Chapter 29: High-Risk Newborn: Complications Associated with Gestational Age and Development My Nursing Test Banks

Chapter 29: High-Risk Newborn: Complications Associated with Gestational Age and Development

MULTIPLE CHOICE

1. Which is most helpful in preventing premature birth?

a.

High socioeconomic status

b.

Adequate prenatal care

c.

Aid to Families with Dependent Children

d.

Women, Infants, and Children (WIC) nutritional program

ANS: B

Prenatal care is vital for identifying possible problems. People with higher socioeconomic status are more likely to seek adequate prenatal care, which is the most helpful for prevention. Lower socioeconomic groups do not seek out health care, and that puts them at risk for preterm labor. Aid to Families with Dependent Children and WIC aid in the nutritional status of the pregnant woman, but the most helpful aid for the prevention of premature births is adequate prenatal care.

PTS: 1 DIF: Cognitive Level: Understanding REF: 623

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. In comparison with the term infant, the preterm infant has:

a.

More subcutaneous fat.

b.

Well-developed flexor muscles.

c.

Few blood vessels visible through the skin.

d.

Greater surface area in proportion to weight.

ANS: D

Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat, well-developed flexor muscles, and few blood vessels visible through the skin are more characteristic of a term infant.

PTS: 1 DIF: Cognitive Level: Analysis REF: 623

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

3. Decreased surfactant production in the preterm lung is a problem because:

a.

Surfactant keeps the alveoli open during expiration.

b.

Surfactant causes increased permeability of the alveoli.

c.

Surfactant dilates the bronchioles, decreasing airway resistance.

d.

Surfactant provides transportation for oxygen to enter the blood supply.

ANS: A

Surfactant prevents the alveoli from collapsing each time the infant exhales, thus reducing the work of breathing. It does not affect the bronchioles. By keeping the alveoli open, it permits better oxygen exchange, but that is not its main purpose.

PTS: 1 DIF: Cognitive Level: Understanding REF: 623

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

4. A preterm infant is on a respirator, with intravenous lines and much equipment. When the parents come to visit for the first time, which is an important response by the nurse?

a.

Encourage the parents to touch their infant.

b.

Reassure the parents that the infant is progressing well.

c.

Discuss the care they will give their infant when the infant goes home.

d.

Suggest that the parents visit for only a short time to reduce their anxiety.

ANS: A

Touching the infant will increase the development of attachment. It is important to keep the parents informed about the infants progress, but the nurse needs to be honest with the explanations. Discussing home care is an important part of parent teaching but is not the most important priority during the first visit. Bonding needs to occur, and this can be fostered by encouraging the parents to spend time with the infant.

PTS: 1 DIF: Cognitive Level: Application REF: 641

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Psychosocial Integrity

5. Which preterm infant should receive gavage feedings instead of bottle feedings?

a.

Sucks on a pacifier during gavage feedings

b.

Sometimes gags when a feeding tube is inserted

c.

Has a sustained respiratory rate of 70 breaths/min

d.

Has an axillary temperature of 98.4 F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min

ANS: C

Infants less than 34 weeks of gestation or those who weigh less than 1500 g generally have difficulty with bottle feeding. Gavage feedings should be initiated if the respiratory rate is above 60 breaths/min. Providing a pacifier during gavage feedings gives positive oral stimulation and helps the infant associate the comfortable feeling of fullness with sucking. The presence of the gag reflex is important before initiating bottle feeding. Axillary temperature of 98.4 F, an apical pulse of 149 beats/min, and respirations of 54 breaths/min are within expected limits and an indication that the infant is not having respiratory problems at that time.

PTS: 1 DIF: Cognitive Level: Analysis REF: 631

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

6. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing intervention helps to avoid this problem?

a.

Group all care activities together to provide long periods of rest.

b.

Keep charts on top of the incubator so the nurses can write on them there.

c.

While giving a report to the next nurse, stand in front of the incubator and talk softly about how the infant responds to stimulation.

d.

Teach the parents signs of overstimulation, such as turning the face away or stiffening and extending the extremities and fingers.

ANS: D

Parents should be taught the signs of overstimulation so they will learn to adapt their care to the needs of their infant. Grouping care activities may understimulate the infant during those long periods and overtire the infant during the procedures. Keeping charts on the incubator and giving the report in front of the incubator may cause overstimulation.

PTS: 1 DIF: Cognitive Level: Application REF: 640

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

7. A characteristic of a post-term infant who weighs 7 lb, 12 oz, and who lost weight in utero, is:

a.

Soft and supple skin.

b.

A hematocrit level of 55%.

c.

Lack of subcutaneous fat.

d.

An abundance of vernix caseosa.

ANS: C

This post-term infant actually lost weight in utero, which is seen as loss of subcutaneous fat. The skin is normally wrinkled, cracked, and peeling. A hematocrit of 55% is within the expected range of all newborns. There is no vernix caseosa in a post-term infant.

PTS: 1 DIF: Cognitive Level: Understanding REF: 646

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

8. In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level?

a.

Necrotizing enterocolitis (NEC)

b.

Retinopathy of prematurity (ROP)

c.

