Chapter 32 The Newborn at Risk: Birth-Related Stressors My Nursing Test Banks

Olds Maternal-Newborn Nursing and Womens Health, 10e (Davidson)

Chapter 32 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?

1. Initial resuscitation

2. Vigorous stimulation at birth

3. Phototherapy immediately

4. An initial feeding of iron-enriched formula

Answer: 1

Explanation: 1. 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.

Page Ref: 826

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and each types related nursing care.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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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?

1. Begin chest compressions.

2. Begin direct tracheal suctioning.

3. Begin bag-and-mask ventilation.

4. Obtain a blood pressure reading.

Answer: 3

Explanation: 3. Most newborns can be effectively resuscitated by bag-and-mask ventilation.

Page Ref: 814

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Describe how to identify infants in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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3) Which fetal/neonatal risk factors would lead the nurse to anticipate a potential need to resuscitate a newborn?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Nonreassuring fetal heart rate pattern/sustained bradycardia

2. Fetal scalp/capillary blood sample pH greater than 7.25

3. History of meconium in amniotic fluid

4. Prematurity

5. Significant intrapartum bleeding

Answer: 1, 3, 4, 5

Explanation: 1. Nonreassuring fetal heart rate pattern/sustained bradycardia would be considered a potential need to resuscitate a newborn.

3. History of meconium in amniotic fluid would be considered a potential need to resuscitate a newborn.

4. Prematurity would be considered a potential need to resuscitate a newborn.

5. Significant intrapartum bleeding would be considered a potential need to resuscitate a newborn.

Page Ref: 812

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Describe how to identify infants in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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4) During newborn resuscitation, how does the nurse evaluate the effectiveness of bag-and-mask ventilations?

1. The rise and fall of the chest

2. Sudden wakefulness

3. Urinary output

4. Adequate thermoregulation

Answer: 1

Explanation: 1. With proper resuscitation, chest movement is observed for proper ventilation. Pressure should be adequate to move the chest wall.

Page Ref: 814

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Describe how to identify infants in need of resuscitation and the appropriate method of resuscitation based on the prenatal/labor record and observable physiologic indicators.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

4

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5) 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?

1. Grunting respirations

2. Nasal flaring

3. Respiratory rate of 40 during sleep

4. Chest retractions

Answer: 3

Explanation: 3. A respiratory rate of 40 during sleep is normal.

Page Ref: 821

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and each types related nursing care.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

5

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6) 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?

1. Delivery of the neonate on its side with head up, to facilitate drainage of secretions.

2. Direct tracheal suctioning by specially trained personnel.

3. Preparation for the immediate use of positive pressure to expand the lungs.

4. Suctioning of the oropharynx when the newborns head is delivered.

Answer: 2

Explanation: 2. 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.

Page Ref: 827

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and each types related nursing care.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

6

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7) 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 infants condition?

1. Meconium aspiration syndrome

2. Transient tachypnea of the newborn

3. Respiratory distress syndrome

4. Prematurity of the neonate

Answer: 2

Explanation: 2. The infant is term and was born by cesarean, and is most likely experiencing transient tachypnea of the newborn.

Page Ref: 822

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and each types related nursing care.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

7

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8) 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 nurses assessment?

1. Decreased urine output

2. Pulmonary vascular resistance increases

3. Increased PCO2

4. Increased urination

Answer: 4

Explanation: 4. In babies with respiratory distress syndrome (RDS) who are on ventilators, increased urination/diuresis may be an early clue that the babys condition is improving.

Page Ref: 820

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and each types related nursing care.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

8

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9) When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Hypoxia

2. Respiratory alkalosis

3. Metabolic acidosis

4. Massive atelectasis

5. Pulmonary edema

Answer: 1, 3, 4, 5

Explanation: 1. The physiologic alterations of RDS can produce hypoxia as a complication. As a result of hypoxia, the pulmonary vasculature constricts, pulmonary vascular resistance increases, and pulmonary blood flow is reduced.

3. The physiologic alterations of RDS can produce metabolic acidosis as a complication. Because cells lack oxygen, the newborn begins an anaerobic pathway of metabolism, with an increase in lactate levels and a resulting base deficit.

4. The physiologic alterations of RDS can produce massive atelectasis as a complication. Upon expiration, the instability increases the atelectasis, which causes hypoxia and acidosis because of the lack of gas exchange.

5. The physiologic alterations of RDS can produce pulmonary edema as a complication. Opacification of the lungs on X-ray image may be due to massive atelectasis, diffuse alveolar infiltrate, or pulmonary edema.

