Chapter 30: High-Risk Newborn: Acquired and Congenital Conditions My Nursing Test Banks

Chapter 30: High-Risk Newborn: Acquired and Congenital Conditions

MULTIPLE CHOICE

1. The infant of a diabetic mother is hypoglycemic. Which type of feeding should be instituted first?

a.

Glucose water

b.

D5W intravenously

c.

Formula via nasogastric tube

d.

Small amount of glucose water followed by formula or breast milk

ANS: D

Glucose followed by formula or breast milk is metabolized more slowly and results in longer normal glucose levels. High levels of dextrose correct the hypoglycemia but will stimulate the production of more insulin. Oral feedings are tried first; intravenous lines would be a later choice if the hypoglycemia continues. Formula results in longer normal glucose levels but would be administered via bottle, not by tube feeding.

PTS: 1 DIF: Cognitive Level: Application REF: 659

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

2. Which defect is present with tetralogy of Fallot?

a.

Patent ductus arteriosus

b.

Coarctation of the aorta

c.

Hypertrophy of the right ventricle

d.

Transposition of the great arteries

ANS: C

Tetralogy of Fallot has four characteristicsventricular septal defect, positioning of the aorta over the defect, pulmonary stenosis, and hypertrophy of the right ventricle. Patent ductus arteriosus is a result of the failure of the ductus arteriosus to close after birth. Blood flow is impeded, though this constricted area of the aorta is not a characteristic of tetralogy of Fallot. In transposition of the great arteries, the positions of the aorta and pulmonary artery are reversed.

PTS: 1 DIF: Cognitive Level: Understanding REF: 674

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

3. The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula feedings or breastfeedings is to:

a.

prevent hyperglycemia.

b.

provide fluids and protein.

c.

decrease gastrointestinal motility.

d.

prevent rapid emptying of the bilirubin from the bowel.

ANS: B

Proteins help maintain the albumin level in the blood, and the extra fluids help eliminate the excess bilirubin from the infants system. Feedings every 2 hours will help prevent hypoglycemia. Increased gastrointestinal motility can facilitate the prompt emptying of the bilirubin from the bowel. The feedings stimulate bowel movements and emptying of the bilirubin from the bowel.

PTS: 1 DIF: Cognitive Level: Application REF: 658

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

4. An infant with severe meconium aspiration syndrome is not responding to conventional treatment. Which method of treatment may be available at a level III facility for use with this infant?

a.

Insertion of an endotracheal tube

b.

Respiratory support with a ventilator

c.

Extracorporeal membrane oxygenation

d.

Insertion of a laryngoscope and suctioning of the trachea

ANS: C

Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, allowing the infants lungs to rest and recover. An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth, before the infant takes the first breath.

PTS: 1 DIF: Cognitive Level: Understanding REF: 653

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

5. Four hours after the birth of a healthy neonate of an insulin-dependent (type 1) diabetic mother, the baby appears jittery and irritable and has a high-pitched cry. Which nursing action has top priority?

a.

Notify the clinician stat.

b.

Test for the blood glucose level.

c.

Start an intravenous line with D5W.

d.

Document the event in the nurses notes.

ANS: B

These symptoms are signs of hypoglycemia in the newborn. Permanent damage can occur if glucose is not constantly available to the brain, but it is not common practice to give intravenous glucose to a newborn. Feeding the infant is preferable because the formula or breast milk will last longer. Determine the blood glucose level according to agency policy, treat symptoms with standing orders protocol, and notify the physician with the results. Documentation can wait until the infant has been tested and treated if a problem is present.

PTS: 1 DIF: Cognitive Level: Application REF: 670

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

6. Which newborn should the nurse recognize as being most at risk for developing respiratory distress syndrome?

a.

A 35-week-gestation male baby born vaginally to a mother addicted to heroin

b.

A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes

c.

A 36-week-gestation male baby born by cesarean birth to a mother with insulin-dependent diabetes

d.

A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension

ANS: C

Infants of mothers with diabetes have delayed production of surfactant, thus placing the infant at risk for respiratory distress syndrome. A 35-week-gestation male baby born vaginally to a mother addicted to heroin is at risk for withdrawal. A 35-week-gestation female baby born vaginally 72 hours after the rupture of membranes is at risk for infection because of the prolonged rupture of membranes. A 35-week-gestation female baby born vaginally to a mother who has pregnancy-induced hypertension is at risk for hypoxia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 651, 652

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

7. Transitory tachypnea of the newborn (TTN) is thought to occur as a result of:

a.

a lack of surfactant.

b.

hypoinflation of the lungs.

c.

delayed absorption of fetal lung fluid.

d.

a slow vaginal birth associated with meconium-stained fluid.

