Chapter 09: Health Problems of Newborns Nursing School Test Banks

Chapter 09: Health Problems of Newborns

MULTIPLE CHOICE

1. Which is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
a. Caput succedaneum
b. Hydrocephalus
c. Cephalhematoma
d. Subdural hematoma
ANS: A
A vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery is the definition of a caput succedaneum. The swelling consists of serum and/or blood accumulated in the tissues above the bone, and it may extend beyond the bone margin. Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid. When production exceeds absorption, fluid accumulates within the ventricular system, causing dilation of the ventricles. A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone) suture line. A subdural hematoma is located between the dura and the cerebrum. It would not be visible on the scalp.

PTS: 1 DIF: Cognitive Level: Remember REF: 229
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

2. Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
a. Negative scarf sign
b. Asymmetric Moro reflex
c. Swelling of fingers on affected side
d. Paralysis of affected extremity and muscles
ANS: B
A newborn with a broken clavicle may have no symptoms. The Moro reflex, which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities, will most likely be asymmetric. The scarf sign that is used to determine gestational age should not be performed if a broken clavicle is suspected. Swelling of fingers on affected side and paralysis of affected extremity and muscles are not indicative of a fractured clavicle.

PTS: 1 DIF: Cognitive Level: Analyze REF: 230
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

3. The parents of a newborn ask the nurse what caused the babys facial nerve paralysis. The nurses response is based on knowledge that this is caused by a(n):
a. genetic defect.
b. birth injury.
c. spinal cord injury.
d. inborn error of metabolism.
ANS: B
Pressure on the facial nerve during delivery may result in injury to cranial nerve VII, which can occur with birth injury. A genetic defect, spinal cord injury, or inborn error of metabolism would not cause facial paralysis.

PTS: 1 DIF: Cognitive Level: Understand REF: 231
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance

4. A mother is upset because her newborn has erythema toxicum neonatorum. The nurse should reassure her that this is:
a. easily treated.
b. benign and transient.
c. usually not contagious.
d. usually not disfiguring.
ANS: B
Erythema toxicum neonatorum, or newborn rash, is a benign, self-limiting eruption of unknown cause that usually appears within the first 2 days of life. The rash usually lasts about 5 to 7 days. No treatment is indicated. Erythema toxicum neonatorum is not contagious. Successive crops of lesions heal without pigmentation.

PTS: 1 DIF: Cognitive Level: Apply REF: 232
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance

5. What is oral candidiasis (thrush) in the newborn?
a. Bacterial infection that is life threatening in the neonatal period
b. Bacterial infection of mucous membranes that responds readily to treatment
c. Yeastlike fungal infection of mucous membranes that is relatively common
d. Benign disorder that is transmitted from mother to newborn during the birth process only
ANS: C
Oral candidiasis, characterized by white adherent patches on the tongue, palate, and inner aspects of the cheeks, is not uncommon in newborns. Candida albicans is the usual causative organism. Oral candidiasis is usually a benign disorder in the newborn, often confined to the oral and diaper regions. It is caused by a yeastlike organism and is treated with good hygiene, application of a fungicide, and correction of any underlying disorder. Thrush can be transmitted in several ways, including by maternal transmission during delivery; person-to-person transmission; and contaminated bottles, hands, or other objects.

PTS: 1 DIF: Cognitive Level: Understand REF: 232
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Health Promotion and Maintenance

6. Nursing care of the newborn with oral candidiasis (thrush) includes:
a. avoiding use of pacifier.
b. removing characteristic white patches with a soft cloth.
c. continuing medication for a prescribed number of days.
d. applying medication to oral mucosa, being careful that none is ingested.
ANS: C
The medication must be continued for the prescribed number of days. To prevent relapse, therapy should continue for at least 2 days after the lesions disappear. Pacifiers can be used. The pacifier should be replaced with a new one or boiled for 20 minutes once daily. One of the characteristics of thrush is that the white patches cannot be removed. The medication is applied to the oral mucosa and then swallowed to treat Candida organisms in the gastrointestinal tract.

PTS: 1 DIF: Cognitive Level: Apply REF: 233
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

7. Which is a bright red, rubbery nodule with a rough surface and a well-defined margin that may be present at birth?
a. Port-wine stain
b. Juvenile melanoma
c. Cavernous hemangioma
d. Strawberry hemangioma
ANS: D
Strawberry hemangiomas or capillary hemangiomas are benign cutaneous tumors that involve capillaries only. They are bright red, rubbery nodules with rough surfaces and well-defined margin. They may or may not be apparent at birth but enlarge during the first year of life and tend to resolve spontaneously by age 2 to 3 years. Port-wine stain is a vascular stain that is a permanent lesion and is present at birth. Initially it is a pink, red, or, rarely, purple stain of the skin that is flat at birth and thickens, darkens, and proportionately enlarges as the child grows. Melanoma is not differentiated into juvenile and adult forms. A cavernous hemangioma involves deeper vessels in the dermis and has a bluish red color and poorly defined margins.

PTS: 1 DIF: Cognitive Level: Understand REF: 234
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

8. The parents of a newborn with a strawberry hemangioma ask the nurse what the treatment will be. The nurses response should be based on knowledge that:
a. excision of the lesion will be necessary.
b. injections of prednisone into the lesion will reduce it.
c. no treatment is usually necessary because of the high rate of spontaneous involution.
d. pulsed dye laser treatments will be necessary immediately to prevent permanent disability.
ANS: C
There is a high rate of spontaneous resolution, so treatment is usually not indicated for hemangiomas. Surgical removal would not be indicated. If steroids are indicated, then systemic prednisone is administered for 2 to 3 weeks. The pulse dye laser is used in the uncommon situation of potential visual or respiratory impairment.

PTS: 1 DIF: Cognitive Level: Apply REF: 234
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance

9. Which term refers to a newborn born before completion of week 37 of gestation, regardless of birth weight?
a. Postterm
b. Premature
c. Low birth weight
d. Small for gestational age
ANS: B
A premature newborn is any child born before 37 weeks of gestation, regardless of birth weight. A postterm or postmature newborn is any child born after 42 weeks of gestational age, regardless of birth weight. A lowbirth-weight newborn is a child whose birth weight is less than 2500 g, regardless of gestational age. A small-for-gestational-age (or small-for-date) newborn is any child whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves.

PTS: 1 DIF: Cognitive Level: Remember REF: 236
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

10. Which refers to a newborn whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth charts?
a. Postterm
b. Postmature
c. Low birth weight
d. Small for gestational age
ANS: D
A small-for-gestational-age (or small-for-date) newborn is any child whose rate of intrauterine growth was slowed and whose birth weight falls below the 10th percentile on intrauterine growth curves. A postterm or postmature newborn is any child born after 42 weeks of gestational age, regardless of birth weight. A lowbirth-weight newborn is a child whose birth weight is less than 2500 g, regardless of gestational age.

