Chapter 09: The High-Risk Newborn and Family My Nursing Test Banks

Chapter 09: The High-Risk Newborn and Family

MULTIPLE CHOICE

1. Which refers to an infant whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?

a.

Postterm

b.

Postmature

c.

Low birth weight

d.

Small for gestational age

ANS: D

A small-for-gestational-age, or small-for-date, infant is one whose rate of intrauterine growth has slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. A postterm, or postmature, infant is any child born after 42 weeks of gestation, regardless of birth weight. A low-birth-weight infant is a child whose birth weight is less than 2500 g, regardless of gestational age.

DIF: Cognitive Level: Understanding REF: p. 338

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. A woman in premature labor delivers an extremely lowbirth-weight (ELBW) infant. Transport to a neonatal intensive care unit is indicated. The nurse explains that which level of service is needed?

a.

Level I

b.

Level IA

c.

Level II

d.

Level IIIB

ANS: D

A level IIIB neonatal unit has the capability of providing care for ELBW infants, including high-frequency ventilation and on-site access to medical subspecialties and pediatric surgery. A level I facility manages normal maternal and newborn care. Infants at less than 35 weeks of gestation are stabilized and transported to a facility that can provide appropriate care. A level IA facility does not exist. Level II facilities provide care for infants born at 32 weeks of gestation and weighing more than 1500 g. If the infant is ill, the health problems are expected to resolve rapidly and are not anticipated to require specialty care.

DIF: Cognitive Level: Applying REF: p. 339

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Integrity

3. What is an essential component in caring for the very low or extremely lowbirth-weight infant?

a.

Holding the infant to help develop trust

b.

Using electronic monitoring devices exclusively

c.

Coordinating care to reduce environmental stress

d.

Incorporating infant stimulation elements during assessment

ANS: C

One of the principles of care for high-risk neonates is close observation and assessment with minimum handling. The nurse checks the apical rate against the monitor readings on a regular basis. The infants care is then clustered, and the infant is disturbed as little as possible. Holding an infant to help develop trust is not part of the assessment. In some areas, parents use skin-to-skin care with their infants. Although electronic monitoring devices are used, the nurse must validate the readings with the infants data. For an ill neonate, excessive stimulation creates stress.

DIF: Cognitive Level: Understanding REF: p. 339

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. What explains why a neutral thermal environment is essential for a high-risk neonate?

a.

The neonate produces heat by increasing activity and shivering.

b.

Metabolism slows dramatically in the neonate experiencing cold stress.

c.

It permits the neonate to maintain a normal core temperature with minimum oxygen consumption.

d.

It permits the neonate to maintain a normal core temperature with increased caloric consumption.

ANS: C

A high-risk neonate is at greater risk for cold stress than a term infant because of the smaller muscle mass and fewer deposits of brown fat for producing heat, lack of insulating subcutaneous fat, and poor reflex control of skin capillaries. By definition, a neutral thermal environment is one that permits the infant to maintain a normal core temperature with minimum oxygen consumption and caloric expenditure. Smaller muscle mass and poor reflex control of skin capillaries decrease the ability of a high-risk neonate to compensate for an environment that is not thermoneutral. Metabolism increases in an infant experiencing cold stress, creating a compensatory increase in oxygen and caloric consumption. Increased caloric consumption is to be avoided. Neonates need available calories for growth.

DIF: Cognitive Level: Analyzing REF: p. 342 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

5. When caring for a neonate in a radiant warmer, what should the nurse be alert to?

a.

Exposure to prolonged cold stress

b.

Need for Plexiglas shields to protect the infant

c.

Transepidermal water loss leading to dehydration

d.

Increased risk of infection from the open environment

ANS: C

Radiant warmers result in greater evaporative fluid loss than normal, thus predisposing the infant to dehydration. Plastic wrap can help reduce this loss. Daily fluid requirements are increased to compensate. The radiant warmer protects the infant from cold stress. Plexiglas shields are not used in radiant warmers because they block the radiant heat waves. With clean and aseptic technique, there is not a greater risk of infection.

DIF: Cognitive Level: Analyzing REF: p. 343 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

6. The nurse is caring for a high-risk neonate who has an umbilical catheter and is in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?

a.

Place socks on the infants feet.

b.

Elevate the infants feet 15 degrees.

c.

Wrap the infants feet loosely in a prewarmed blanket.

d.

Report the findings immediately to the practitioner.

ANS: D

Blanching of the feet in a neonate with an umbilical catheter is an indication of vasospasm. Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency situation and must be reported immediately.

DIF: Cognitive Level: Applying REF: p. 344

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

7. Which statement is true concerning the nutritional needs of preterm infants?

a.

The secretion of lactase is low.

b.

Carbohydrates and fats are better tolerated than protein.

c.

The demand for nutrients is less than in full-term infants.

d.

Breast milk lacks the proper concentration of nutrients.

