Chapter 19: Caring for the Newborn at Risk Nursing School Test Banks

Chapter 19: Caring for the Newborn at Risk

MULTIPLE CHOICE

1. The pediatric nurse prepares a newborn for phototherapy. The nurse explains to the parents that certain organs need to be protected during treatment. Which organs are these?
A. Eyes and ears
B. Eyes and hands
C. Eyes and genitals
D. Genitals and hands
ANS: C
Phototherapy uses daylight and cool white, blue, or special blue fluorescent light tubes. These lights are the most effective form of phototherapy and are placed around and above the newborn. The eyes and genitals of the newborn are always covered to prevent tissue and retinal damage. The hands and ears of the newborn are not damaged by phototherapy.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. The pediatric nurse is receiving a morning report via phone call on an infant who will be arriving in the neonatal intensive care unit. The report indicates that shoulder dystocia may have occurred during the birth process. The nurse assesses the neonate as at risk for which additional condition?
A. Brachial plexus injury
B. Hyperbilirubinemia
C. Hypoglycemia
D. Intracranial hemorrhage
ANS: A
Risk factors for a brachial plexus injury include LGA or macrosomic newborns, newborns with a diabetic mother, instrument delivery, prolonged labor, shoulder dystocia, and multiparity.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

3. The pediatric nurse explains to the nursing student that respiratory distress syndrome results from a developmental lack of which substance?
A. Calcium
B. Lecithin
C. Magnesium
D. Surfactant
ANS: D
Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The other substances are not related to this disorder.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

4. A baby with brachial plexus injury is being discharged home. What information should the nurse include on the teaching plan?
A. Encourage the baby to move the arm by holding out toys to reach for.
B. Keep the babys arm in the sling for 23 out of every 24 hours.
C. Perform passive range-of-motion exercises to affected extremity.
D. Return to the hospital on day 7 for microsurgical repair.
ANS: C
Brachial plexus injuries (BPI) manifest by lack of movement of an arm, elbow, wrist, or hand. The arm is initially rested, then after 5 to 10 days, passive range of motion (ROM) is started. Parents are taught to do the passive ROM several times a day. This baby is too young to reach for toys and active movement is not encouraged. The baby does not need a sling. Microsurgical repair is indicated if repair is needed, but day 7 would be too early.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

5. A postterm baby is born, and the nurse notes that the baby has dirty-looking skin and nails. The baby has moderate respiratory distress with rales and rhonchi noted. What nursing care does the nurse anticipate providing for this infant?
A. Giving the baby oxygen via an oxygen hood
B. Increasing oxygenation by using CPAP
C. Providing chest physiotherapy every 8 hours
D. Sitting the infant upright to feed and sleep
ANS: B
This baby has a dirty appearance because he or she was born in meconium-stained amniotic fluid, and the respiratory manifestations signal meconium aspiration syndrome. To improve oxygenation, treatment often involves CPAP. Less invasive means of providing oxygen (the hood) are usually not adequate. Chest physiotherapy is usually done every 3 to 4 hours. Sleeping and feeding in an upright position is helpful for GERD.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

6. An infant who is possibly infected with herpes simplex infection is being dismissed. What medication should the nurse anticipate instructing the parents on giving?
A. Acyclovir (Avirax)
B. Ampicillin (Omnipen)
C. Cephtriaxone (Rocephin)
D. Hydroxyzine (Atarax)
ANS: A
Herpes simplex is a viral infection, so an antiviral such as acyclovir is warranted. Antibiotics such as ampicillin and cephtriaxone are not used. Hydroxyzine is for itching.
Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

7. An infant in the NICU has persistent pulmonary hypertension. The nurse places highest priority on which of the following nursing diagnoses?
A. Ineffective tissue perfusion: cardiopulmonary
B. Ineffective tissue perfusion: cerebral
C. Ineffective tissue perfusion: peripheral
D. Ineffective tissue perfusion: neurovascular
ANS: A
Persistent pulmonary hypertension has a right-to-left shunting of blood across the foramen ovale and through the ductus arteriosus of the heart. Therefore, the appropriate nursing diagnosis prioritizes the cardiovascular and pulmonary systems.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Diagnosis
Difficulty: Moderate