Intraventricular hemorrhage (IVH)

d.

Bronchopulmonary dysplasia (BPD)

ANS: B

ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is due to the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. IVH is caused by rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow. BPD is caused by the use of positive-pressure ventilation against the immature lung tissue.

PTS: 1 DIF: Cognitive Level: Analysis REF: 644

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

9. In caring for the post-term infant, thermoregulation can be a concern, especially in an infant who also has a(n):

a.

Hematocrit level of 58%.

b.

RBC count of 5 million/mL.

c.

WBC count of 15,000 cells/mm3.

d.

Blood glucose level of 25 mg/dL.

ANS: D

Because glucose is necessary to produce heat, the infant who is also hypoglycemic will not be able to produce enough body heat. A hematocrit level of 58% is within the expected range for newborns. WBC count may be as high as 30,000 cells/mm3. RBC count ranges from 3.9 to 5.5 million/mL.

PTS: 1 DIF: Cognitive Level: Understanding REF: 622

OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

10. Which is true about newborns classified as small for gestational age (SGA)?

a.

They weigh less than 2500 g.

b.

They are born before 38 weeks of gestation.

c.

They are below the tenth percentile on gestational growth charts.

d.

Placental malfunction is the only recognized cause of this condition.

ANS: C

SGA infants are defined as below the tenth percentile in growth when compared with other infants of the same gestational age. SGA is not defined by weight. Infants born before 38 weeks are defined as preterm. There are many causes of SGA infants.

PTS: 1 DIF: Cognitive Level: Understanding REF: 646

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. Which nursing action is especially important for an SGA newborn?

a.

Promote bonding.

b.

Observe for and prevent dehydration.

c.

Observe for respiratory distress syndrome.

d.

Prevent hypoglycemia with early and frequent feedings.

ANS: D

The SGA infant has poor glycogen stores and is subject to hypoglycemia. Promoting bonding is a concern for all infants and is not specific for SGA infants. Dehydration is a concern for all infants and is not specific for SGA infants. Respiratory distress syndrome is seen in preterm infants.

PTS: 1 DIF: Cognitive Level: Understanding REF: 647

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

12. What will the nurse note when assessing an infant with asymmetric intrauterine growth restriction?

a.

All body parts appear proportionate.

b.

The extremities are disproportionate to the trunk.

c.

The head seems large compared with the rest of the body.

d.

One side of the body appears slightly smaller than the other.

ANS: C

In asymmetric intrauterine growth restriction, the head is normal in size but appears large because the infants body is long and thin because of lack of subcutaneous fat. The left and right side growth should be symmetric. With asymmetric intrauterine growth restrictions, the body appears smaller than normal compared to the head. The body parts are out of proportion, with the body looking smaller than expected because of the lack of subcutaneous fat. The body, arms, and legs have lost subcutaneous fat so they will look small compared with the head.

PTS: 1 DIF: Cognitive Level: Understanding REF: 647

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

13. Which data should alert the nurse caring for an SGA infant that additional calories may be needed?

a.

The latest hematocrit was 53%.

b.

The infants weight gain is 40 g/day.

c.

The infant is taking 120 mL/kg every 24 hours.

d.

Three successive temperature measurements were 97, 96, and 97 F.

ANS: D

Low body temperature indicates that additional calories are needed to maintain body temperature. The hematocrit is within the expected range for a newborn. A weight gain of about 20 g/day is expected. Preterm SGA infants need about 120 kcal/kg/day.

PTS: 1 DIF: Cognitive Level: Analysis REF: 624

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

14. Which statement is most true about large-for-gestational age (LGA) infants?

a.

They weigh more than 3500 g.

b.

They are above the 80th percentile on gestational growth charts.

c.

They are prone to hypoglycemia, polycythemia, and birth injuries.

d.

Postmaturity syndrome and fractured clavicles are the most common complications.

ANS: C

Hypoglycemia, polycythemia, and birth injuries are all common in LGA infants. LGA infants are determined by their weight compared to their age. They are above the 90th percentile on gestational growth charts. Birth injuries are a problem, but postmaturity syndrome is not an expected complication with LGA infants.

PTS: 1 DIF: Cognitive Level: Understanding REF: 647

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

15. Following the vaginal birth of a macrosomic infant, the nurse should assess the infant for:

a.

Hyperglycemia.

b.

Clavicle fractures.

c.

Hyperthermia.

d.

An increase in red blood cells.

ANS: B

Macrosomic infants may have a complicated birth and are susceptible to birth injuries, such as fractured clavicles, cephalohematomas, and brachial palsy. A macrosomic infant would have the potential to be hypoglycemic. The macrosomic infant would be at risk for hypothermia. An increase in red blood cells would not be the priority assessment for a macrosomic infant.

PTS: 1 DIF: Cognitive Level: Application REF: 647

OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

16. An infant delivered preterm at 28 weeks gestation weighs 1200 g. Based on this information, the infant is designated as:

a.

SGA.

b.

VLBW.

c.

ELBW.

d.

Low birth weight at term.