ANS: A

The enzyme lactase is not readily available in an infants body until after 34 weeks of gestation. Formulas containing lactose are not well tolerated. Carbohydrates and fats are less well tolerated than protein. Preterm infants require significantly higher intake of calories and other nutrients than full-term infants. The American Academy of Pediatrics recommends 105 to 130 kcal/kg/day. Breast milk from the infants mother is considered the ideal enteral nutrition for the infant. Several commercial formulas are designed for preterm infants.

DIF: Cognitive Level: Analyzing REF: p. 345

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

8. While a mother is feeding her high-risk neonate, the nurse observes the neonate having occasional apnea, pallor, and bradycardia. What is the most appropriate nursing action?

a.

Let the neonate rest before breastfeeding again.

b.

Resume gavage feedings until the neonate is asymptomatic.

c.

Recognize that this may indicate an underlying illness.

d.

Use a high-flow, pliable nipple because it requires less energy to use.

ANS: C

Apnea, pallor, and bradycardia may be signs of an underlying illness. The infant should be evaluated to ensure he or she is not developing problems. The infant can rest while waiting for the evaluation. If the child is becoming ill, the capacity to digest enteral feedings may be compromised. The type of nipple that is being used should not produce the signs being observed.

DIF: Cognitive Level: Applying REF: p. 347

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

9. A preterm infant who is being fed commercial formula by gavage has had an increase in gastric residuals, abdominal distention, and apneic episodes. Which is the most appropriate nursing action?

a.

Notify the practitioner.

b.

Reduce the amount fed by gavage.

c.

Feed human milk by gavage.

d.

Feed only a glucose solution until the infant stabilizes.

ANS: A

These are signs that may indicate early necrotizing enterocolitis. The practitioner is notified for further evaluation. Enteral feedings are usually stopped until the cause of increased residuals is identified.

DIF: Cognitive Level: Applying REF: p. 347

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

10. A mother planned to breastfeed her infant before giving birth at 33 weeks of gestation. The infant is stable and receiving oxygen. What is the most appropriate nursing action related to this?

a.

Assist the mother in expressing breast milk.

b.

Assess the infants readiness to breastfeed.

c.

Explain to the mother that the infant is too small to receive breast milk.

d.

Reassure the mother that infant formula is a good alternative to breastfeeding.

ANS: B

Research confirms that human milk is the best source of nutrition for term and preterm infants. Preterm infants should be breastfed as soon as they have adequate sucking and swallowing reflexes and no other complications such as respiratory complications or concurrent illnesses. If the infant has adequate sucking and swallowing, the infant should breastfeed for some of the feedings. The mother can express milk to be used in her absence.

DIF: Cognitive Level: Applying REF: p. 348

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

11. A preterm neonate has begun breastfeeding, but the infant tires easily and has weak sucking and swallowing reflexes. What is the most appropriate nursing intervention?

a.

Encourage the mother to breastfeed.

b.

Resume orogastric feedings of formula.

c.

Try nipple feeding the preterm infant formula.

d.

Feed the remainder of breast milk by the orogastric route.

ANS: D

If a preterm infant tires easily or has weak sucking when breastfeeding is initiated, the nurse should feed the additional breast milk by the enteral route. The nurse supports the mother in the attempts to breastfeed and ensures that the infant is receiving adequate nutrition. Breast milk should be used as long as the mother can supply it.

DIF: Cognitive Level: Applying REF: p. 350

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

12. A preterm infant is being fed by gavage. What is an important consideration for this infant?

a.

Warm the feeding to body temperature before feeding.

b.

Feed the infant in an isolette to minimize handling.

c.

Provide a pacifier for nonnutritive sucking during bolus feeding.

d.

Do not allow the infant to have increased stress by becoming hungry.

ANS: C

Nonnutritive sucking during feedings will help the infant associate sucking with food. This can minimize feeding resistance and aversion. Warming the feeding to body temperature is not necessary. The food can be at room temperature. If possible, the infant should be held in a feeding position. The infant should be allowed to become hungry so that the food and nonnutritive sucking are associated with satisfying the hunger.

DIF: Cognitive Level: Applying REF: p. 347

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

13. Which is an important nursing action related to the use of tape or adhesives on premature neonates?

a.

Avoid using tape and adhesives until skin is more mature.

b.

Remove adhesives with water, mineral oil, or petrolatum.

c.

Use scissors carefully to remove tape instead of pulling off the tape.

d.

Use solvents to remove tape and adhesives instead of pulling on the skin.

ANS: B

Warm water, mineral oil, or petrolatum can facilitate the removal of adhesive. In a premature neonate, often it is impossible to avoid using adhesives and tape. The smallest amount of adhesive necessary should be used. Scissors should not be used to remove dressings or tape from very small and immature infants because it is easy to snip off tiny extremities or nick loosely attached skin. Solvents should be avoided because they tend to dry and burn the delicate skin.