PTS: 1

8. The pediatric nurse is providing care to an infant diagnosed with phenylketonuria. What education is vital for this nurse to provide the parents?
A. Information available from the Centers for Disease Control and Prevention
B. High-protein, low-carbohydrate diet for the life of the baby
C. Special phenylalanine-free infant formula and diet restriction
D. Very-low-protein diet supplemented with thiamine during childhood
ANS: C
Phenylketonuria (PKU) is an autosomal recessive inborn error of metabolism. Individuals with PKU cannot convert phenylalanine to tyrosine, and if left untreated, the condition causes complications such as intellectual deficits. The person must follow a phenylalanine-free diet, which means eliminating protein, for the rest of his or her life. There are special formulas for infants with PKU. Information for the parents about informational resources is important, too, but the priority is on educating them regarding the diet. The child should not be on a high-protein diet. A low-protein diet supplemented with thiamine is the treatment for maple syrup urine disease, not for PKU.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

9. A preterm infant in the NICU is receiving oxygen, and the nurse notes that the oxygen saturation is 98%. Which action by the nurse is most appropriate?
A. Call respiratory therapy to draw an arterial blood gas.
B. Document the findings and continue to monitor.
C. Lower the infants oxygen concentration and reassess.
D. See if the infant can tolerate more stimulation and activity.
ANS: C
Preterm infants receiving oxygen should only receive the amount of oxygen needed to maintain an oxygen saturation of greater than 92%, due to the risk of developing retinopathy of prematurity (ROP). Because this babys O2 saturation is well above this reading, the nurse can try to reduce the flow and reassess. ABGs are not warranted. The nurse should document the findings, but further action is needed. Assessing activity tolerance is an ongoing assessment and is not related to preventing ROP.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

10. A nurse explains to a student that which of the following is the mechanism by which circulation of oxygen is increased to the organs of a newborn?
A. Deeper respirations
B. Increased stroke volume
C. Increased tidal volume
D. Tachycardia
ANS: D
In a newborn, ability to alter cardiac output is limited, and stroke volume cannot be improved. The physiological mechanism by which circulation of oxygenated blood to organs is improved in the newborn is tachycardia.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

11. A woman gave birth to an infant weighing 390 g. Which action by the NICU charge nurse is most appropriate?
A. Begin the discharge planning process when the child is admitted.
B. Consult social services to help make arrangements for home care.
C. Consult the palliative care team and admit the infant for comfort care.
D. Prepare for aggressive resuscitation and admission to the NICU.
ANS: C
Very premature infants present moral and ethical dilemmas regarding their care. According to the International Liaison Committee on Resuscitation, infants born at less than 23 weeks gestation or weighing less than 400 g are not candidates for resuscitation. The nurse should plan to admit this infant for comfort care only. The other options are not warranted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

12. A nurse is preparing to admit a newborn to the NICU who weighs 1,750 g. What classification does the nurse use to describe this infant?
A. Extremely low birth weight
B. Low birth weight
C. Normal birth weight
D. Very low birth weight
ANS: B
A normal birth weight baby is between the 10th and 90th percentile on the developmental growth chart for developmental age. A low-birth-weight baby is a newborn weighing less than 2,500 g. A very-low-birth-weight infant weighs less than 1,500 g, and an extremely low-birth-weight infant weighs less than 1,000 g.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

13. A small-for-gestational-age (SGA) newborn is admitted to the NICU. The nurse notes that the babys head circumference is in the 68th percentile for gestational age, but the babys weight is under the 10th percentile. The baby also has a scaphoid abdomen and long fingernails. How does the nurse classify this baby in the handoff report?
A. Asymmetrical intrauterine growth restriction
B. Cold-stressed infant
C. Intrauterine growth retardation
D. Small for gestational age
ANS: A
An SGA newborn has a weight under the 10th percentile for gestational age. This results from intrauterine growth restriction (IUGR). A baby with symmetrical IUGR has low weight plus a head circumference that falls below the 10th percentile. Asymmetrical IUGR results in weight under the 10th percentile and a head of an appropriate size. The terminology intrauterine growth retardation is no longer used. This baby is not cold stressed.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Difficult

PTS: 1

14. A nurse is assessing a newborn infant and notes cool skin, poor feeding attempts, and bradycardia. Which action by the nurse is best?
A. Obtain a rectal temperature.
B. Place the infant in a radiant warmer.
C. Provide a neutral thermal environment.
D. Put the infant on a warm pack.
ANS: A
This infant appears to be hypothermic, but the diagnosis of hypothermia is based on a rectal temperature in addition to the characteristic signs, so the nurse needs to do that first. Then the nurse can place the infant under a radiant warmer or on a warm pack. Infants should be provided with a neutral thermal environment at all times, but this will not warm this baby fast enough on its own.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