PTS: 1 DIF: Cognitive Level: Remember REF: 236
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

11. The nurse is caring for a very lowbirth-weight (VLBW) newborn with a peripheral intravenous infusion. Which statement describes nursing considerations regarding infiltration?
a. Infiltration occurs infrequently because VLBW newborns are inactive.
b. Continuous infusion pumps stop automatically when infiltration occurs.
c. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
d. Infusion site should be checked for infiltration at least once per 8-hour shift.
ANS: C
Hypertonic fluids can damage cells if the fluid leaks from the vein. Careful monitoring is required to prevent severe tissue damage. Infiltrations occur for many reasons, not only activity. The vein, catheter, and fluid used all contribute to the possibility of infiltration. The continuous infusion pump may alarm when the pressure increases, but this does not alert the nurse to all infiltrations. Infusion rates and sites should be checked hourly to prevent tissue damage from extravasations, fluid overload, and dehydration.

PTS: 1 DIF: Cognitive Level: Understand REF: 240
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

12. The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?
a. Elevate feet 15 degrees.
b. Place socks on newborn.
c. Wrap feet loosely in prewarmed blanket.
d. Report findings immediately to the practitioner.
ANS: D
Blanching of the feet, in a newborn with an umbilical catheter, is an indication of vasospasm. Vasoconstriction of the peripheral vessels, triggered by the vasospasm, can seriously impair circulation. It is an emergency situation and must be reported immediately.

PTS: 1 DIF: Cognitive Level: Apply REF: 240
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

13. The mother of a preterm newborn asks the nurse when she can start breastfeeding. The nurse should explain that breastfeeding can be initiated when her newborn:
a. achieves a weight of at least 3 pounds.
b. indicates an interest in breastfeeding.
c. does not require supplemental oxygen.
d. has adequate sucking and swallowing reflexes.
ANS: D
Research supports that human milk is the best source of nutrition for term and preterm newborns. Preterm newborns should be breastfed as soon as they have adequate sucking and swallowing reflexes and no other complications such as respiratory complications or concurrent illnesses. Weight is not an issue. Interest in breastfeeding can be evaluated by having nonnutritive sucking at the breast during skin-to-skin kangaroo care so the mother and child may become accustomed to each other. Supplemental oxygen can be provided during breastfeeding by using a nasal cannula.

PTS: 1 DIF: Cognitive Level: Analyze REF: 240
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance

14. Which is the most appropriate nursing action when intermittently gavage-feeding a preterm newborn?
a. Allow formula to flow by gravity.
b. Insert tube through nares rather than mouth.
c. Avoid letting newborn suck on tube.
d. Apply steady pressure to syringe to deliver formula to stomach in a timely manner.
ANS: A
The formula is allowed to flow by gravity. The length of time to complete the feeding will vary. Preferably, the tube is inserted through the mouth. Newborns are obligatory nose breathers, and the presence of the tube in the nose irritates the nasal mucosa. Passage of the tube through the mouth allows the nurse to observe and evaluate the sucking response. The feeding should not be done under pressure. This procedure is not used as a timesaver for the nurse.

PTS: 1 DIF: Cognitive Level: Apply REF: 242
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

15. A healthy, stable, preterm newborn will soon be discharged. The nurse should recommend which position for sleep?
a. Prone
b. Supine
c. Side lying
d. Position of comfort
ANS: B
The American Academy of Pediatrics recommends that healthy newborns be placed to sleep in a supine position. Other positions are associated with sudden infant death syndrome. The prone position can be used for supervised play.

PTS: 1 DIF: Cognitive Level: Apply REF: 244
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance

16. Which intervention should the nurse implement to maintain the skin integrity of the premature newborn?
a. Cleanse skin with a gentle alkaline-based soap and water.
b. Cleanse skin with a neutral pH solution only when necessary.
c. Thoroughly rinse skin with plain water after bathing in a mild hexachlorophene solution.
d. Avoid cleaning skin.
ANS: B
The premature newborn should be given baths no more than two or three times per week with a neutral pH solution. The eyes, oral and diaper areas, and pressure points should be cleansed daily. Alkaline-based soaps might destroy the acid mantle of the skin. They should not be used. The increased permeability of the skin facilitates absorption of the chemical ingredients. The newborns skin must be cleaned to remove stool and urine, which are irritating to the skin.

PTS: 1 DIF: Cognitive Level: Apply REF: 244
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

17. Which is an important nursing action related to the use of tape and/or adhesives on premature newborns?
a. Avoid using tape and adhesives until skin is more mature.
b. Use solvents to remove tape and adhesives instead of pulling on skin.
c. Remove adhesives with warm water or mineral oil.
d. Use scissors carefully to remove tape instead of pulling tape off.
ANS: C
Warm water, mineral oil, or petrolatum can be used to facilitate the removal of adhesive. In the premature newborn, often it is impossible to avoid using adhesives and tape. The smallest amount of adhesive necessary should be used. Solvents should be avoided because they tend to dry and burn the delicate skin. Scissors should not be used to remove dressings or tape from the extremities of very small and immature newborns because it is easy to snip off tiny extremities or nick loosely attached skin.

PTS: 1 DIF: Cognitive Level: Analyze REF: 244
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

18. The nurse is caring for a 3-week-old preterm newborn born at 29 weeks of gestation. While taking vital signs and changing the newborns diaper, the nurse observes the newborns color is pink but slightly mottled, arms and legs are limp and extended, hiccups are present, and heart rate is regular and rapid. The nurse should recognize these behaviors as manifestations of:
a. stress.
b. subtle seizures.
c. preterm behavior.
d. onset of respiratory distress.
ANS: A
Color pink but slightly mottled, arms and legs limp and extended, hiccups, respiratory pauses and gasping, and an irregular, rapid heart rate are signs of stress or fatigue in a newborn. Neonatal seizures usually have some type of repetitive movement from twitching to rhythmic jerking movements. The behavior of a preterm newborn may be inactive and listless. Respiratory distress is exhibited by retractions and nasal flaring.

PTS: 1 DIF: Cognitive Level: Understand REF: 247
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

19. When is the best time for the neonatal intensive care unit (NICU) nurse to initiate an individualized stimulation program for the preterm newborn?
a. As soon as possible after newborn is born
b. As soon as parent is available to provide stimulation
c. When newborn is over 38 weeks of gestation
d. When developmental organization and stability are sufficient
ANS: D
Newborn stimulation is essential for growth and development. The appropriate time for the introduction of an individualized program is when developmental organization and stability are achieved at approximately 34 and 36 weeks of gestation. The newborn needs to be developmentally ready for a stimulation program. The newborn must be assessed to determine the readiness and appropriateness of the stimulation program. The program should be designed and implemented by the nursing staff. The family can be involved, as the nurses help teach the parents to be responsive to the childs cues, but the stimulation should not depend on the familys availability. An individualized stimulation program should be started when the child is developmentally ready.