DIF: Cognitive Level: Applying REF: p. 351

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

14. The nurse is caring for a 3-week-old boy born at 29 weeks of gestation. While taking vital signs and changing his diaper after stooling, the nurse observes his color is pink but slightly mottled, his arms and legs are limp and extended, he has the hiccups, his respirations are deep and rapid, and his heart rate is regular and rapid. The nurse should recognize these behaviors as signs of what?

a.

Stress

b.

Subtle seizures

c.

Preterm behaviors

d.

Onset of respiratory distress

ANS: A

These are signs of stress or fatigue in a newborn. Neonatal seizures usually have some type of repetitive movement, from twitching to rhythmic jerking movements. The behavior of a preterm infant may be inactive and listless. Respiratory distress is exhibited by retractions and nasal flaring.

DIF: Cognitive Level: Analyzing REF: p. 354

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

15. The nurse knows that during deep sleep the neonate should not be disturbed if possible. Characteristics of deep sleep include what?

a.

Regular breathing

b.

Occasional smiling

c.

Rapid eye movements

d.

Apneic pauses of less than 20 seconds

ANS: A

Regular breathing is characteristic of deep sleep. During active sleep, irregular breathing may be present. Occasional smiling, rapid eye movements, and apneic pauses of less than 20 seconds are characteristic of active sleep.

DIF: Cognitive Level: Understanding REF: p. 355

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

16. The nurse is providing care to a preterm infant. Which characteristic of daily care should be considered supportive?

a.

Coordinated with parental visiting times

b.

Given on a fixed schedule to ensure needs are met

c.

Provided when infants heart rate is at its lowest level

d.

Directed toward development of sleep organization

ANS: D

Developmentally supportive care uses both behavioral and physiologic information as the basis of caregiving. A focus in preterm infants is to be alert for infant behavioral states and intervene during alert times. The parents should be taught how to recognize the infants behavioral states. Infants sleep for approximately 1 1/2 hours. The parents can provide care when the infant is awake. Care should not be delivered on a fixed schedule. It should always be responsive to the infants cues. The heart rate is at its lowest when the infant is in a sleep period. The infant should not be disturbed during this time if possible.

DIF: Cognitive Level: Applying REF: p. 355

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

17. What can stroking infants who are physiologically unstable result in?

a.

Fewer sleep periods

b.

Increased weight gain

c.

Shortened hospital stay

d.

Decreased oxygen saturation

ANS: D

Tactile interventions can have both positive and negative effects on neonates. For physiologically unstable infants and those who are disturbed during sleep, outcomes such as gasping, grunting, decreased oxygen saturation, apnea, and bradycardia have been observed. Fewer sleep periods are not associated with tactile stimulation in physiologically unstable infants. Increased weight gain and shortened hospital stays are positive outcomes that are observed when tactile stimulation is done at developmentally supportive times.

DIF: Cognitive Level: Applying REF: p. 356

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

18. In about 1 week, a stable preterm infant will be discharged. The nurse should teach the parents to place the infant in which position for sleep?

a.

Prone

b.

Supine

c.

Position of comfort

d.

Abdomen with head elevated

ANS: B

The American Academy of Pediatrics recommends that healthy infants be placed to sleep in a nonprone position. The prone position is associated with sudden infant death syndrome but can be used for supervised play.

DIF: Cognitive Level: Applying REF: p. 357

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

19. The nurse is planning care for a family expecting their newborn infant to die because of an incurable birth defect. What should the nurses interventions be based on?

a.

Tangible remembrances of the infant (e.g., lock of hair, picture) prolong grief.

b.

Photographs of infants should not be taken after death.

c.

Funerals are not recommended because the mother is still recovering from childbirth.

d.

The parents should be given the opportunity to parent the infant, including seeing, holding, touching, or talking to the infant in private.

ANS: D

Providing care for the neonate is an important step in the grieving process. It gives the parents a tangible person for whom to grieve, which is a key component of the grieving process. Tangible remembrances and photographs can make the infant seem more real to the parents. Many neonatal intensive care units make bereavement memory packets, which may include a lock of hair, handprints, footprints, a bedside name card, and other individualized objects. Families need to be informed of their options. The ritual of a funeral provides an opportunity for the parents to be supported by relatives and friends.

DIF: Cognitive Level: Applying REF: p. 360 TOP: Nursing Process: Planning

MSC: Client Needs: Psychosocial Integrity

20. The nurse has been caring for an infant who has just died. The parents are present but appear to be afraid to hold the dead infant. What is the most appropriate nursing intervention?

a.

Tell them there is nothing to fear.

b.

Insist that they hold the infant one last time.

c.

Respect their wishes and release the body to the morgue.

d.

Keep the infants body available for a few hours in case they change their minds.

ANS: D

When the parents are hesitant about holding and touching their infant, the nurse should wrap the infant in blankets and keep the infants body on the unit for a few hours. Many parents change their minds after the initial shock of the infants death. This will provide the parents time to see and hold their infant if they desire. Telling the parents there is nothing to fear minimizes the parents feelings. The nurse should allow the family to parent their child as they wish in death, as in life.