ANS: B

VLBW (very-low-birth-weight) infants weigh 1500 g or less at birth. SGA infants fall below the tenth percentile in growth charts. ELBW (extremely-low-birth-weight) infants weigh 100 g or less at birth. Low birth weight pertains to an infant weighing 2500 g or less at birth. However, this option is incorrect because it specifies at term and the infant in question is designated as preterm at 28 weeks gestation.

 

PTS: 1 DIF: Cognitive Level: Application REF: 622

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

17. A nurse is observing a 38-week gestation newborn in the nursery. Data reveals periods of apnea lasting approximately 10 seconds followed by a period of rapid respirations. The infants color and heart rate remain unchanged. The nurse suspects that the infant:

a.

Is exhibiting signs of RDS.

b.

Requires tactile stimulation around the clock to ensure that apneic periods do not progress further.

c.

Is experiencing periodic breathing episodes and will require continuous monitoring while in the nursery unit.

d.

Requires the use of CPAP to promote airway expansion.

ANS: C

Periodic breathing can occur in term or preterm infants; it consists of periods of breathing cessation (5 to 10 seconds) followed by a period of increased respirations (10 to 15 breaths/min). It is not associated with any color or heart rate changes. Infants who exhibit this pattern should continue to be observed. There is no clinical evidence that the infant is exhibiting signs of respiratory distress syndrome (RDS). There is no indication that a pattern of tactile stimulation should be initiated. Continuous positive airway pressure (CPAP) and tactile stimulation would be indicated if the infant were to have apneic spells.

PTS: 1 DIF: Cognitive Level: Application REF: 623

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

18. Which nursing diagnosis would be considered a priority for a newborn infant who is receiving phototherapy in an isolette?

a.

Hypothermia because of phototherapy treatment

b.

Impaired skin integrity related to diarrhea as a result of phototherapy

c.

Fluid volume deficit related to phototherapy treatment

d.

Knowledge deficit (parents) related to initiation of medical therapy

ANS: C

Infants who undergo phototherapy as a result of the medical diagnosis of hyperbilirubinemia are at risk for hyperthermia, not hypothermia. Although impaired skin integrity can occur, the priority nursing diagnosis focuses on the physiologic effects of fluid volume deficit. The infant is losing fluid via insensible losses, increased output (in the form of diarrhea), and limited intake. Lack of knowledge is a pertinent nursing diagnosis for parents but physiologic needs take precedence.

 

PTS: 1 DIF: Cognitive Level: Analysis REF: 626

OBJ: Nursing Process Step: Nursing Diagnosis

MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care

19. An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable but muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of:

a.

RDS.

b.

PIVH.

c.

BPD.

d.

ROP.

ANS: B

IVH or PIVH (intraventricular hemorrhage or periventricular hemorrhage) can be seen during the first week of life. Signs and symptoms are based on the extent of hemorrhage. Typically, one would see lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, acidosis, and seizures. If the newborn had RDS or BPD, there would be more respiratory symptoms exhibited. If the infant had ROP, there would be signs and symptoms related to the eyes. Other physical characteristics are reported as being normal.

PTS: 1 DIF: Cognitive Level: Analysis REF: 644

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation

20. To determine a preterm infants readiness for nipple feeding, the nurse should assess the:

a.

Skin turgor.

b.

Bowel sounds.

c.

Current weight.

d.

Respiratory rate.

ANS: D

Coordination of suck, swallow, and breathing is a common task for preterm infants. The infant must have a respiratory rate less than 60 breaths/min before nipple feeding can be implemented; skin turgor, bowel sounds, and current weight are not indications for nipple feeding.

PTS: 1 DIF: Cognitive Level: Application REF: 631

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

21. Following a traumatic birth of a 10-pound infant, the nurse should assess:

a.

gestational age status.

b.

flexion of both upper extremities.

c.

infants percentile on growth chart.

d.

blood sugar to detect hyperglycemia.

ANS: B

Large infants are at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Gestational age or the infants growth chart percentile will not provide data about potential injuries from a traumatic birth. A large infant is at risk for hypoglycemia.

PTS: 1 DIF: Cognitive Level: Application REF: 647

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

22. A newborn assessment finding that would support the nursing diagnosis of postmaturity would be:

a.

loose skin.

b.

ruddy skin color.

c.

presence of vernix.

d.

absence of lanugo.

ANS: A

Decreased placental function because of a prolonged pregnancy results in loss of subcutaneous tissue in the neonate, which is evidenced by loose skin. Ruddy skin color, presence of vernix, and absence of lanugo do not indicate a postmature infant.

PTS: 1 DIF: Cognitive Level: Assessment REF: 646

OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

23. Because late preterm infants are more stable than early preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these infants are at increased risk for which of the following? (Select all that apply.)

a.

Sepsis

b.

Hyperglycemia

c.

Hyperbilirubinemia

d.

Cardiac distress

e.

Problems with thermoregulation

ANS: A, C, E

Sepsis, hyperbilirubinemia, and problems with thermoregulation are all conditions that are related to immaturity and warrant close observation. After discharge, the infant is at risk for rehospitalization related to these problems. The Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) has launched the Near-Term Infant Initiative to study the problem and determine ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications. These infants are at risk for respiratory distress and hypoglycemia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 621

OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

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