PTS: 1 DIF: Cognitive Level: Analyze REF: 248
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance

20. A preterm newborn, after spending 8 weeks in the NICU, is being discharged. The parents of the newborn express apprehension and worry that the newborn may still be in danger. The nurse should recognize that this is:
a. normal.
b. a reason to postpone discharge.
c. suggestive of maladaptation.
d. suggestive of inadequate bonding.
ANS: A
Parents become apprehensive and excited as the time for discharge approaches. They have many concerns and insecurities regarding the care of their newborn. A major concern is that they may be unable to recognize signs of illness or distress in their newborn. Preparation for discharge should begin early and include helping the parent acquire the skills necessary for care. Apprehension and worry are normal adaptive responses. The NICU nurses should facilitate discharge by involving parents in care as soon as possible.

PTS: 1 DIF: Cognitive Level: Understand REF: 251
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity

21. The nurse is planning care for a family expecting their newborn to die. The nurses interventions should be based on which statement?
a. Tangible remembrances of the newborn (e.g., lock of hair, picture) prolong grief.
b. Photographs of newborns should not be taken after the death has occurred.
c. Funerals are not recommended because mother is still recovering from childbirth.
d. Parents should be encouraged to name their newborn if they have not done so already.
ANS: D
Naming the deceased newborn is an important step in the grieving process. It gives the parents a tangible person for whom to grieve, which is a key component of the grieving process. Tangible remembrances and photographs can make the newborn seem more real to the parents. Many NICUs will make bereavement memory packets, which may include a lock of hair, handprint, footprints, bedside name card, and other individualized objects. Families need to be informed of their options. The ritual of a funeral provides an opportunity for the parents to be supported by relatives and friends.

PTS: 1 DIF: Cognitive Level: Analyze REF: 249
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Psychosocial Integrity

22. The nurse has been caring for a newborn who just died. The parents are present but say they are afraid to hold the dead newborn. Which is the most appropriate nursing intervention?
a. Tell them there is nothing to fear.
b. Insist that they hold newborn one last time.
c. Respect their wishes and release body to morgue.
d. Keep newborns body available for a few hours in case they change their minds.
ANS: D
When the parents are hesitant about holding and touching their newborn, the nurse should keep the newborns body for a few hours. Many parents change their minds after the initial shock of the newborns death. This will provide the parents time to see and hold their newborn if they desire. Stating that there is nothing to fear minimizes the parents feelings. The nurse should allow the family to parent their child as they wish in death, as in life. Many parents change their minds; if possible, the nurse should wrap the newborn in blankets and keep the newborns body on the unit for a few hours.

PTS: 1 DIF: Cognitive Level: Apply REF: 253
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity

23. The nurse is planning care for a low-birth-weight newborn. Which is an appropriate nursing intervention to promote adequate oxygenation?
a. Place in Trendelenburg position periodically.
b. Suction at least every 2 to 3 hours.
c. Maintain neutral thermal environment.
d. Hyperextend neck with nose pointing to ceiling.
ANS: C
A neutral thermal environment is one that permits the newborn to maintain a normal core temperature with minimal oxygen consumption and caloric expenditure. The Trendelenburg position should be avoided. This position can contribute to increased intracranial pressure (ICP) and reduced lung capacity from gravity pushing organs against diaphragm. Suctioning should be done only as necessary. Routine suctioning may cause bronchospasm, bradycardia due to vagal nerve stimulation, hypoxia, and increased ICP. Neck hyperextension is avoided because it reduces diameter of trachea.

PTS: 1 DIF: Cognitive Level: Apply REF: 236
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

24. A preterm newborn has been receiving orogastric feedings of breast milk. The nurse initiates nipple feedings, but the newborn tires easily and has weak sucking and swallowing reflexes. The most appropriate nursing intervention is to:
a. encourage mother to breastfeed.
b. try nipple-feeding preterm newborn formula.
c. resume orogastric feedings of breast milk.
d. resume orogastric feedings of formula.
ANS: C
If a preterm newborn tires easily or has weak sucking when nipple feedings are initiated, the nurse should resume orogastric feedings with the milk of mothers choice. When nipple feeding is unsuccessful, it is unlikely that the newborn will be able to breastfeed. Breast milk should be continued as long as the mother desires.

PTS: 1 DIF: Cognitive Level: Apply REF: 241
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

25. The parents of a newborn who has just died decide they want to hold their deceased infant. The most appropriate nursing intervention at this time is to:
a. explain gently that this is no longer possible.
b. encourage parents to accept the loss of their newborn.
c. offer to take a photograph of their newborn because they cannot hold newborn.
d. get the newborn, wrap in a blanket, and rewarm in a radiant warmer so parents can hold their deceased infant.
ANS: D
The parents should be allowed to hold their newborn in the hospital setting. The newborns body should be retrieved and rewarmed in a radiant warmer. The nurse should provide a private place where the parents can hold their child for a final time. A photograph is an excellent idea, but it does not replace the parents need to hold the child.

PTS: 1 DIF: Cognitive Level: Apply REF: 253
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Psychosocial Integrity

26. Which statement best describes the clinical manifestations of the preterm newborn?
a. Head is proportionately small in relation to the body.
b. Sucking reflex is absent, weak, or ineffectual.
c. Thermostability is well established.
d. Extremities remain in attitude of flexion.
ANS: B
Reflex activity is only partially developed. Sucking is absent, weak, or ineffectual. The preterm newborns head is proportionately larger than the body. Thermoregulation is poorly developed, and the preterm newborn needs a neutral thermal environment to be provided. The preterm newborn may be listless and inactive compared with the overall attitude of flexion and activity of a full-term newborn.

PTS: 1 DIF: Cognitive Level: Understand REF: 241
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

27. Physiologic jaundice in a newborn can be caused by:
a. fetal-maternal blood incompatibility.
b. destruction of red blood cells as a result of antibody reaction.
c. livers inability to bind bilirubin adequately for excretion.
d. immature kidneys inability to hydrolyze and excrete bilirubin.
ANS: C
Physiologic jaundice is caused by the immature hepatic function of the newborns liver coupled with the increased load from red blood cell hemolysis. The excess bilirubin from the destroyed red blood cells cannot be excreted from the body. The fetal-maternal blood incompatibility and the associated red cell destruction by antibodies are the causes of hemolytic disease of the newborn. The kidneys are not involved in the excretion of bilirubin.