DIF: Cognitive Level: Applying REF: p. 363

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

21. The parents of an infant who has just died decide they want to hold the infant after their infant has gone to the morgue. What is the most appropriate nursing intervention at this time?

a.

Explain gently that this is no longer possible.

b.

Encourage the parents to accept the loss of their infant.

c.

Offer to take a photograph of their infant because they cannot hold the infant.

d.

Have the infant brought back to the unit, wrapped in a blanket, and rewarmed in a radiant warmer.

ANS: D

The parents should be allowed to hold their infant in the hospital setting. The infants body should be retrieved and rewarmed in a radiant warmer. The nurse should provide a private place where the parents can hold their child for a final time. If possible, to facilitate the parents grieving, the nurse should bring the infant back to the unit. A photograph is an excellent idea, but it does not replace the parents need to hold the child.

DIF: Cognitive Level: Applying REF: p. 363

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

22. Which statement best describes the characteristics of preterm infants?

a.

Thermoregulation is well established.

b.

Extremities remain in attitude of flexion.

c.

Sucking reflex is absent, weak, or ineffectual.

d.

The head is proportionately small in relation to the body.

ANS: C

Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. Thermoregulation is poorly developed, and a preterm infant needs to be in a neutral thermal environment. A preterm infant may be listless and inactive compared with the overall attitude of flexion and activity of a full-term infant. A preterm infants head is proportionately larger than the body.

DIF: Cognitive Level: Understanding REF: p. 365

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. Which is a characteristic of postmature infants?

a.

Abundant lanugo

b.

Lack of scalp hair

c.

Plump appearance

d.

Parchment-like skin

ANS: D

In postterm infants, the skin is often cracked, parchment-like, and desquamating. Lanugo is usually absent. Scalp hair is usually abundant. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance.

DIF: Cognitive Level: Understanding REF: p. 365

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

24. Which is a central factor responsible for respiratory distress syndrome in a newborn?

a.

Absence of alveoli

b.

Immature bronchioles

c.

Overdeveloped alveoli

d.

Deficient surfactant production

ANS: D

The successful adaptation to extrauterine breathing requires numerous factors, which most term infants successfully accomplish. Preterm infants with respiratory distress are not able to adjust. The most likely central cause is the abnormal development of the surfactant system. The number and state of development of the alveoli are not central factors in respiratory distress syndrome. The instability of the alveoli related to the lack of surfactant is the causative issue. The bronchioles are sufficiently developed in newborns.

DIF: Cognitive Level: Understanding REF: p. 368

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

25. A preterm infant of 33 weeks of gestation is admitted to the neonatal intensive care unit. Approximately 2 hours after birth, the neonate begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. What should the nurse recognize?

a.

This is a normal finding.

b.

Further evaluation is needed.

c.

Improvement should occur within 24 hours.

d.

This is not significant unless cyanosis is present.

ANS: B

These are signs of respiratory distress syndrome and require further evaluation. There is no way to predict the infants clinical course based on the available data. Cyanosis may be present, but these are significant findings indicative of respiratory distress even without cyanosis.

DIF: Cognitive Level: Analyzing REF: pp. 375-376

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

26. The nurse is caring for a preterm neonate who requires mechanical ventilation for treatment of respiratory distress syndrome. Because of the mechanical ventilation, the nurse should recognize an increased risk of what?

a.

Pneumothorax

b.

Transient tachypnea

c.

Meconium aspiration

d.

Retractions and nasal flaring

ANS: A

Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Tachypnea may be an indication of a pneumothorax, but it should not be transient. Meconium aspiration is not associated with mechanical ventilation. Retractions and nasal flaring are indications of the use of accessory muscles when the infant cannot obtain sufficient oxygen. The use of mechanical ventilation bypasses the infants need to use these muscles.

DIF: Cognitive Level: Understanding REF: p. 375

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

27. What are possible premature infant complications from oxygen therapy and mechanical ventilation?

a.

Bronchopulmonary dysplasia and retinopathy of prematurity

b.

Anemia and necrotizing enterocolitis

c.

Cerebral palsy and persistent patent ductus arteriosus

d.

Congestive heart failure and cerebral edema

ANS: A

Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by mechanical ventilation creates an increase in the number of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Oxygen therapy puts the infant at risk for retinopathy of prematurity. Anemia, necrotizing enterocolitis, cerebral palsy, persistent patent ductus, congestive heart failure, and cerebral edema are not primarily caused by oxygen therapy and mechanical ventilation.

DIF: Cognitive Level: Analyzing REF: p. 381 TOP: Nursing Process: Evaluation

MSC: Client Needs: Physiological Integrity

28. A preterm infant with respiratory distress syndrome is receiving inhaled nitric oxide (NO). What is the reason for administering the inhaled nitric oxide?

a.

To mature the lungs

b.

To deliver a level of oxygen that is safe

c.

To increase the removal of pulmonary debris such as meconium

d.