ANS: C

Delayed absorption of fetal lung fluid is thought to be the reason for TTN. Lack of surfactant causes respiratory distress syndrome. A slow vaginal birth will help prevent TTN.

PTS: 1 DIF: Cognitive Level: Understanding REF: 653

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

8. The nurse must continually assess the infant who has meconium aspiration syndrome for the complication of:

a.

persistent pulmonary hypertension.

b.

bronchopulmonary dysplasia.

c.

transitory tachypnea of the newborn.

d.

left-to-right shunting of blood through the foramen ovale.

ANS: A

Persistent pulmonary hypertension can result from the aspiration of meconium. Bronchopulmonary dysplasia is caused by the use of positive-pressure oxygenation, which stretches the immature lung membranes. Transitory tachypnea of the newborn is caused by delayed absorption of fetal lung fluid. Left-to-right shunting of blood through the foramen ovale is a congenital defect that can be caused by atrial septal defects, ventricular septal defects, patent ductus arteriosus, or atrioventricular canal defects.

PTS: 1 DIF: Cognitive Level: Application REF: 655

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

9. The nurse present at the birth is reporting to the nurse who will be caring for the neonate after birth. Which information should be included for an infant who had thick meconium in the amniotic fluid?

a.

The parents spent an hour bonding with the baby after birth.

b.

An IV was started immediately after birth to treat dehydration.

c.

There was no meconium below the vocal cords when they were visualized.

d.

The infant needed vigorous stimulation immediately after birth to initiate crying.

ANS: C

A laryngoscope is inserted to examine the vocal cords. If no meconium is below the cords, probably no meconium is present in the lower air passages, and the infant will not develop meconium aspiration syndrome. Bonding after birth is an expected occurrence. There is no relationship between dehydration and meconium fluid. Vigorous stimulation in the presence of meconium fluid is contraindicated to prevent aspiration.

PTS: 1 DIF: Cognitive Level: Understanding REF: 653

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

10. Which intervention should make phototherapy most effective in reducing the indirect bilirubin in an affected newborn?

a.

Turn the infant every 2 hours.

b.

Place eye patches on the newborn.

c.

Wrap the infant in triple blankets to prevent cold stress.

d.

Increase the oral intake of water between and before feedings.

ANS: A

Exposure of all parts of the skin increases the effectiveness of phototherapy. Placing eye patches is important to protect the eyes; however, this is not what affects the bilirubin levels. Wrapping the infant in blankets will prevent the phototherapy from getting to the skin and being effective. The infant should be uncovered and unclothed. It is important to increase oral feedings, but water should not necessarily be given, which would not reduce the bilirubin.

PTS: 1 DIF: Cognitive Level: Application REF: 660

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Health Promotion and Maintenance

11. A mother with diabetes has done some reading about the effects of her condition on a newborn. Which statement shows a misunderstanding that should be clarified by the nurse?

a.

The red appearance of my babys skin is due to an excessive number of red blood cells.

b.

My baby will be watched closely for signs of low blood sugar, especially during the early days after birth.

c.

My babys pancreas may not produce enough insulin because the cells became smaller than normal during my pregnancy.

d.

Although my baby is large, some women with diabetes have very small babies because the blood flow through the placenta may not be as good as it should be.

ANS: C

Infants of diabetic mothers may have hypertrophy of the islets of Langerhans, which may cause them to produce more insulin than they need. High hematocrit values in neonates of diabetic mothers cause them to have a have a ruddy look. Neonates of diabetic mothers are prone to hypoglycemia. It is correct that some women with diabetes have very small babies because of poor blood flow through the placenta.

PTS: 1 DIF: Cognitive Level: Analysis REF: 665

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

12. Newborns whose mothers are substance abusers frequently have which behaviors?

a.

Hypothermia, decreased muscle tone, and weak sucking reflex

b.

Excessive sleep, weak cry, and diminished grasp reflex

c.