PTS: 1 DIF: Cognitive Level: Understand REF: 258
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

28. When should the nurse expect breastfeeding-associated jaundice to first appear in a normal newborn?
a. 0 to 12 hours
b. 12 to 24 hours
c. 2 to 4 days
d. 4 to 5 days
ANS: C
Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the newborn before the mothers milk is well established. Fasting is associated with decreased hepatic clearance of bilirubin; 0 to 24 hours is too soon. Jaundice within the first 24 hours is associated with hemolytic disease of the newborn; 4 to 5 days is too late. Jaundice at this time may be due to breast-milk jaundice.

PTS: 1 DIF: Cognitive Level: Understand REF: 258
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

29. The newborn with severe jaundice is at risk for developing:
a. encephalopathy.
b. bullous impetigo.
c. respiratory distress.
d. blood incompatibility.
ANS: A
Unconjugated bilirubin, which can cross the blood-brain barrier, is highly toxic to neurons. A newborn with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy. Encephalopathy is a highly infectious bacterial infection of the skin. It has no relation to severe jaundice and is the most likely complication of severe jaundice. A blood incompatibility may be the causative factor for the severe jaundice.

PTS: 1 DIF: Cognitive Level: Understand REF: 259-260
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

30. Early clinical manifestations of bilirubin encephalopathy in the newborn include:
a. mental retardation.
b. absence of stooling.
c. lethargy or irritability.
d. increased or decreased temperature.
ANS: C
Clinical manifestations of bilirubin encephalopathy are those of nervous system depression or excitation. Prodromal symptoms consist of decreased activity, lethargy, irritability, hypotonia, and seizures. Newborns who survive may have evidence of mental retardation. Absence of stooling and increased/decreased temperature are not manifestations of bilirubin encephalopathy.

PTS: 1 DIF: Cognitive Level: Understand REF: 260
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

31. A nurse is assessing for jaundice in a dark-skinned newborn. Where is the best place to assess for jaundice in this newborn?
a. Buttocks
b. Tip of nose and sclera
c. Sclera, conjunctiva, and oral mucosa
d. Palms of hands and soles of feet
ANS: C
Assessing for jaundice is part of the routine physical assessment in newborns. In dark-skinned newborns, the sclera, conjunctiva, and oral mucosa are the best place to observe jaundice because of the lack of skin pigmentation in these areas. The skin pigmentation in the buttocks, tip of nose and sclera, and palms of hands and soles of feet can mask the appearance of jaundice.

PTS: 1 DIF: Cognitive Level: Apply REF: 261
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

32. A blood sample for measurement of bilirubin is required from a newborn receiving phototherapy. In what environment should this blood sample be drawn?
a. While phototherapy lights are turned off
b. While newborn remains under phototherapy lights
c. When newborn is covered with a blanket
d. When newborn has been off phototherapy for 30 to 60 minutes
ANS: A
When blood is drawn, phototherapy lights are turned off, and the blood is transported in a covered tube to avoid a false reading as a result of bilirubin destruction in the test tube. The lights will cause a degradation of the bilirubin in the sample, resulting in a falsely lowered result. The newborn does not need to be covered with a blanket. The phototherapy lights must be off. There is no reason to delay obtaining the blood sample. It can be drawn as soon as the lights are turned off.

PTS: 1 DIF: Cognitive Level: Apply REF: 261-262
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

33. The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?
a. I should change the babys position many times during the day.
b. I can dress the baby in lightweight clothing while under phototherapy.
c. I should be sure that the babys eyelids are closed before applying patches.
d. I can take the patches off the baby during feedings and other caregiving activities.
ANS: B
The baby should be placed nude under the lights. The newborn should be repositioned frequently to expose all body surfaces to the lights. The newborns eyelids must be closed before the patches are applied because the corneas may become excoriated if in contact with the dressing. The eye patches should be removed so the newborn can have visual and sensory stimulation.

PTS: 1 DIF: Cognitive Level: Analyze REF: 260
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Physiologic Integrity

34. The nurse is caring for a newborn with hyperbilirubinemia who is receiving phototherapy. Which is an appropriate nursing intervention for this newborn?
a. Apply lotion as prescribed to moisturize skin.
b. Maintain nothing-by-mouth (NPO) status to prevent nausea and vomiting.
c. Monitor temperature to prevent hypothermia or hyperthermia.
d. Keep eye patches on for at least 8 to 12 of every 24 hours.
ANS: C
Newborns who are receiving phototherapy are at risk for thermoregulation issues. The nurse must monitor the newborns temperature closely to rapidly detect either hypothermia or hyperthermia. Lotions are not used. They may predispose the newborn to increased tanning or frying effect. Newborns receiving phototherapy require additional fluid to compensate for increased fluid losses caused by the lights. The eye patches must be in place whenever the child is under the phototherapy lights.

PTS: 1 DIF: Cognitive Level: Apply REF: 262
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

35. Hemolytic disease is suspected in a mothers second newborn. Which factor is important in understanding how this could develop?
a. The mothers first child was Rh positive.
b. The mother is Rh positive.
c. Both parents have type O blood.
d. RhIG (RhoGAM) was given to the mother during her first pregnancy.
ANS: A
Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell (RBC) destruction. The major causes of this are Rh and maternal-fetal ABO incompatibility. If an Rh-negative mother has previously been exposed to Rh-positive blood through pregnancy or blood transfusion, antibodies to this blood group antigen may develop so that she is isoimmunized. With further exposure to Rh, the maternal antibodies will agglutinate with the red cells of the fetus who has the antigen and destroy the cells. Hemolytic disease is also caused by ABO incompatibilities. Blood type is the important consideration. If both parents are type O blood, ABO incompatibility would not be a possibility. The mother should have received Rho(D) immune globulin to prevent antibody development after the first pregnancy.

PTS: 1 DIF: Cognitive Level: Analyze REF: 263
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

36. When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
a. At birth
b. During first 24 hours after birth
c. 24 to 48 hours after birth
d. 48 to 72 hours after birth
ANS: B
In hemolytic disease of the newborn, jaundice is usually evident within the first 24 hours of life. Newborns with hemolytic disease are usually not jaundiced at birth, although some degree of hepatosplenomegaly, pallor, and hypovolemic shock may occur when the most severe form, hydrops fetalis, is present; 24 to 72 hours is too late for hemolytic disease of the newborn. Jaundice at these ages is most likely due to physiologic or early-onset breastfeeding jaundice.