To reduce pulmonary vasoconstriction and pulmonary hypertension

ANS: D

NO is used for infants with conditions such as meconium aspiration syndrome, pneumonia, sepsis, and congenital diaphragmatic hernia. Most infants with these disorders do have mature lungs. NO is not oxygen. Inhaled NO is beneficial for infants with meconium aspiration syndrome, but it does not work by removing debris. Inhaled NO is a significant treatment for infants with persistent pulmonary hypertension, pulmonary vasoconstriction, and subsequent acidosis and severe hypoxia. When inhaled into the lungs, it causes smooth muscle relaxation and reduction of pulmonary vasoconstriction and subsequent pulmonary hypertension.

DIF: Cognitive Level: Understanding REF: p. 375 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

29. The nurse is caring for a neonate with respiratory distress syndrome. The infant has an endotracheal tube. What should nursing considerations related to suctioning include?

a.

Suctioning should not be carried out routinely.

b.

The infant should be in the Trendelenburg position for suctioning.

c.

Routine suctioning, usually every 15 minutes, is necessary.

d.

Frequent suctioning is necessary to maintain the patency of the bronchi.

ANS: A

Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia, and increased intracranial pressure (ICP). It should never be carried out routinely. The Trendelenburg position should be avoided because it can contribute to increased ICP and reduced lung capacity from gravity pushing the organs against the diaphragm.

DIF: Cognitive Level: Applying REF: p. 376

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

30. What signs should the nurse expect when a pneumothorax occurs in an infant on mechanical ventilation?

a.

Tachycardia

b.

Clear, distinct heart tones

c.

Widened pulse pressure

d.

Abrupt duskiness or cyanosis

ANS: D

The early signs of a pneumothorax in an infant on mechanical ventilations include the abrupt onset of duskiness or cyanosis. Tachypnea is the presenting sign. Usually the heart rate is decreased. The heart sounds usually become muffled, diminished, or shifted. The pulse pressure decreases in pneumothorax.

DIF: Cognitive Level: Understanding REF: p. 379

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

31. What is most descriptive of the signs observed in neonatal sepsis?

a.

Seizures

b.

Sudden hyperthermia

c.

Decreased urinary output

d.

Subtle, vague, and nonspecific physical signs

ANS: D

The signs of neonatal sepsis are usually characterized by the infant generally not doing well. Poor temperature control, usually with hypothermia, lethargy, poor feeding, pallor, cyanosis or mottling, and jaundice, may be evident. Seizures are not a manifestation of sepsis. Severe neurologic sequelae may occur in lowbirth-weight infants with sepsis. Hyperthermia is rare in neonatal sepsis. Urinary output is not affected by sepsis.

DIF: Cognitive Level: Understanding REF: p. 384

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

32. What is the most common cause of iatrogenic anemia in preterm infants?

a.

Frequent blood sampling

b.

Respiratory distress syndrome

c.

Meconium aspiration syndrome

d.

Persistent pulmonary hypertension

ANS: A

The most common cause of anemia in preterm infants is frequent blood-sample withdrawal and inadequate erythropoiesis in acutely ill infants. Microsamples should be used for blood tests, and the amount of blood drawn should be monitored. Respiratory distress syndrome, meconium aspiration syndrome, and persistent pulmonary hypertension are not causes of anemia. They may require frequent blood sampling, which contributes to the problem of decreased erythropoiesis and anemia.

DIF: Cognitive Level: Understanding REF: p. 388

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

33. A newborn is diagnosed with retinopathy of prematurity. What should the nurse know about this condition?

a.

Blindness cannot be prevented.

b.

No treatment is currently available.

c.

Cryotherapy and laser therapy are effective treatments.

d.

Long-term administration of oxygen will be necessary.

ANS: C

Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular proliferation process that causes the retinal damage. Blindness can be prevented with early recognition and treatment. Long-term administration of oxygen is one of the causes. Oxygen should be used judiciously.

DIF: Cognitive Level: Understanding REF: p. 389

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

34. What is a priority of care for an infant with an intraventricular hemorrhage?

a.

Avoid use of analgesia.

b.

Keep the infants head to the right side.

c.

Minimize interventions that cause crying.

d.

Encourage the staff and parents to hold the infant.

ANS: C

The priority goal is to decrease intracranial pressure (ICP). Allowing the infant to cry will cause an increase in pressure. Analgesia is used as necessary to maintain the child pain free. This reduces ICP. The infant should be positioned with the body and head in the midline position. Turning the childs head to the right side can cause cerebral venous congestion and increased ICP. The child should have minimum stimulation to avoid increases in ICP.

DIF: Cognitive Level: Applying REF: p. 392

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

35. What is a characteristic of most neonatal seizures?

a.

Clonic

b.

Generalized

c.

Well organized

d.

Subtle and barely discernible

ANS: D

Seizures in newborns may be subtle and barely discernible or grossly apparent. Most neonatal seizures are subcortical and do not have the etiologic or prognostic significance of seizures in older children. Clonic seizures are slow, rhythmic jerking movements. Generalized seizures are bilateral jerks of the upper and lower limbs that are associated with electroencephalographic discharges. Neonatal seizures are not well organized.