Circumoral cyanosis, hyperactive Babinski reflex, and constipation

d.

Decreased amounts of sleep, hyperactive Moro reflex, and difficulty feeding

ANS: D

Infants exposed to drugs in utero often have poor sleeping patterns, hyperactive reflexes, and uncoordinated sucking and swallowing behaviors. They will have hyperactive muscle tone, a high-pitched cry, and diarrhea, not constipation.

PTS: 1 DIF: Cognitive Level: Understanding REF: 667

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

13. When a cardiac defect causes the mixing of arterial and venous blood in the right side of the heart, the nurse might expect to find:

a.

cyanosis.

b.

diuresis.

c.

signs of pulmonary congestion.

d.

increased oxygenation of the tissues.

ANS: C

Mixing of the blood in the right side of the heart will cause excessive blood flow to the lungs and pulmonary congestion. Cyanosis is seen more frequently with right-to-left shunts. Diuresis is not a common finding with cardiac defects. Increased oxygenation of the tissues is not seen with this type of cardiac defect.

PTS: 1 DIF: Cognitive Level: Analysis REF: 673

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

14. In an infant with cyanotic cardiac anomaly, the nurse should expect to see:

a.

feedings taken eagerly.

b.

a consistent and rapid weight gain.

c.

a decrease in the heart rate with activity.

d.

little to no improvement in color with oxygen administration.

ANS: D

With a cyanotic cardiac defect, the shunting of blood is right to left, so there is little if any improvement in the oxygenation of the blood with the administration of oxygen. Infants with cardiac anomalies are usually difficult feeders, have difficulty gaining weight, and have an increase in the heart rate with activity.

PTS: 1 DIF: Cognitive Level: Application REF: 665

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

15. The difference between pathologic jaundice and physiologic jaundice is that pathologic jaundice:

a.

usually results in kernicterus.

b.

appears during the first 24 hours of life.

c.

begins on the head and progresses down the body.

d.

results from the breakdown of excessive erythrocytes not needed after birth.

ANS: B

Nonphysiologic jaundice appears during the first 24 hours of life, whereas physiologic jaundice appears after the first 24 hours of life. Pathologic jaundice may lead to kernicterus, but it needs to be stopped before that occurs. Jaundice proceeds from the head down. Both jaundices are the result of the breakdown of erythrocytes. Pathologic jaundice is caused by a pathologic condition, such as Rh incompatibility.

PTS: 1 DIF: Cognitive Level: Understanding REF: 673, 674

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

16. While caring for a post-term infant, the nurse recognizes that the elevated hematocrit level most likely results from:

a.

hypoxia in utero.

b.

underproduction of red blood cells.

c.

increased breakdown of red blood cells.

d.

the normal expected shift from fetal hemoglobin to normal hemoglobin.

ANS: A

While in utero, the infant who is hypoxic will compensate by producing more red blood cells. An elevated hematocrit results from an overproduction of red blood cells. It would be seen with a decreased breakdown of red blood cells and is not a normal shift from fetal hemoglobin to normal hemoglobin.

PTS: 1 DIF: Cognitive Level: Analysis REF: 657

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

17. Shortly after a cesarean birth, a newborn begins to exhibit difficulty breathing. Nasal flaring and slight retractions are noted. The newborn is admitted to the neonatal intensive care unit (NICU) for closer observation, with a diagnosis of transient tachypnea (TTN). The parents are notified and become anxious because they have no idea what this means in terms of medical condition. The best action that the nurse can take at this time is to:

a.

refer them to the neonatologist for more information.

b.

tell them not to worry because their infant will be monitored closely by trained staff.

c.

explain to them that this often occurs following a birth but it will most likely resolve in the next 24 to 48 hours.

d.

tell them that they will be able to come and see their baby, which will help make them feel better.

ANS: C

The clinical diagnosis of TTN has been established, and the nurse should provide factual information relative to the clinical condition. The RN should be able to provide information to clarify the parents concern. Telling someone not to worry usually has the opposite effect in terms of a medical crisis. Facilitating an interaction with the newborn and parents may help ease anxiety but does not address the parents knowledge deficit.

PTS: 1 DIF: Cognitive Level: Analysis REF: 664

OBJ: Nursing Process Step: Evaluation

MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

18. While in utero, the fetus passes meconium. Based on this assessment, which nursing diagnosis takes priority for the newborn at birth?

a.