PTS: 1 DIF: Cognitive Level: Understand REF: 263
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

37. To prevent Rh isoimmunization, RhIG (RhoGAM) is administered to all:
a. Rh-negative women who deliver an Rh-positive newborn.
b. Rh-positive women who deliver an Rh-negative newborn.
c. Rh-negative newborns whose mothers are Rh positive.
d. Rh-positive fathers before conception of second newborn when first newborn was Rh positive.
ANS: A
Rh IG human gamma globulin concentrate of anti-D is administered to all unsensitized Rh-negative women after delivery or abortion of an Rh-positive newborn or fetus. Administering RhIG to an individual who is Rh positive will result in agglutination of red cells and hemolysis. It will not alter the persons genetic makeup. The anti-D antibody contained in RhIG will have no effect on Rh-negative newborns because the D antibody is not present.

PTS: 1 DIF: Cognitive Level: Apply REF: 265
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

38. The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurses first action be?
a. Notify practitioner.
b. Stop the transfusion.
c. Administer calcium gluconate.
d. Monitor vital signs electronically.
ANS: B
When signs of cardiac or respiratory problems occur, the procedure is stopped, and the newborns cardiorespiratory status is allowed to stabilize. The practitioner is usually performing the exchange transfusion with the nurses assistance. The procedure must be stopped so the newborn can stabilize. Respiratory distress and tachycardia are signs of cardiorespiratory problems, not hypocalcemia. Calcium gluconate is not indicated. The vital signs should be monitored electronically throughout the entire procedure.

PTS: 1 DIF: Cognitive Level: Apply REF: 266
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

39. Which is the primary treatment for hypoglycemia in newborns with feeding intolerance?
a. Oral glucose feedings
b. Intravenous (IV) infusion of glucose
c. Short-term insulin therapy
d. Feedings (formula or breast milk) at least every 2 hours
ANS: B
IV infusions of glucose are indicated when the glucose level is very low and when feedings are not tolerated. Early feedings in the normoglycemic newborn are preventive. When the newborn is unable to tolerate feedings or the blood glucose level has become extremely low, then IV infusions are indicated. Insulin administration will further depress the blood glucose level. Feedings can be preventive. The child may not be able to tolerate this frequency.

PTS: 1 DIF: Cognitive Level: Apply REF: 267
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

40. Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?
a. Monitor blood pressure closely.
b. Obtain urine sample to detect glycosuria.
c. Obtain serum glucose and serum calcium levels.
d. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
ANS: C
These are signs and symptoms of hypocalcemia and hypoglycemia. A blood test is useful to determine the treatment. Laboratory analysis for calcium and blood glucose should be the priority intervention. Monitoring vital signs is important, but recognition of the possible hypocalcemia and hypoglycemia is imperative. A finding of glycosuria would not facilitate the diagnosis of hypoglycemia. A determination must be made between the hypocalcemia and hypoglycemia before treatment can be initiated.

PTS: 1 DIF: Cognitive Level: Apply REF: 267
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

41. The nurse is planning care for a newborn receiving IV calcium gluconate for treatment of hypocalcemia. Which intervention is the most appropriate during the acute phase?
a. Allow newborn to sleep with pacifier to decrease stimuli.
b. Keep newborn awake to monitor central nervous system changes.
c. Encourage parents to hold and feed newborn to facilitate attachment during illness.
d. Awaken newborn periodically to assess level of consciousness.
ANS: A
For newborns with hypocalcemia, the nurse should manipulate the environment to reduce stimuli that might precipitate a seizure or tremors. A quiet, nonstimulating environment should be maintained for the newborn until calcium levels are normalized. Care should be provided without sudden jarring. Parents can be involved in observations and care when the child is awake.

PTS: 1 DIF: Cognitive Level: Apply REF: 267
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

42. Which is the central factor responsible for respiratory distress syndrome?
a. Deficient surfactant production
b. Overproduction of surfactant
c. Overdeveloped alveoli
d. Absence of alveoli
ANS: A
The successful adaptation to extrauterine breathing requires numerous factors, which most term newborns successfully accomplish. Preterm newborns with respiratory distress are not able to adjust. The most likely central cause is the abnormal development of the surfactant system. The deficient production of surfactant results in unequal inflation of alveoli on inspiration and the collapse of the alveoli on end expiration. The number and state of development of the alveoli is not a central factor in respiratory distress syndrome. The instability of the alveoli related to the lack of surfactant is the causative issue.

PTS: 1 DIF: Cognitive Level: Remember REF: 268
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

43. A preterm newborn of 36 weeks of gestation is admitted to the NICU. Approximately 2 hours after birth, the newborn begins having difficulty breathing, with grunting, tachypnea, and nasal flaring. Which is important for the nurse to recognize?
a. This is a normal finding.
b. This is not significant unless cyanosis is present.
c. Improvement should occur within 24 hours.
d. Further evaluation is needed.
ANS: D
Difficulty breathing, with grunting, tachypnea, and nasal flaring are clinical manifestations of respiratory distress syndrome and require further evaluation. This is not a normal finding and requires further evaluation. Cyanosis may be present, but these are significant findings indicative of respiratory distress without cyanosis. The childs condition will most likely worsen for approximately 48 hours without intervention. Improvement may begin at 72 hours.

PTS: 1 DIF: Cognitive Level: Analyze REF: 273
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

44. The nurse is caring for a preterm newborn who requires mechanical ventilation for the treatment of respiratory distress syndrome. The nurse should recognize that, because of the mechanical ventilation, there is an increased risk of:
a. alveolar rupture.
b. meconium aspiration.
c. transient tachypnea.
d. retractions and nasal flaring.
ANS: A
Positive pressure introduced by mechanical apparatus has created an increase in the incidence of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Meconium aspiration is not associated with mechanical ventilation. Tachypnea may be an indication of a pneumothorax, but it would not be transient. Retractions and nasal flaring are indications of the use of accessory muscles when the newborn cannot obtain sufficient oxygen. The use of mechanical ventilation bypasses the newborns need to use these muscles.

PTS: 1 DIF: Cognitive Level: Understand REF: 273 | 275
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

45. The nurse is caring for a newborn with respiratory distress syndrome. The newborn has an endotracheal tube. Which statement describes nursing considerations related to suctioning?
a. Suctioning should not be carried out routinely.
b. Newborn should be in Trendelenburg position for suctioning.
c. Routine suctioning, usually every 15 minutes, is necessary.
d. Frequent suctioning is necessary to maintain patency of bronchi.
ANS: A
Suctioning is not an innocuous procedure and can cause bronchospasm, bradycardia, hypoxia, and increased ICP. It should never be carried out routinely. The Trendelenburg position should be avoided. This position can contribute to increased ICP and reduced lung capacity from gravity pushing organs against diaphragm. Routine suctioning is avoided because of the potential complications of bronchospasm, bradycardia, hypoxia, and increased ICP.