Page Ref: 818

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 2 Differentiate, based on clinical manifestations, among the various types of respiratory distress (respiratory distress syndrome, transient tachypnea of the newborn, meconium aspiration syndrome, and persistent pulmonary hypertension) in the newborn and each types related nursing care.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

9

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10) Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn?

1. Jitteriness

2. Sucking on fingers

3. Lusty cry

4. Axillary temperature of 98F

Answer: 1

Explanation: 1. 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.

Page Ref: 832

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Context and Environment: Apply professional standards; show accountability for nursing judgment and actions; develop advocacy skills. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress and hypoglycemia), their effects on the newborn, and their nursing implications.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

11) 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?

1. Rub the heel vigorously with an isopropyl alcohol swab prior to obtaining blood.

2. Use a previous puncture site.

3. Cool the heel prior to obtaining blood.

4. Use a sterile needle and aspirate.

Answer: 1

Explanation: 1. The site should be cleaned by rubbing vigorously with 70% isopropyl alcohol swab. The friction produces local heat, which aids vasodilation.

Page Ref: 833

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress and hypoglycemia), their

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effects on the newborn, and their nursing implications.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

12) 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?

1. Increased skin temperature and respirations

2. Blood glucose level of 45

3. Room-temperature IV running

4. Positioned under radiant warmer

Answer: 3

Explanation: 3. 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.

Page Ref: 831, 832

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress and hypoglycemia), their effects on the newborn, and their nursing implications.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

11

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13) Which nursing intervention is appropriate in the management of the preterm infant with hypothermia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Warm the baby rapidly to reverse the hypothermia.

2. Monitor skin temperature every 2 hours to determine whether the infants temperature is increasing.

3. Keep IV fluids at room temperature.

4. Initiate efforts to maintain the newborn in a neutral thermal environment.

5. Warm the baby slowly to reverse hypothermia and reach a neutral thermal environment.

Answer: 4, 5

Explanation: 4. The nurse should initiate efforts to block heat loss by evaporation, radiation, convection, and conduction.

5. The infant should be warmed slowly to prevent hypotension and apnea.

Page Ref: 831

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3 Discuss the types of metabolic abnormalities (cold stress and hypoglycemia), their effects on the newborn, and their nursing implications.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

12

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14) 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?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Lights can stay on all the time.

2. The eyes do not need to be covered.

3. The lights will need to be removed for feedings.

4. Newborns do not get overheated.

5. Weight loss is not a complication of this system.

Answer: 1, 2, 4, 5

Explanation: 1. With the fiber-optic blanket, the light stays on at all times.

2. The eyes do not have to be covered with a fiber optic blanket.

4. With the fiber-optic blanket, greater surface area is exposed and there are no thermoregulation issues.

5. Fluid and weight loss are not complications of fiber-optic blankets.

Page Ref: 838

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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15) The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention?

1. Eyes are covered, no clothing on, diaper in place

2. Axillary temperature 99.7F

3. Infant removed from the isolette for breastfeeding

4. Loose bowel movement

Answer: 2

Explanation: 2. Temperature assessment is indicated to detect hypothermia or hyperthermia. Normal temperature ranges are 97.7F-98.6F. Vital signs should be monitored every 4 hours with axillary temperatures.

Page Ref: 843

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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16) The nurse is preparing an educational in-service presentation about jaundice in the newborn. What content should the nurse include in this presentation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Physiologic jaundice occurs after 24 hours of age.

2. Pathologic jaundice occurs after 24 hours of age.

3. Phototherapy increases serum bilirubin levels.

4. The need for phototherapy depends on the bilirubin level and age of the infant.

5. Kernicterus causes irreversible neurological damage.

Answer: 1, 5

Explanation: 1. Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life.

5. 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: 835

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 12. Create a safe environment that results in high quality patient outcomes. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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17) The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Jaundice present within the first 24 hours of life

2. Appearance of jaundice symptoms after 24 hours of life

3. Yellowish coloration of the sclera of the eyes

4. Cephalohematoma or excessive bruising

5. Cyanosis

Answer: 2, 3

Explanation: 2. Physiologic or neonatal jaundice is a normal process that occurs during transition from intrauterine to extrauterine life and appears after 24 hours of life.

3. Jaundice is a yellowish coloration of the skin and sclera of the eyes that develops from the deposit of yellow pigment bilirubin in lipid/fat-containing tissues.

Page Ref: 835

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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18) The nurse notes that a 36-hour-old newborns 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?

1. Continue to observe

2. Begin phototherapy

3. Begin blood exchange transfusion

4. Stop breastfeeding

Answer: 2

Explanation: 2. 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.

