Chapter 37: Nursing Care of the High Risk Newborn My Nursing Test Banks

Lowdermilk: Maternity & Womens Health Care, 10th Edition

Chapter 37: Nursing Care of the High Risk Newborn

Test Bank

MULTIPLE CHOICE

1. An infant at 36 weeks of gestation has increasing respirations (80 to 100 breaths/min with marked substernal retractions). The infant is given oxygen by continuous nasal positive airway pressure (CPAP). Which arterial oxygen level indicates hypoxia?

a.

PaO2 of 67

b.

PaO2 of 89

c.

PaO2 of 45

d.

PaO2 of 73

ANS: C

A PaO2 of 45 is below the normal range for a normal neonate. The range for arterial oxygen pressure is 60 to 80 mm Hg. The lab value of PaO2 of 45 indicates hypoxia in this infant.

A PaO2 of 67 falls within the normal range.

A PaO2 of 89 is greater than the normal range.

A PaO2 of 73 falls within the normal range.

DIF: Cognitive Level: Comprehension REF: 916

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

2. On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask if they may hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response does the nurse give?

a.

Parents are not allowed to hold their infants who are dependent on oxygen.

b.

You may only hold your babys hand during the feeding.

c.

Feedings cause more physiologic stress, so the baby must be closely monitored. Therefore, I dont think you should hold the baby.

d.

You may hold your baby during the feeding.

ANS: D

Physical contact with the infant is important to establish early bonding. The nurse as the support person and teacher is responsible for shaping the environment and making the caregiving responsive to the needs of both the parents and the infant. This is the most appropriate response by the nurse.

Parental interaction via holding is encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions.

The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant.

Swaddling or kangaroo care during feedings provides positive interactions for the infant.

DIF: Cognitive Level: Application REF: 913

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

3. A premature infant with respiratory distress syndrome (RDS) receives artificial surfactant. How does the nurse explain surfactant therapy to the parents?

a.

Surfactant improves the ability of your babys lungs to exchange oxygen and carbon dioxide.

b.

The drug keeps your baby from requiring too much sedation.

c.

Surfactant is used to reduce episodes of periodic apnea.

d.

Your baby needs this medication to fight a possible respiratory tract infection.

ANS: A

Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own.

Surfactant has no bearing on the sedation needs of the infant.

Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with RDS is to stimulate production of surfactant in the type 2 cells of the alveoli.

The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

DIF: Cognitive Level: Application REF: 905

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

4. An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?

a.

Rapid bolusing of the entire amount in 15 minutes

b.

Warm cloths to the abdomen for the first 10 minutes

c.

Slow, small, warm bolus feedings over 30 minutes

d.

Cold, medium bolus feedings over 20 minutes

ANS: C

Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions.

Rapid bolusing will most likely lead to the adverse reactions listed.

Temperature stability in the newborn is critical. This type of warming is not appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind.

Small feedings at room temperature are recommended to prevent adverse reactions.

DIF: Cognitive Level: Application REF: 909

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

5. A premature infant never seems to sleep longer than an hour at a time. Each time a light is turned on, an incubator closes, or people talk near her crib, she wakes up and cries inconsolably until held. The correct nursing diagnosis is ineffective coping, related to:

a.

Severe immaturity

b.

Environmental stress

c.

Physiologic distress

d.

Behavioral responses

ANS: B

This nursing diagnosis is the most appropriate for this infant. Light and sound are known adverse stimuli that add to an already stressed premature infant. The nurse must monitor the environment closely for sources of overstimulation.

Although the infant may be severely immature, in this case she is responding to environmental stress.

Physiologic distress is the response to environmental stress. The result is stress cues such as increased metabolic rate, increased oxygen and caloric use, and depression of the immune system.

The infants behavioral response is crying. The nursing diagnosis should reflect the cause of this response, which is environmental stress.

DIF: Cognitive Level: Application REF: 911

OBJ: Client Needs: Safe and Effective Care Environment

TOP: Nursing Process: Diagnosis

6. Which combination of expressing pain could be demonstrated in a neonate?

a.

Low-pitched crying, tachycardia, eyelids open wide

b.

Cry face, flaccid limbs, closed mouth

c.

High-pitched, shrill cry; withdrawal; change in heart rate

d.

Cry face, eye squeeze, increase in blood pressure

ANS: D

These manifestations are indicative of pain in the neonate.

Cry and an increased heart rate are manifestations of neonatal pain. Typically, infants close their eyes tightly when in pain, not open them wide.

Infants may cry in response to pain. Additionally, they may display a rigid posture with the mouth open.

A high-pitched, shrill cry is associated with genetic/neurologic anomalies. The infant may cry, withdraw limbs, and become tachycardic with pain.