PTS: 1 DIF: Cognitive Level: Apply REF: 271
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

46. A premature newborn requires oxygen and mechanical ventilation. Which complications should the nurse assess for?
a. Bronchopulmonary dysplasia, pneumothorax
b. Anemia, necrotizing enterocolitis
c. Cerebral palsy, persistent patent ductus
d. Congestive heart failure, cerebral edema
ANS: A
Oxygen therapy, although lifesaving, is not without hazards. The positive pressure created by mechanical ventilation creates an increase in the number of ruptured alveoli and subsequent pneumothorax and bronchopulmonary dysplasia. Anemia, necrotizing enterocolitis, cerebral palsy, persistent patent ductus, congestive heart failure, and cerebral edema are complications not primarily due to oxygen therapy and mechanical ventilation.

PTS: 1 DIF: Cognitive Level: Analyze REF: 273 | 275
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

47. Meconium aspiration syndrome is caused by:
a. hypoglycemia.
b. carbon dioxide retention.
c. bowel obstruction with meconium.
d. aspiration of meconium in utero or at birth.
ANS: D
Meconium aspiration syndrome is caused by the aspiration of amniotic fluid containing meconium into the fetal or newborn trachea in utero or at first breath. Hypoglycemia and carbon dioxide retention are not related to meconium aspiration. Bowel obstruction with meconium may be an indication of cystic fibrosis or Hirschsprung disease, not meconium aspiration.

PTS: 1 DIF: Cognitive Level: Understand REF: 273
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

48. Which is the most common cause of anemia in preterm newborns?
a. Frequent blood sampling
b. Respiratory distress syndrome
c. Meconium aspiration syndrome
d. Persistent pulmonary hypertension
ANS: A
The most common cause of anemia in preterm newborns is frequent blood-sample withdrawal and inadequate erythropoiesis in acutely ill newborns. Microsamples should be used for blood tests, and the amount of blood drawn should be monitored. Respiratory distress syndrome, meconium aspiration syndrome, and persistent pulmonary hypertension are not causes of anemia. They may require frequent blood sampling, which will contribute to the problem of decreased erythropoiesis and anemia.

PTS: 1 DIF: Cognitive Level: Understand REF: 263
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

49. A newborn is diagnosed with retinopathy of prematurity. The nurse should know that:
a. blindness cannot be prevented.
b. no treatment is currently available.
c. cryotherapy and laser therapy are effective treatments.
d. long-term administration of oxygen will be necessary.
ANS: C
Cryotherapy and laser photocoagulation therapy can be used to minimize the vascular proliferation process that causes the retinal damage. Blindness can be prevented with early recognition and treatment. Cryotherapy and laser therapy can be used to stop the process. Surgical intervention can be used to repair a detached retina if necessary. Long-term administration of oxygen is one of the causes. Oxygen should be used judiciously.

PTS: 1 DIF: Cognitive Level: Understand REF: 276
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

50. Several types of seizures can occur in the newborn. Which is characteristic of clonic seizures?
a. Apnea
b. Tremors
c. Rhythmic jerking movements
d. Extensions of all four limbs
ANS: C
Clonic seizures are characterized by slow rhythmic jerking movements that occur approximately 1 to 3 per second. Apnea is a common manifestation of subtle seizures. Tremors are not characteristic of seizure activity. They may be indicative of hypoglycemia or hypocalcemia. A clonic seizure would have extension and contraction of the extremities, not just extension.

PTS: 1 DIF: Cognitive Level: Understand REF: 282
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

51. Newborns are highly susceptible to infection as a result of:
a. excessive levels of immunoglobulin A (IgA) and immunoglobulin M (IgM).
b. diminished nonspecific and specific immunity.
c. increased humoral immunity.
d. overwhelming anti-inflammatory response.
ANS: B
Newborns have diminished inflammatory (nonspecific) and humoral (specific) immunity. They are unable to mount a local inflammatory reaction at the portal of entry to signal infection, and the resulting symptoms are vague and nonspecific, delaying diagnosis and treatment. Newborns have diminished or absent IgA and IgM. Humoral and anti-inflammatory immune responses are diminished in newborns.

PTS: 1 DIF: Cognitive Level: Understand REF: 282
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

52. Which is most descriptive of the clinical manifestations observed in neonatal sepsis?
a. Seizures and sunken fontanels
b. Sudden hyperthermia and profuse sweating
c. Decreased urinary output and frequent stools
d. Nonspecific physical signs with hypothermia
ANS: D
The clinical manifestations of neonatal sepsis are usually characterized by the newborn generally not doing well. Poor temperature control, usually with hypothermia, lethargy, poor feeding, pallor, cyanosis or mottling, and jaundice, may be evident. Seizures and sunken fontanels are not manifestations of the sepsis. Severe neurologic sequelae may occur in low-birth-weight children with sepsis. Hyperthermia is rare in neonatal sepsis. Urinary output is not affected by sepsis.

PTS: 1 DIF: Cognitive Level: Understand REF: 283-284
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

53. The nurse is caring for a newborn whose mother is diabetic. Which clinical manifestations should the nurse expect to see?
a. Hypoglycemic, large for gestational age
b. Hyperglycemic, large for gestational age
c. Hypoglycemic, small for gestational age
d. Hyperglycemic, small for gestational age
ANS: A
The clinical manifestations of a newborn born to a mother with diabetes include being large for gestational age, being plump and full-faced, having abundant vernix caseosa, being listless and lethargic, and having hypoglycemia. These manifestations appear a short time after birth. The newborn is hypoglycemic from increased fetal production of insulin and large for gestational age.

PTS: 1 DIF: Cognitive Level: Understand REF: 285-286
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

54. The nurse is caring for a newborn who was born 24 hours ago to a mother who received no prenatal care. The newborn is a poor feeder but sucks avidly on his hands. Clinical manifestations also include loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating. Which should the nurse suspect?
a. Seizure disorder
b. Narcotic withdrawal
c. Placental insufficiency
d. Meconium aspiration syndrome
ANS: B
Newborns exposed to drugs in utero usually show no untoward effects until 12 to 24 hours for heroin or much longer for methadone. The newborn usually has nonspecific signs that may coexist with other conditions such as hypocalcemia and hypoglycemia. In addition, these newborns may have loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating, which is uncommon in newborns. Loose stools, tachycardia, fever, projectile vomiting, sneezing, and generalized sweating are manifestations not descriptive of seizure activity. Placental insufficiency usually results in a child who is small for gestational age. Meconium aspiration syndrome usually has manifestations of respiratory distress.