DIF: Cognitive Level: Understanding REF: p. 393

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

36. What should the nurse anticipate in an infant who was exposed to cocaine during pregnancy?

a.

Seizures

b.

Hyperglycemia

c.

Large for gestational age

d.

Hypertonia and jitteriness

ANS: D

The nurse should anticipate neurobehavioral depression or excitability and implement care directed at the infants manifestations. Few or no neurologic sequelae appear in infants born to mothers who used cocaine during pregnancy. The infant is usually a poor feeder, so hypoglycemia should be more likely than hyperglycemia. The infant usually has intrauterine growth restriction.

DIF: Cognitive Level: Understanding REF: p. 399

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

37. What does the nursing care for infants with fetal alcohol syndrome (FAS) include?

a.

Nutritional guidance

b.

An intensive stimulation program

c.

Facilitation of improvement in cardiovascular status

d.

An individualized program based on maternal alcohol consumption

ANS: A

Infants with FAS have characteristic poor feeding behaviors that persist throughout childhood. The nurse assists in devising strategies to improve nutrition. The infant is protected from overstimulation. FAS does not include cardiovascular problems. The effects of FAS do not depend on the quantity of maternal alcohol consumption.

DIF: Cognitive Level: Applying REF: p. 401

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

38. Women who smoke during pregnancy are most likely to have infants who are what?

a.

Large for gestational age

b.

Preterm but size appropriate for gestational age

c.

Growth restricted in weight only

d.

Growth restricted in weight, length, and chest and head circumference

ANS: D

Infants born to mothers who smoke have retardation in all aspects of growth. Infants of mothers with diabetes are large for gestational age. Infants of mothers who smoke are small for gestational age.

DIF: Cognitive Level: Understanding REF: p. 401

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

39. An infant of a mother with herpes simplex infection has just been born. What should nursing considerations include?

a.

The infant should be isolated in a nursery.

b.

No special precautions are necessary.

c.

The mother and infant should be together in a private room.

d.

Immediate discharge is indicated to prevent spread of infection.

ANS: C

The herpes virus can be transmitted to the infant intrapartum or by direct contact. The mother and infant should room together in a private room to reduce the risk of transmission to other infants and mothers. The infant should be kept with the mother. Placement in the nursery creates the possibility of transmission of the virus. Immediate discharge is not necessary. Good handwashing and a private room will minimize the risk of transmission while allowing the mother and infant to receive postpartum care.

DIF: Cognitive Level: Applying REF: p. 402 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

40. The nurse is caring for a newborn who was born at 35 weeks of gestation and is considered a late preterm infant. What intervention should be included in the infants care plan?

a.

Feed the infant dextrose water as the first feeding after 12 hours.

b.

Promote skin-to-skin care in the immediate postpartum period.

c.

Avoid administration of the hepatitis B vaccine until after discharge.

d.

Delay the newborn screening and hearing test until the infant is at 40 weeks corrected age.

ANS: B

Late preterm infants can usually tolerate skin-to-skin care in the immediate postpartum period, which enhances the bonding process with the parents. A late preterm infant should be given an early feeding of human milk or formula; dextrose water is not required for the first feeding. The hepatitis B vaccine and all newborn screening, including the hearing test, should be done before discharge, with no limitation on corrected age.

DIF: Cognitive Level: Applying REF: p. 337

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

41. The nurse is caring for a preterm infant who is receiving caffeine citrate for treatment of apnea of prematurity. What signs should indicate caffeine toxicity?

a.

Bradycardia and hypotension

b.

Oliguria and sleepiness

c.

Vomiting and irritability

d.

Constipation and weight loss

ANS: C

Caffeine citrate is the medication of choice for the treatment of apnea of prematurity because it has fewer side effects, requires once-daily dosing, has slower elimination, and has a wider therapeutic range than other options. Caffeine toxicity can still occur, so the preterm infant needs to be monitored for signs of toxicity, including vomiting and irritability. Bradycardia, hypotension, oliguria, sleepiness, constipation, and weight loss are not symptoms of toxicity.

DIF: Cognitive Level: Analyzing REF: p. 368

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

42. The nurse is attending a delivery of a full-term infant with meconium noted in the amniotic fluid. The nurse should understand that what action should be performed in the delivery room?

a.

The infant will be suctioned with a DeLee trap suctioning device after delivery of the head while the chest is still compressed in the birth canal.

b.

The infants nose will be suctioned at the delivery of the head; subsequent suctioning of the mouth will occur after completion of the delivery.

c.

The infant will need to take the first breath after delivery of the head and shoulders and will require tracheal suctioning.

d.

The infants mouth, nose, and posterior pharynx will be suctioned just after the head is delivered while the chest is still compressed in the birth canal.