15. An NICU nurse is caring for several infants who are being treated for hypothermia. Which baby can be dressed and taken out of the warmer?
A. Skin pale but pink
B. Sucks vigorously
C. Temperature 97.4F (36.3C)
D. Temperature 98.2F (36.7C)
ANS: D
When the newborn is able to maintain her or his own temperature above 97.7F (36.5C), the nurse can switch the baby to air mode and dress him or her. The physical manifestations do not dictate the timing of this switch. The baby with a temperature of 97.4F (36.3C) is too cold to take out of the warmer.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

16. A nurse assesses an infant using the Premature Infant Pain Profile and gives the baby a score of 19. What action by the nurse is most appropriate?
A. Administer morphine (Astramorph).
B. Give an oral sucrose solution.
C. Provide nonnutritive sucking.
D. Swaddle and cuddle the infant.
ANS: A
The Premature Infant Pain Profile is a common pain tool used in NICUs. Scores range from 0to 21. The higher the score, the worse pain the baby is in. A score of 19 indicates severe pain, and the nurse needs to administer morphine sulfate. The other options are all useful treatments for pain, but in this case, the severity of the pain warrants the opioid analgesic.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

17. A nurse has administered an analgesic to a premature infant in pain. What assessment would indicate to the nurse that the babys pain is improving?
A. Crunching the forehead
B. Keeps eyes tightly closed
C. Shallow respirations
D. Sleeps after feeding
ANS: D
Signs of pain in the infant include crunching the forehead, closing the eyes tightly, having shallow respirations, and experiencing altered sleep cycles. This baby is sleeping after a feeding, which is a normal sleep pattern, and thus indicates the pain is improving.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

18. A nurse assesses a premature infant and finds shearing injuries to the infants arms and legs. What action by the nurse is best?
A. Apply emollient lotion to the skin.
B. Assess the baby for pain.
C. Order hypoallergenic crib linens.
D. Place sheepskin under the baby.
ANS: B
Skin breakdown due to rubbing and shearing is a common occurrence in a baby with unrelieved pain. The nurse should first assess the baby for pain and treat accordingly. Emollient should not be used on open skin. Hypoallergenic linens are not warranted. Sheepskin may or may not be helpful, but the best action is to assess and treat any pain.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

19. A nurse has given a premature hypoglycemic infant an IV glucose solution. How would the nurse best determine if the goals for this treatment have been met?
A. Blood glucose is 42 mg/dL.
B. Blood glucose is 58 mg/dL.
C. The baby has a normal-sounding cry.
D. The baby is sucking vigorously.
ANS: B
Many nurseries consider a high-risk newborn hypoglycemic when blood glucose readings are below 5060 mg/dL. For this premature infant, a glucose of 58 mg/dL indicates that treatment has been effective. A blood glucose of 42 mg/dL would be acceptable for a healthy newborn. One sign of hypoglycemia is a high-pitched or weak cry, so this might be an assessment finding associated with euglycemia; however, it is not as specific as a laboratory test. Vigorous sucking is not related.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

20. A 2-hour-old infant has ruddy skin and delayed capillary refill. What laboratory value best correlates with this condition?
A. Blood glucose is 38 mg/dL.
B. Blood glucose is 65 mg/dL.
C. Hematocrit is 42%.
D. Hematocrit is 72%.
ANS: D
This infant has some characteristic signs of polycythemia (ruddy skin, delayed capillary refill). The diagnosis of this disorder is based on a hematocrit of 65% or greater. A hematocrit of 42% is low. Blood glucose is not related.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

21. The nurse caring for small-for-gestational-age (SGA) infants assesses them for attainment of outcomes related to nursing diagnoses. Which assessment finding best demonstrates attainment of priority outcomes?
A. Body temperature of 97.5F (36.4 C)
B. Gains weight regularly
C. Parents visit daily
D. Skin remains intact
ANS: B
The SGA infant has several important nursing diagnoses, including risk for activity intolerance related to increased metabolic needs, risk for ineffective feeding pattern related to increased metabolic need, and nutritional imbalance related to hypoglycemia. The fact that this infant is gaining weight demonstrates that he or she is meeting outcomes related to all three diagnoses. A body temperature of 97.5F is too cool for removal of the baby from the incubator. Parental involvement may indicate no unmet psychosocial needs on their part, but physical diagnoses take precedence over psychosocial ones. Intact skin is a good finding, but risk for impaired skin integrity would not be a higher priority than the other three.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Evaluation
Difficulty: Difficult