PTS: 1 DIF: Cognitive Level: Apply REF: 287
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

55. Which should the nurse anticipate in the newborn whose mother used cocaine during pregnancy?
a. Seizures
b. Hyperglycemia
c. Cardiac and respiratory problems
d. Neurobehavioral depression or excitability
ANS: D
The nurse should anticipate neurobehavioral depression or excitability and implement care directed at the newborns manifestations. Few or no neurologic sequelae appear in newborns born to mothers who use cocaine during pregnancy. The newborn is usually a poor feeder, so hypoglycemia would be a more likely occurrence. Cardiac and respiratory problems are usually not evident in these newborns.

PTS: 1 DIF: Cognitive Level: Understand REF: 289
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

56. Which genetic term refers to the transfer of all or part of a chromosome to a different chromosome after chromosome breakage?
a. Trisomy
b. Monosomy
c. Translocation
d. Nondisjunction
ANS: C
A translocation occurs when a part of a chromosome breaks off and attaches to another chromosome. When this occurs in the germ cells, the translocation can be transmitted to the next generation. Trisomy is the condition in which three of a specific chromosome are found rather than the usual two. Monosomy is the condition in which one of a specific chromosome is noted rather than the usual two. The term is not used for males when the normal complement of sex chromosomes (one X and one Y) is present. Nondisjunction is the failure of a chromosome to separate during cell division. Of the resultant daughter cells, one will be trisomic and one will be monosomic.

PTS: 1 DIF: Cognitive Level: Understand REF: 294
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

57. Trisomy 13, trisomy 18, and trisomy 21 have which in common?
a. Viability is rare.
b. They are considered deletion syndromes.
c. Diagnosis is difficult, time-consuming, and expensive.
d. Diagnosis can be made early, based on physical characteristics.
ANS: D
Each of these disorders, trisomy 13, 18, and 21, has unique physical characteristics. A presumptive diagnosis can often be made soon after birth and later confirmed by chromosomal analysis. Children with trisomy 13 and 18 usually have short life expectancies. Trisomy 21 has a variable life expectancy, with 80% of individuals living to age 30 years. Trisomy 13, trisomy 18, and trisomy 21 are not deletion syndromes.

PTS: 1 DIF: Cognitive Level: Understand REF: 294
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

58. Which is characteristic of newborns whose mothers smoked during pregnancy?
a. Large for gestational age
b. Preterm, but size appropriate for gestational age
c. Growth retardation in weight only
d. Growth retardation in weight, length, and head circumference
ANS: D
Newborns born to mothers who smoke had growth failure in weight, length, and chest circumference when compared with newborns of mothers who did not smoke. A dose-effect relation exists. Newborns have significant growth failure, which is related to the number of cigarettes smoked.

PTS: 1 DIF: Cognitive Level: Understand REF: 296
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

59. Which is an important nursing consideration in preventing the complications of congenital hypothyroidism (CH)?
a. Assess for family history of CH.
b. Assess mother for signs of hypothyroidism.
c. Be certain appropriate screening is done prenatally.
d. Be certain appropriate screening is done on newborn.
ANS: D
Early diagnosis and treatment are essential to prevent the complications of CH. Neonatal screening is mandatory in all 50 United States and territories and is usually obtained in the first 24 to 48 hours of birth. A number of different etiologies exist for CH; family history will identify a small percentage only. The screening can be done postnatally on blood obtained via heel stick.

PTS: 1 DIF: Cognitive Level: Understand REF: 297
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

60. Phenylketonuria (PKU) is a genetic disease that results in the bodys inability to correctly metabolize:
a. glucose.
b. phenylalanine.
c. phenylketones.
d. thyroxine.
ANS: B
PKU is an inborn error of metabolism caused by a deficiency or absence of the enzyme needed to metabolize the essential amino acid phenylalanine. Phenylalanine hydroxylase is missing in PKU. Individuals with this disorder can metabolize glucose. Phenylketones are metabolites of phenylalanine, excreted in the urine. Thyroxine is one of the principal hormones secreted by the thyroid gland.

PTS: 1 DIF: Cognitive Level: Understand REF: 298
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

61. The commonly used Guthrie blood test is performed on newborns to diagnose:
a. Down syndrome.
b. isoimmunization.
c. PKU.
d. congenital hypothyroidism (CH).
ANS: C
The Guthrie blood test is an assay commonly used to diagnosis PKU. The test should be performed after the newborn has received postnatal feedings. Down syndrome is diagnosed through chromosomal analysis. Isoimmunization is detected by analysis of blood for unexpected antibodies. CH is diagnosed by analysis of a filter paper blood spot for thyroxine (T4).

PTS: 1 DIF: Cognitive Level: Remember REF: 298-299
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

62. The screening test for PKU is most reliable if the blood sample is:
a. from cord blood.
b. taken 14 days after birth.
c. taken before oral feedings are initiated.
d. fresh blood from the heel.
ANS: D
Fresh heel-stick blood is the preferred source for the test. Fresh heel-stick blood, not cord blood, must be used. The test must be performed soon after birth so that a low-phenylalanine diet can be instituted if required. The newborn should ingest breast milk or formula before the test is performed.

PTS: 1 DIF: Cognitive Level: Understand REF: 298-299
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

63. Which is an important nursing consideration in the care of the newborn with PKU?
a. Suggest ways to make formula more palatable.
b. Teach proper administration of phenylalanine hydroxylase.
c. Encourage the breastfeeding mother to adhere to low-phenylalanine diet.
d. Give reassurance that dietary restrictions are a temporary inconvenience.
ANS: A
To achieve optimal metabolic control, a restricted phenylalanine diet will probably be required for virtually all individuals with classic PKU throughout life. The nurse and nutritionist should work with families to make the formula more palatable for the newborn. Phenylalanine hydroxylase is not effective because it cannot act within the cell where phenylalanine is metabolized. Partial breastfeeding may be possible, but only with extremely careful monitoring of the newborns blood levels. According to the latest research, lifelong dietary restriction may be necessary.

PTS: 1 DIF: Cognitive Level: Apply REF: 299
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

1. The nurse needs to obtain blood for ongoing assessment of a high-risk newborns progress. Which tests should the nurse monitor? (Select all that apply.)
a. Blood glucose
b. Complete blood count (CBC)
c. Calcium
d. Serum electrolytes
e. Neonatal prothrombin time (PTT)
ANS: A, C, D
The most common blood tests done on high-risk newborns are blood glucose, bilirubin, calcium, hematocrit, serum electrolytes, and blood gases. Hematocrits rather than CBCs are performed. This will monitor the red cell volume. Neonatal prothrombin time (PTT) is not a test.