Page Ref: 836, 837

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Differentiate between physiologic and pathologic jaundice according to timing of onset (age in hours), etiology, possible sequelae, and specific management.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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19) The client with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. 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?

1. The RhoGAM you received at 28 weeks gestation did not prevent alloimmunization.

2. Your body has made antibodies against the babys blood that are destroying her red blood cells.

3. The red blood cells of your baby are breaking down because you both have type O blood.

4. Your babys liver is too immature to eliminate the red blood cells that are no longer needed.

Answer: 2

Explanation: 2. 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.

Page Ref: 835

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Explain how Rh incompatibility or ABO incompatibility can lead to the development of hyperbilirubinemia.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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20) Which of the following are considered risk factors for development of severe hyperbilirubinemia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Northern European descent

2. Previous sibling received phototherapy

3. Gestational age 27 to 30 weeks

4. Exclusive breastfeeding

5. Infection

Answer: 2, 4, 5

Explanation: 2. Previous sibling received phototherapy is considered a risk factor for development of severe hyperbilirubinemia.

4. 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.

5. Infection is considered a risk factor for development of severe hyperbilirubinemia.

Page Ref: 836

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5 Explain how Rh incompatibility or ABO incompatibility can lead to the development of hyperbilirubinemia.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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21) A newborn is receiving phototherapy. Which intervention by the nurse would be most important?

1. Measurement of head circumference

2. Encouraging the mother to stop breastfeeding

3. Stool blood testing

4. Assessment of hydration status

Answer: 4

Explanation: 4. 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: 843

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

22) The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care?

1. Urine specific gravity is assessed each voiding.

2. Eye coverings are left off to help keep the baby calm.

3. Temperature is checked every 6 hours.

4. The infant is taken out of the isolette for diaper changes.

Answer: 1

Explanation: 1. 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.

Page Ref: 843

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. C. 2. Appreciate the cognitive and physical limits of human performance. | AACN Essentials Competencies: IX. 10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregivers knowledge of care requirements to promote safe care. | NLN Competencies: Quality and Safety: Stay current in professional health care knowledge. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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23) The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy?

1. The newborn maintains a normal temperature

2. An increase of serum bilirubin levels

3. Weight loss

4. Skin blanching yellow

Answer: 1

Explanation: 1. 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.

Page Ref: 843

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 13. Revise the plan of care based on an ongoing evaluation of patient outcomes. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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24) Which nursing interventions are appropriate when caring for the newborn undergoing phototherapy?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Cover the newborns eyes at all times, even when not under the lights.

2. Close the newborns eyelids before applying eye patches.

3. Inspect the eyes each shift for conjunctivitis.

4. Keep the baby swaddled in a blanket to prevent heat loss.

5. Reposition the baby every 2 hours.

Answer: 2, 3, 5

Explanation: 2. Apply eye patches over the newborns closed eyes during exposure to banks of phototherapy.

3. Discontinue conventional phototherapy and remove the eye patches at least once per shift to assess the eyes for the presence of conjunctivitis.

5. Repositioning allows equal exposure of all skin areas and prevents pressure areas.

Page Ref: 843

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Identify the nursing responsibilities in caring for the newborn receiving phototherapy.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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Copyright 2016 Pearson Education, Inc.

25) 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?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Increased pulse

2. High blood pressure

3. Tachycardia

4. Bradycardia

5. Capillary filling time greater than 3 seconds

Answer: 3, 5

Explanation: 3. Tachycardia would be a sign of shock.

5. Capillary filling time greater than 3 seconds would be a sign of shock.

Page Ref: 844

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Explain the etiology and the nursing care of infants with anemia.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

26) Mild or chronic anemia in an infant may be treated adequately which of the following?

1. Transfusions with O-negative or typed and cross-matched packed red cells

2. Iron supplements or iron-fortified formulas

3. Steroid therapy

4. Antibiotics or antivirals

Answer: 2

Explanation: 2. Mild or chronic anemia in an infant may be treated adequately with iron supplements or iron-fortified formulas.

Page Ref: 844

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Explain the etiology and the nursing care of infants with anemia.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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27) The nurse caring for a newborn with anemia would expect which initial laboratory data to be included in the initial assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Hemoglobin

2. Hematocrit

3. Reticulocyte count

4. Direct Coombs test

5. Cord serum OgM

Answer: 1, 2, 3, 4

Explanation: 1. The initial laboratory workup for anemia should include hemoglobin measurements.

