) Parents express grief as shock and disbelief, denial of reality, anger toward self and others, guilt, blame, and concern for the future. Page Ref: 835 29) An infant with a pneumothorax has the following chest x-ray result. Which area should the nurse identify as being the pneumothorax? A) A B) B C) C D) D Answer: B Explanation: B) In a pneumothorax, rupture of the alveoli sacs allows air to leak through the pleura, forming collections of air outside the lung. Air shows on X-ray as a dark area over the lung. Page Ref: 824 30) The nurse is preparing to measure a newborn's blood glucose level. Which areas on the heel should be used to obtain a blood sample for this test? 1. A 2. B 3. C 4. D 5. E Answer: 1, 5 Explanation: The infant's lateral heel is the site of choice because it precludes damaging the posterior tibia nerve and artery, plantar artery, and the important longitudinally oriented fat pad of the heel, which in later years could impede walking. Page Re