PTS: 1

22. A newborn has a blood glucose level of 188 mg/dL. What further assessment on this baby takes priority?
A. Airway status
B. Breathing status
C. Circulatory status
D. Skin status
ANS: C
Hyperglycemia causes an osmotic diuresis and can lead to dehydration. The nurse needs to prioritize the assessment of fluid status over the other assessments.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

23. A diabetic woman had a cesarean delivery and her baby is noted to have a respiratory rate of 82 breaths/minute with retractions. The babys blood gas analyses are as follows: pH, 7.20; PCO2, 52 mm Hg; PaO2, 80 mm Hg; PHCO3, 21 mEq/L. What is an important safety measure the nurse should plan to implement when caring for this infant?
A. Ensure the CPAP pressures do not exceed 6 cm H2O.
B. Maintain secure position of the endotracheal tube with tape.
C. Place the skin temperature sensor over the liver border.
D. Plan to check the babys blood glucose every 2 hours.
ANS: A
This baby is at risk for, and has signs of, transient tachypnea of the newborn (TTN). These babies are often started on CPAP with pressures of 206 cm H2O. Pressures higher than that can cause septal damage and necrosis. The other interventions are not appropriate.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

24. A newborn baby has a calcium level of 7.1 mg/dL. What information should the nurse provide the parents?
A. Low calcium can cause high blood sugars.
B. Postterm babies are most at risk for this condition.
C. The level will be rechecked at 72 hours.
D. Your baby needs to have a magnesium level check.
ANS: C
Hypocalcemia is a blood calcium level below 7.5 mg/dL. Calcium levels are lowest at 2448 hours after birth; if levels remain low at 72 hours, the baby needs calcium supplements. The nurse should advise the parents that the level will be checked again at 72 hours. Hypocalcemia is often accompanied by hypoglycemia, but is not related to magnesium levels. Babies at risk for hypocalcemia include those whose mothers are diabetic, preterm newborns, and newborns with perinatal asphyxia.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

25. A nurse sees a baby whose left arm is in a flexed position and is held in place by pinning the cuff of the babys T-shirt sleeve to the opposite shoulder. What can the nurse conclude about this baby?
A. Broken clavicle
B. Broken wrist
C. Duchenne-Erb paralysis
D. Klumpke paralysis
ANS: A
A broken clavicle is often treated by pinning the infants arm as described. Duchenne-Erb paralysis is a type of brachial plexus injury caused by nerve injury to C5T1. Klumpke paralysis is another type of brachial plexus injury caused by nerve injury to C5C7. Wrist fractures in infants are uncommon.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

26. The nurse working in labor and delivery knows that which infant is at highest risk of having a long-bone fracture?
A. Intrauterine growth restriction
B. Mother with osteoporosis
C. Multiples with one breech presentation
D. Premature
ANS: C
Risk factors for long-bone fractures include breech presentation, multiples, prematurity, and fetal osteoporosis. The premature baby has some risk, but not as much as multiple births with one breech presentation.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

27. A preterm infant was born at 31 weeks and has been admitted to the NICU. The nurse notes expiratory grunting, nasal flaring, and cyanosis on room air. Which laboratory findings would correlate with this condition?
A. PaCO2: 56 mm Hg
B. PaO2: 76 mm Hg
C. pH: 7.30
D. SaO2: 94%
ANS: A
This premature infant is at risk for respiratory distress syndrome (RDS) and has classic signs of the disorder. Laboratory values consistent with this condition are hypercarbia, metabolic acidosis, and low measured levels of oxygen either by arterial blood gas analysis or oxygen saturation. Normal PaCO2 for infants is 3540 mm Hg, so this level is high. The other values are normal.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

28. A premature infant has apnea of prematurity accompanied by bradycardia and desaturation. The infant was started on caffeine citrate (Cafcit), and the results from a blood level have just now returned. The infants blood level of Cafcit is 2.3 mg/mL. What action by the nurse is most appropriate?
A. Allow infant to grow out of the current Cafcit dose.
B. Document results; maintain cardiorespiratory monitor.
C. Inform parents that this blood level is therapeutic.
D. Prepare for immediate intubation and ventilation.
ANS: B
The therapeutic blood level for caffeine citrate (Cafcit) is 520 mg/mL; therefore, this blood level is subtherapeutic. The nurse should document the results and continue monitoring the infant with the cardiorespiratory monitor. The physician should also be informed so the dose can be adjusted if warranted. The child should not be allowed to outgrow the dose for weaning as the apnea and bradycardia episodes continue. The parents should not be informed that the level is therapeutic because it is not. There is no information leading to a conclusion that the infant needs intubation and mechanical ventilation.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