ANS: D

Meconium aspiration syndrome can occur when a fetus is subjected to intrauterine stress that causes relaxation of the anal sphincter and passage of meconium into the amniotic fluid, and the meconium-stained fluid is aspirated with the first breath. To prevent meconium aspiration, the infants mouth, nose, and posterior pharynx should be suctioned just after delivery of the head while the chest is still compressed in the birth canal. A DeLee trap is no longer used in the delivery room. The infants mouth should be suctioned before the nose and during the delivery, not at the completion of delivery. The infant should not take its first breath without suctioning first and may or may not require tracheal suctioning.

DIF: Cognitive Level: Applying REF: p. 376 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

43. The nurse is placing an infant in a servocontrol radiant warmer. The nurse should attach the temperature probe to which area of the infants body?

a.

Scapula

b.

Sternum

c.

Abdomen

d.

Front of the lower leg

ANS: C

The temperature probe should be placed over a nonbony, well-perfused tissue area such as the abdomen or flank. The scapula, sternum, and front of the lower leg would be a bony area.

DIF: Cognitive Level: Applying REF: p. 342

TOP: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

44. The nurse is preparing to administer a gavage feeding to an infant. The nurse should place the infant in which position for the feeding?

a.

Supine with the head flat

b.

Sitting upright in a car seat

c.

Left side-lying with the head flat

d.

Prone with the head slightly elevated

ANS: D

The gavage feeding is best performed when an infant is in a prone or a right side-lying position with the head slightly elevated. Supine and left side-lying with the head flat would not be a recommended position. The infant should not be gavage fed sitting in a car seat.

DIF: Cognitive Level: Applying REF: p. 347

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

45. The neonatal intensive care nurse is planning care for an infant in an incubator. Which interventions should the nurse plan to assure therapeutic visual stimulation for the neonate?

a.

Use an incubator cover.

b.

Keep lights bright in the unit.

c.

Place a cloth over the infants face.

d.

Leave a visual stimulus at the head of the infants bed.

ANS: A

Decrease ambient light levels by using an incubator cover and by dimming lights, not keeping them bright. Avoid placing a cloth over the face because it will cause tactile irritation. Avoid leaving visual stimuli in the beds of infants who cannot escape from it.

DIF: Cognitive Level: Applying REF: p. 359 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

46. Parents of an infant born at 36 weeks gestation ask the nurse, Will our infant need a car seat trial before being discharged? What is the nurses best response?

a.

Yes, to see if the car seat is the appropriate size.

b.

Yes, to determine if blanket rolls will be needed.

c.

No, your infant was old enough at birth to not need a trial.

d.

Yes, to monitor for possible apnea and bradycardia while in the seat.

ANS: D

It is recommended that infants younger than 37 weeks of gestation have a period of observation in an appropriate car seat to monitor for possible apnea and bradycardia. The trial is not done to check the size of the car seat or to determine if blanket rolls will be needed. The infant was born at 36 weeks of gestation, so it is recommended to perform a car sear trial.

DIF: Cognitive Level: Applying REF: p. 362

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

47. The nurse is caring for an infant born at 37 weeks of gestation of a nondiabetic mother just admitted to the neonatal intensive care unit for observation. The nurse notes that which lecithin/sphingomyelin (L/S) ratio obtained before delivery indicates no risk of respiratory distress syndrome (RDS)?

a.

1.4:1

b.

1.6:1

c.

1.8:1

d.

2:1

ANS: D

An L/S ratio of 2:1 in nondiabetic mothers indicates virtually no risk of RDS.

DIF: Cognitive Level: Analyzing REF: p. 372

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

48. The health care provider has prescribed surfactant, beractant (Survanta), to be administered to an infant with respiratory distress syndrome (RDS). The nurse understands that the beractant will be administered by which route?

a.

Orally

b.

Intravenously

c.

Via the ET tube

d.

Intramuscularly

ANS: C

Surfactant is administered via the ET tube directly into the infants trachea.

DIF: Cognitive Level: Analyzing REF: p. 373 TOP: Nursing Process: Planning

MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1. The nurse is monitoring an infants temperature to avoid cold stress. The nurse understands that cold stress in the infant can cause which complications? (Select all that apply.)

a.

Hypoxia

b.

Hypoglycemia

c.

Metabolic acidosis

d.

Respiratory alkalosis

e.

Increased shivering response

ANS: A, B, C

Cold stress poses hazards to the neonate through hypoxia, metabolic acidosis, and hypoglycemia. Cold stress does not cause respiratory alkalosis. The infant lacks a shivering response, so it is not a complication of cold stress.

DIF: Cognitive Level: Understanding REF: p. 342

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. The neonatal intensive care nurse is caring for a neonate born at 36 weeks of gestation in an incubator. Which actions should the nurse plan to assure adequate skin care for the neonate? (Select all that apply.)

a.

Changing any adhesives every 12 hours

b.

Removing adhesives or skin barriers slowly

c.

Using an adhesive remover when removing tape

d.

Applying emollient as needed for dry, flaking skin

e.