Risk for infection related to release of meconium

b.

Risk for injury related to high-risk birth interventions, such as amino infusion

c.

Risk for aspiration related to retained secretions

d.

Risk for thermoregulation because of high-risk labor status

ANS: C

Because the fetus has already passed meconium in utero, the labor and birth take on a high-risk management perspective. The likelihood that the infant will develop meconium aspiration syndrome (MAS) is increased, so airway abnormalities take precedence in terms of nursing diagnosis and medical management.

PTS: 1 DIF: Cognitive Level: Application REF: 653

OBJ: Nursing Process Step: Nursing Diagnosis

MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities

19. Which diagnostic test is used to help confirmation of hyperbilirubinemia in an infant?

a.

Direct Coombs test based on maternal blood sample

b.

Indirect Coombs test based on infant cord blood sample

c.

Infant bilirubin level

d.

Maternal blood type

ANS: C

The direct Coombs test is based on cord blood drawn from the infant, whereas the indirect Coombs test is based on maternal blood samples. Although maternal blood type is important in determining whether there is a potential ABO incompatibility, the infants bilirubin level provides the best evidence of whether the infant has hyperbilirubinemia or pathologic jaundice.

PTS: 1 DIF: Cognitive Level: Analysis REF: 657

OBJ: Nursing Process Step: Planning

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

20. Which of the following lab values indicates that an infant may have polycythemia?

a.

Hb 18 g/dL, Hct 50%

b.

Hb 25/dL, Hct 55%

c.

Hb 20/dL, Hct 65%

d.

Hb 30 g/dL, Hct 70%

ANS: D

The presence of polycythemia in an infant is characterized by a hemoglobin level greater than 22 g/dL and a hematocrit value greater than 65%.

PTS: 1 DIF: Cognitive Level: Application REF: 665

OBJ: Nursing Process Step: Assessment

MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

21. The nurses immediate action after the birth of a post-term infant with meconium stained amniotic fluid is to:

a.

stimulate the infant to cry.

b.

suction the infants airways.

c.

complete the 1- and 5-minute Apgars.

d.

vigorously dry the infants head and trunk.

ANS: B

Meconium in the upper airways may be pulled deep into the respiratory passages when the infant takes the first breath after birth. Stimulating the infant to cry may cause aspiration of meconium in the upper airways, completing the 1- and 5-minute Apgars would delay suctioning and allow initiation of respirations, and vigorously drying the infant would increase stimulation and crying.

PTS: 1 DIF: Cognitive Level: Application REF: 653

OBJ: Nursing Process Step: Implementation

MSC: Client Needs: Physiologic Integrity

22. The nurse notes that the infant has been feeding poorly over the last 24 hours. She should immediately assess for other signs of:

a.

hyperglycemia.

b.

neonatal infection.

c.

hemolytic anemia.

d.

increased bilirubin levels.

ANS: B

Signs of neonatal infection (sepsis) in the newborn are subtle. Temperature instability, respiratory problems, and changes in feeding habits may be common. Hyperglycemia, hemolytic anemia, and increased bilirubin levels are not associated with poor infant feeding.

PTS: 1 DIF: Cognitive Level: Application REF: 662

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

23. The priority assessment for the Rh-positive infant whose mothers indirect Coombs test was positive at 36 weeks is:

a.

skin color.

b.

temperature.

c.

respiratory rate.

d.

blood glucose level.

ANS: A

An Rh-negative infant whose mother was sensitized during the current pregnancy will have decreased red blood cells (RBCs) and exhibit skin pallor because of erythroblastosis fetalis. The temperature, respiratory rate, and blood glucose level are not assessments associated with erythroblastosis fetalis.

PTS: 1 DIF: Cognitive Level: Application REF: 657

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

24. The nurse should be alert to a blood group incompatibility if:

a.

both mother and infant are O-positive.

b.

mother is A-positive and infant is A-negative.

c.

mother is O-positive and infant is B-negative.

d.

mother is B-positive and infant is O-negative.

ANS: D

Blood group incompatibilities occur because O-positive mothers have natural antibodies to type A or B blood. When mother and infant both have blood group O or A, no incompatibility exists. The mother with blood group B does not have any antibodies to group O.

PTS: 1 DIF: Cognitive Level: Analysis REF: 657

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

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