2. The initial laboratory workup for anemia should include hematocrit measurements.

3. The initial laboratory workup for anemia should include a reticulocyte count.

4. The direct Coombs test reveals the presence of antibody-coated (sensitized) Rh-positive red blood cells in the newborn and should be included in the initial laboratory workup for anemia.

Page Ref: 837, 844

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Explain the etiology and the nursing care of infants with anemia.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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Copyright 2016 Pearson Education, Inc.

28) What indications would lead the nurse to suspect sepsis in a newborn?

1. Respiratory distress syndrome developing 48 hours after birth

2. Temperature of 97.0F 2 hours after warming the infant from 97.4F

3. Irritability and flushing of the skin at 8 hours of age

4. Bradycardia and tachypnea developing when the infant is 36 hours old

Answer: 2

Explanation: 2. Temperature instability is often seen with sepsis. Fever is rare in a newborn.

Page Ref: 846

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care; Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8 Describe the clinical manifestations that would lead the nurse to suspect newborn sepsis.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

29) Antibiotics have been ordered for a newborn with an infection. Which interventions would the nurse prepare to implement?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Obtain skin cultures.

2. Restrict parental visits.

3. Evaluate bilirubin levels.

4. Administer oxygen as ordered.

5. Observe for signs of hypoglycemia.

Answer: 1, 3, 4, 5

Explanation: 1. The nurse will assist in obtaining skin cultures. Skin cultures are taken of any lesions or drainage from lesions or reddened areas.

3. The nurse will observe for hyperbilirubinemia, anemia, and hemorrhagic symptoms.

4. The nurse will administer oxygen as ordered.

5. The nurse will observe for signs of hypoglycemia.

Page Ref: 847, 849

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

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Learning Outcome: 9 Delineate the nursing care of the newborn with an infection.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

30) 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?

1. Ill bring you to your baby and then leave so you can have some privacy.

2. Your baby is on a ventilator with 50% oxygen, and has an umbilical line.

3. I am so sorry this has all happened. I know how stressful this can be.

4. Your baby is working hard to breathe and lying quite still, and has an IV.

Answer: 4

Explanation: 4. 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: 852

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Safety and Infection Control

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

31) 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?

1. A history of obsessive-compulsive disorder (OCD)

2. Chlamydia

3. Delivered six other children by cesarean section

4. A urinary tract infection (UTI)

Answer: 2

Explanation: 2. 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.

Page Ref: 847

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that con

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tribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (HSV or CMV), and chlamydia, to the management of the infant in the neonatal period.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

32) 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?

1. Meticulous hand washing and antibiotic eye ointment administration.

2. Intravenous acyclovir (Zovirax) and contact precautions.

3. Cultures of blood and CSF and serial chest x-rays every 12 hours.

4. Parental rooming-in and four intramuscular injections of penicillin.

Answer: 2

Explanation: 2. Administering intravenous acyclovir (Zovirax) and contact precautions are appropriate measures for an infant at risk for developing herpes simplex 2 infection.

Page Ref: 846

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (HSV or CMV), and chlamydia, to the management of the infant in the neonatal period.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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Copyright 2016 Pearson Education, Inc.

33) Which findings would the nurse expect when assessing a newborn infected with syphilis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Rhinitis

2. Fissures on mouth corners

3. Red rash around anus

4. Lethargy

5. Large for gestational age

Answer: 1, 2, 3

Explanation: 1. Rhinitis is evident in the newborn exposed to syphilis.

2. Fissures on mouth corners and an excoriated upper lip indicate exposure to syphilis.

3. A red rash around the mouth and anus is observed.

Page Ref: 846

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 10 Relate the consequences of maternally transmitted infections, such as maternal syphilis, gonorrhea, herpesviridae family (HSV or CMV), and chlamydia, to the management of the infant in the neonatal period.

MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.

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Copyright 2016 Pearson Education, Inc.

34) 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?

1. Your newborn likes to be touched.

2. Stroking the newborn will help with stimulation.

3. Visits must be scheduled between feedings.

4. Your baby loves her pink blanket.

Answer: 3

Explanation: 3. The nurse always should 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.

Page Ref: 852

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Communication

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 11 Describe interventions to facilitate parental attachment and meet the special initial and long-term needs of parents of at-risk newborns.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

35) 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?

1. If I had taken better care of myself, this wouldnt have happened.

2. Ive been sleeping very well since I had the baby.

3. This is probably the doctors fault.

4. If I hadnt seen our babys birth, I wouldnt believe she is ours.

Answer: 2

Explanation: 2. A sick infant is a source of great anxiety for parents. This response is from the mother would be unexpected.

Page Ref: 849

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9 Delineate the nursing care of the newborn with an infection.

MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.

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