DIF: Cognitive Level: Comprehension REF: 920

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

7. A newborn was admitted to the neonatal intensive care unit (NICU) after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian female whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborns parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurses most appropriate action is to:

a.

Wait quietly at the newborns bedside until the parents come closer

b.

Go to the parents, introduce himself or herself, and gently encourage them to meet their infant; explain the equipment first and then focus on the newborn

c.

Leave the parents at the bedside while they are visiting so that they can have some privacy

d.

Tell the parents only about the newborns physical condition and caution them to avoid touching their baby

ANS: B

The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them.

Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infants condition.

Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infants appearance and condition. Encouragement from the nurse is instrumental in this process.

Telling the parents to avoid touching their baby is inappropriate and unhelpful.

DIF: Cognitive Level: Application REF: 914

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

8. An infant is being discharged from the neonatal intensive care unit (NICU) after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infants mother asks the nurse if her baby will meet developmental milestones on time, as did her son who was born at term. The nurses most appropriate response is:

a.

Your baby will develop exactly like your first child did.

b.

Your baby does not appear to have any problems at this time.

c.

Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing.

d.

Your baby will need to be followed very closely.

ANS: C

The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infants responses are accordingly evaluated against the norm expected for the corrected age of the infant.

Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life.

Development needs to be evaluated over time.

The growth and developmental milestones are corrected for gestational age until the child is approximately 2 years old.

DIF: Cognitive Level: Application REF: 898

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

9. A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetricians office revealed a nonreactive tracing. On artificial rupture of membranes, thick meconium-stained fluid was noted. The nurse caring for the infant after birth anticipates:

a.

Meconium aspiration, hypoglycemia, and dry, cracked skin

b.

Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome

c.

Golden yellow to green-stained skin and nails, absence of scalp hair, and an increased amount of subcutaneous fat

d.

Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance

ANS: A

Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant.

Excessive vernix caseosa, lethargy, and respiratory distress syndrome are consistent with a very premature infant.

The skin may be meconium stained, but the infant will most likely have longer hair and decreased amounts of subcutaneous fat.

Postmaturity with a nonreactive NST is indicative of hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

DIF: Cognitive Level: Analysis REF: 926

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning

10. In the continuing assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:

a.

Hypovolemia and/or shock

b.

A nonneutral thermal environment

c.

Central nervous system (CNS) injury

d.

Pending renal failure

ANS: A

Other symptoms might include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.

Preterm infants are susceptible to temperature instability. The goal of thermoregulation is to provide a neutral thermal environment. Hypoglycemia is likely to occur if the infant is attempting to conserve heat.

CNS injury is manifested by hyperirritability, seizures, and abnormal movements of the extremities.

Urine output and testing of specific gravity are appropriate interventions for the infant with suspected renal failure. This neonate is unlikely to present with respiratory distress.

DIF: Cognitive Level: Application REF: 898

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Diagnosis

11. There are numerous signs and symptoms of neonatal infection. Interestingly, the most common is ________________, whereas ________________ is rare.

a.

Hyperthermia, hypothermia

b.

Hypotension, hypothermia

c.

Hypothermia, hyperthermia

d.

Hypotension, hyperthermia

ANS: C

The most common sign/symptom of infection is hypothermia (low body temperature), whereas hyperthermia (high body temperature) is rare.

The most common sign/symptom of infection is hypothermia (low body temperature), whereas hyperthermia (high body temperature) is rare.

The most common sign/symptom of infection is hypothermia (low body temperature), whereas hyperthermia (high body temperature) is rare. The infant with a neonatal infection may not present with hypotension.

The most common sign/symptom of infection is hypothermia (low body temperature), whereas hyperthermia (high body temperature) is rare. The infant with a neonatal infection may not present with hypotension.

DIF: Cognitive Level: Knowledge REF: 896

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

12. In appraising the growth and development potential of a preterm infant, nurses should:

a.

Tell parents their child wont catch up until about age 10 (girls) to 12 (boys)

b.

Correct for milestones, such as motor competencies and vocalizations, until the child is approximately 2 years of age

c.

Know that the greatest catch-up period is between 9 and 15 months postconceptual age

d.

Know that the length and breadth of the trunk is the first part of the infant to experience catch-up growth

ANS: B

Corrections are made with a formula that adds gestational age and postnatal age.

The infant, girl or boy, experiences catch-up body growth during the first 2 to 3 years of life.

Maximum catch-up growth occurs between 36 and 40 weeks postconceptual age.

The head is the first to experience catch-up growth.

DIF: Cognitive Level: Comprehension REF: 898

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

13. A nurse practicing in the perinatal setting should promote kangaroo care regardless of an infants gestational age. This intervention:

a.

Is adopted from classical British nursing traditions

b.

Helps infants with motor and central nervous system impairment

c.