PTS: 1 DIF: Cognitive Level: Understand REF: 236
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Physiologic Integrity

2. Which are clinical manifestations of postmaturity in the newborn? (Select all that apply.)
a. Excessive lanugo
b. Increased subcutaneous fat
c. Absence of scalp hair
d. Parchment-like skin
e. Minimal vernix caseosa
f. Long fingernails
ANS: D, E, F
In postmature newborns, the skin is often cracked, parchment-like, and desquamating; there is little to no vernix caseosa; and fingernails are long. Lanugo is usually absent in postmature newborns. Subcutaneous fat is usually depleted, giving the child a thin, elongated appearance. Scalp hair is usually abundant.

PTS: 1 DIF: Cognitive Level: Understand REF: 256
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance

3. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions are appropriate? (Select all that apply.)
a. Avoid stimulation.
b. Decrease fluid intake.
c. Expose all the newborns skin.
d. Monitor skin temperature closely.
e. Reposition the newborn every 2 hours.
f. Cover the newborns eyes with eye shields or patches.
ANS: D, E, F
Several nursing interventions are instituted to protect the newborn during phototherapy. Temperature is closely monitored to prevent hyperthermia or hypothermia. The newborn is repositioned every 2 hours to maximize exposure to the phototherapy and to prevent skin breakdown. The infants eyes are shielded by an opaque mask to prevent exposure to the light. The newborn is clothed in a diaper because a side effect of phototherapy includes loose, greenish stools. Other side effects include increased metabolic rate; dehydration; electrolyte disturbances, such as hypocalcemia; and priapism. Infants receiving phototherapy may require additional fluid volume to compensate for insensible and intestinal fluid loss. The infant should receive adequate stimulation, which includes feeding and touching.

PTS: 1 DIF: Cognitive Level: Apply REF: 262
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Safe and Effective Care Environment

4. A nurse is planning care for a premature newborn. Which interventions should the nurse implement for skin care? (Select all that apply.)
a. Use cleaning agents with neutral pH.
b. Rub skin during drying.
c. Use adhesive remover solvent when removing tape.
d. Avoid removing adhesives for at least 24 hours.
e. Consider pectin barriers beneath adhesives.
ANS: A, D, E
The skin care for a premature newborn should include use of pH-neutral cleanser or soaps no more than two or three times a week. Adhesives should not be removed for at least 24 hours after application. Pectin barriers should be used beneath adhesives to protect skin. Avoid rubbing skin during bathing or drying. Do not use adhesive remover, solvents, or bonding agents. Adhesive removal can be facilitated using water, mineral oil, or petrolatum.

PTS: 1 DIF: Cognitive Level: Apply REF: 244
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

5. A nurse is assessing a premature newborn for the possibility of necrotizing enterocolitis (NEC). Which assessment findings should the nurse expect to find if NEC is confirmed? (Select all that apply.)
a. Minimal gastric residual
b. Abdominal distention
c. Apnea
d. Urinary output at 2 ml/kg/hr
e. Unstable temperature
ANS: B, C, E
The nurse should observe for indications of early development of NEC by checking the appearance of the abdomen for distention (measuring abdominal girth, measuring residual gastric contents before feedings, and listening for bowel sounds) and performing all routine assessments for high-risk neonates. The premature newborn may have apnea and unstable temperature if NEC is developing. The urinary output will be decreased and will be below the expected 2 ml/kg/hr.

PTS: 1 DIF: Cognitive Level: Apply REF: 285
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

6. A nurse is admitting a premature newborn to the NICU. Which interventions should the nurse implement to prevent retinopathy? (Select all that apply.)
a. Place on pulse oximetry.
b. Decrease exposure to bright, direct lighting.
c. Place on a cardiac monitor.
d. Cover eyes with an eye shield at night.
e. Use supplemental oxygen only when needed.
ANS: A, B, E
To prevent retinopathy, the nurse should provide preventive care by closely monitoring blood oxygen levels, responding promptly to saturation alarms, and preventing fluctuations in blood oxygen levels. Pulse oximetry is recommended to monitor the infants oxygenation status during resuscitation and to prevent excessive use of oxygen in both term and preterm infants. Decrease exposure to bright, direct lighting; although exposure to bright light has not been proven to contribute to retinopathy of prematurity, such exposure is undesirable from a neurobehavioral developmental perspective. Use supplemental oxygen judiciously and monitor oxygen blood levels carefully; prevent wide fluctuations in oxygen blood levels (hyperoxia and hypoxia). Placing the newborn on a cardiac monitor will not prevent retinopathy. Covering the eyes with eye shields is not a preventive measure for retinopathy.

PTS: 1 DIF: Cognitive Level: Apply REF: 276
TOP: Integrated Process: Nursing Process: Implementation
MSC: Area of Client Needs: Physiologic Integrity

7. A nurse is assessing a premature newborn. Which assessment findings are consistent with prematurity? (Select all that apply.)
a. Abundant lanugo over the body
b. Ear cartilage soft and pliable
c. Flexed body posture
d. Deep creases on the sole of the foot
e. Skin is bright pink, smooth, and shiny.
ANS: A, B, E
The premature newborn has fine lanugo hair that is abundant over the body. The ear cartilage is soft and pliable, and the soles and palms have minimal creases, resulting in a smooth appearance. The premature newborns skin is bright pink (often translucent, depending on the degree of immaturity), smooth, and shiny, with small blood vessels clearly visible underneath the thin epidermis. In contrast to full-term infants overall attitude of flexion and continuous activity, preterm infants may be inactive and listless. The extremities maintain an attitude of extension and remain in any position in which they are placed.

PTS: 1 DIF: Cognitive Level: Apply REF: 254
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Physiologic Integrity

8. A nurse is reviewing acid-base laboratory data on a newborn admitted to the NICU for meconium aspiration. Which laboratory values should the nurse report to the physician? (Select all that apply.)
a. pH: 7.35
b. PCO2 : 49
c. HCO3-: 30
d. PaO2: 96
ANS: B, C
Normal values of pH for a newborn are:
Birth: 7.117.36
1 day: 7.297.45
Child: 7.357.45.
Normal values of PCO2 are:
Newborn: 2740 mm Hg
Infant: 2741 mm Hg
Girls: 3245 mm Hg
Boys: 3548 mm Hg.
Normal values for HCO3- are:
Infant: 2128 mEq/ml
Thereafter: 2226 mEq/ml.
The PaO2 is within normal limits for a newborn. Therefore, the nurse should report the PCO2 of 49 and the HCO3- of 30.

PTS: 1 DIF: Cognitive Level: Analyze REF: 279
TOP: Integrated Process: Nursing Process: Evaluation
MSC: Area of Client Needs: Physiologic Integrity

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