Using cleanser or soaps no more than two or three times a week

ANS: B, D, E

Skin care for the neonate involves removing adhesive or skin barriers slowly, supporting the skin underneath with one hand and gently peeling away from the skin with the other hand. Emollient should be applied as needed for dry, flaking skin, and cleansers or soaps should be used no more than two or three times a week because they can dry the skin. Adhesive remover, solvents, and bonding agents should be avoided. Adhesives should not be removed for at least 24 hours after application, not 12.

DIF: Cognitive Level: Applying REF: p. 352 TOP: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

3. The nurse is positioning a preterm neonate. What are therapeutic positions the nurse should implement? (Select all that apply.)

a.

Elbows extended

b.

Hands at the side

c.

Neutral or slightly flexed neck

d.

Trunk slightly rounded with pelvic tilt

e.

Hips partially flexed and adducted to near midline

ANS: C, D, E

Therapeutic positioning of the neonate includes a neutral or slightly flexed neck and the trunk slightly rounded with the pelvis tilted and hips partially flexed and adducted to near midline. The elbows should be flexed, not extended, and the hands should be brought to the face or midline as the position allows, not by the side.

DIF: Cognitive Level: Applying REF: p. 357

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

4. The nurse is caring for a neonate on positive-pressure ventilation. The nurse monitors for which complications of positive-pressure ventilation? (Select all that apply.)

a.

Pneumothorax

b.

Pneumomediastinum

c.

Respiratory distress syndrome

d.

Meconium aspiration syndrome

e.

Pulmonary interstitial emphysema

ANS: A, B, E

Positive-pressure introduced by mechanical apparatus increases complications such as pulmonary interstitial emphysema, pneumothorax, and pneumomediastinum. Respiratory distress syndrome and meconium aspiration syndrome are not complications of positive-pressure ventilation.

DIF: Cognitive Level: Analyzing REF: p. 375

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5. The home care nurse is visiting a 6-month-old infant with bronchopulmonary dysplasia (BPD). The nurse assesses the child for which signs of overhydration? (Select all that apply.)

a.

Edema

b.

Serum sodium of 140 mEq/L

c.

Urine specific gravity of 1.008

d.

Weight gain of 1 lb in 1 week

ANS: A, D

Nurses must be alert to signs of overhydration in an infant with BPD such as changes in weight, electrolytes, output measurements, and urine specific gravity and signs of edema. Six-month-old infants gain around 4 to 5 oz a week. One pound in 1 week would indicate fluid retention. Serum sodium of 140 mEq/L and urine specific gravity of 1.008 are normal values and indicate adequate fluid balance.

DIF: Cognitive Level: Analyzing REF: p. 383

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

6. The nurse is caring for a neonate with an intraventricular hemorrhage. What interventions should the nurse avoid to prevent any increase in intracranial pressure? (Select all that apply.)

a.

Keeping the head of the bed flat

b.

Keeping the environment quiet

c.

Handling the neonate minimally

d.

Suctioning the endotracheal tube frequently

e.

Maintaining the neonates head in a midline position

ANS: A, D

Some nursing procedures increase intracranial pressure (ICP). For example, blood pressure increases significantly during endotracheal suctioning in preterm infants, and head positioning produces measurable changes in ICP. ICP is highest when infants are in the dependent (flat) position and decreases when the head is in a midline position and elevated 30 degrees. Keeping the environment quiet, handling the neonate minimally, and maintaining the neonates head in a midline position are measures to keep the ICP down.

DIF: Cognitive Level: Applying REF: p. 392

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

7. The nurse is admitting a drug-exposed newborn to the neonatal intensive care unit. The nurse should assess the newborn for which signs of withdrawal? (Select all that apply.)

a.

Tremors

b.

Nasal stuffiness

c.

Loose, watery stools

d.

Hypoactive Moro reflex

e.

Decrease in respiratory rate

ANS: A, B, C

Signs of withdrawal in a drug-exposed newborn include increased tone; increased respiratory rate; disturbed sleep; fever; excessive sucking; and loose, watery stools. Other signs observed included projectile vomiting, mottling, crying, nasal stuffiness, hyperactive Moro reflex, and tremors.

DIF: Cognitive Level: Applying REF: p. 396

TOP: Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

8. The nurse is teaching parents of a bottle-fed preterm infant techniques to facilitate feeding. Which techniques should the nurse include? (Select all that apply.)

a.

Choose a soft nipple.

b.

Avoid arousing the infant.

c.

Recognize the infants limits.

d.

Prepare a calm, quiet area for the feeding.

e.

Ensure a restful environment between feedings.

ANS: C, D, E

Feeding facilitation techniques for preterm infants include recognizing the infants limits; preparing a calm, quiet area for the feeding; and ensuring a restful environment between feedings. Using a firm nipple with slower flow and gently arousing the infant for the feeding are other facilitation techniques. Using a soft nipple and avoiding arousing the infant are techniques that would not facilitate feeding.

DIF: Cognitive Level: Applying REF: p. 349

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

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