Helps infants to interact directly with their parents and enhances their temperature regulation

d.

Gets infants ready for breastfeeding

ANS: C

Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parents bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.

Kangaroo care was established in Bogota, Colombia.

Kangaroo care assists the infant in maintaining an organized state and decreases pain perception during heelsticks.

Even premature infants who are unable to suckle benefit from kangaroo care. This practice fosters increased vigor and an enhanced breastfeeding experience as the infant matures.

DIF: Cognitive Level: Knowledge REF: 912

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

14. For clinical purposes, preterm and postterm infants are defined as:

a.

Preterm: Before 34 weeks if AGA; before 37 weeks if SGA

b.

Postterm: After 40 weeks if LGA; beyond 42 weeks if AGA

c.

Preterm: Before 37 weeks, postterm beyond 42 weeks; no matter the size for gestational age at birth

d.

Preterm: SGA before 38 to 40 weeks; postterm, LGA beyond 40 to 42 weeks

ANS: C

Preterm and postterm are strictly measures of timebefore 37 weeks and beyond 42 weeks, respectivelyregardless of size for gestational age.

Preterm and postterm are strictly measures of timebefore 37 weeks and beyond 42 weeks, respectivelyregardless of size for gestational age.

Preterm and postterm are strictly measures of timebefore 37 weeks and beyond 42 weeks, respectivelyregardless of size for gestational age.

Preterm and postterm are strictly measures of timebefore 37 weeks and beyond 42 weeks, respectivelyregardless of size for gestational age.

DIF: Cognitive Level: Comprehension REF: 895

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Diagnosis

15. With regard to eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that:

a.

Infants stay in the neonatal intensive care unit (NICU) until they are ready to go home

b.

Once discharged to home, the high risk infant should be treated like any healthy term newborn

c.

Parents of high risk infants need special support and detailed contact information

d.

If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized

ANS: C

High risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby.

Parents and their high risk infant should get to spend a night or two in a predischarge room, where care for the infant is provided away from the NICU.

Just because high risk infants are discharged does not mean they are normal, healthy babies. Follow-up by specialized practitioners is essential.

Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

DIF: Cognitive Level: Comprehension REF: 927

OBJ: Client Needs: Psychosocial Integrity

TOP: Nursing Process: Planning

16. As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. In understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation) the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:

a.

Decreased respiratory rate

b.

Bradycardia followed by an increased heart rate

c.

Mottled skin with acrocyanosis

d.

Increased physical activity

ANS: C

The infant has minimal to no fat stores. During times of cold stress the skin becomes mottled and acrocyanosis develops, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurses role is to observe the infant frequently in order to prevent heat loss and respond quickly if signs and symptoms occur.

The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive.

In the preterm infant experiencing heat loss, the heart rate initially increases followed by periods of bradycardia.

In the term infant the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

DIF: Cognitive Level: Analysis REF: 897

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Evaluation

MULTIPLE RESPONSE

1. Risk factors associated with necrotizing enterocolitis (NEC) include (choose all that apply):

a.

Polycythemia

b.

Anemia

c.

Congenital heart disease

d.

Bronchopulmonary dysphasia

e.

Retinopathy

ANS: A, B, C

Risk factors for NEC include asphyxia, respiratory distress syndrome (RDS), umbilical artery catheterization, exchange transfusion, early enteral feedings, patent ductus arteriosus (PDA), congenital heart disease, polycythemia, anemia, shock, and gastrointestinal infection.

Bronchopulmonary dysphasia and retinopathy are not associated with NEC.

DIF: Cognitive Level: Comprehension REF: 918

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Assessment

COMPLETION

1. Calculate the corrected age of an infant who was born at 25 1/7 weeks and is preparing for discharge 124 days past delivery.

ANS:

42 6/7 weeks

The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. For example, an infant born at 32 weeks gestation 4 weeks ago would now be considered 36 weeks of age.

DIF: Cognitive Level: Analysis REF: 898

OBJ: Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Planning

TRUE/FALSE

1. Insensible water loss (IWL) is an evaporative loss that occurs largely through the skin. The effects of radiant warmers, incubators, phototherapy, and other factors can augment the IWL. Increased stooling or voiding, increased evaporative losses, inadequate volume or incorrect fluid administration, and problems of malabsorption may cause weight loss. Calculate the weight loss for the following scenario. Is the infants weight loss in an acceptable range?

Day 9 weight: 2340 g

Day 10 weight: 2299 g

ANS: T

After the initial week, a premature infants loss or gain of weight during each 24-hour period should not exceed 2% of the previous days weight.

DIF: Cognitive Level: Application REF: 907

OBJ: Client Needs: Physiologic Integrity

TOP: Nursing Process: Planning, Diagnosis

Mosby items and derived items 2012, 2007, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

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