29. A nurse is caring for a premature infant on oxygen. What action is critical for the infants safety?
A. Educate the parents to care for an infant on oxygen.
B. Keep the infant in an incubator while on oxygen.
C. Obtain daily chest x-rays to monitor lung maturity.
D. Use the lowest amount of oxygen possible.
ANS: D
Although oxygen therapy is often needed, it has complications, one of which is bronchopulmonary dysplasia (BPD). The use of supplemental oxygen results in lungs that fail to develop normal compliance. Preventative measures for BPD include using the lowest amount of oxygen needed to keep saturations in the desired range. If the child goes home on oxygen, the parents will need to be taught how to care for the baby. Lung maturity is assessed on the basis of function, not daily chest x-rays. The infant may need a warmer due to prematurity and inability to regulate temperature, but this is not a safety measure related to oxygen.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

30. A premature infant has not had a bowel movement, and the nurse assesses abdominal distention after the last feeding. What action by the nurse takes priority?
A. Document the findings in the chart.
B. Facilitate a bowel x-ray.
C. Notify the health-care provider.
D. Place the infant on NPO status.
ANS: D
This baby has signs of necrotizing enterocolitis (NEC). When the nurse suspects this condition, the priority action is to stop all oral feedings. The other actions are appropriate, but do not take priority over placing the infant on NPO status.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

31. An infant with gastroesophageal reflux disease (GERD) is being discharged home. Which of the following is the priority topic the nurse plans to include in the teaching plan?
A. Managing a multi-medication regime at home
B. Positioning the infant during feeding and sleeping
C. Type of formula to best prevent episode of GERD
D. When to return for surgical correction of the bowel
ANS: B
GERD is common in infants and is not always treated. Prevention includes maintaining an upright position when feeding and feeding the baby slowly. Medications are not always used, but when given, they consist of proton-pump inhibitor or medication to increase gastric motility. Treatment does not include a multi-drug regimen. Formula type is not related. GERD is an upper gastrointestinal disorder, so surgical correction of the bowel is not indicated.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

32. A premature infant in the NICU has a sudden increase in head circumference. Which drug does the nurse anticipate administering?
A. Betamethasone (Celestone)
B. Caffeine citrate (Cafcit)
C. Morphine sulfate (Astromorph)
D. Phenobarbital (Luminal Sodium)
ANS: D
Premature infants are at risk of developing intraventricular hemorrhage and periventricular leukomalacia hemorrhage. A sign of this bleeding within the skull is increasing head circumference, which is measured frequently. The medication of choice is phenobarbital. Betamethasone is given to encourage fetal lung development. Morphine is a pain medication. Caffeine citrate is used for apnea of prematurity.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

33. A postterm newborn is being treated for persistent pulmonary hypertension. Which assessment finding best indicates that a priority outcome has been met?
A. Blood pressure in normal range for age
B. Maintains temperature
C. Oxygen saturation 95%
D. Weight gain
ANS: C
A priority outcome for this patient is maintenance of oxygen saturation in the normal range. The other assessment findings are good but do not relate to the primary outcome.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

34. A nurse is asked to record preductal and postductal oxygen saturations on an infant with possible persistent pulmonary hypertension. Where does the nurse assess the preductal saturation?
A. Earlobe
B. Left finger
C. Left great toe
D. Right finger
ANS: D
Measuring the preductal (right radial) pulse oximetry and comparing it to the postductal (left radial) can help diagnose persistent pulmonary hypertension. A difference of 5% or more demonstrates the right-to-left shunt that this condition produces.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Diagnostic Tests
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

35. A child diagnosed with congenital hypothyroidism is being dismissed from the NICU. What information should the nurse plan to teach the parents?
A. Avoid foods such as fish, milk, or meat-based broth soups.
B. The correct dose of levothyroxine (Synthroid) is 1015 mg/kg/day.
C. The correct dose of levothyroxine (Synthroid) is 1015 mg/kg/day.
D. Regular eye examinations should be undertaken every 6 months.
ANS: C
The treatment for congenital hypothyroidism is Synthroid, the dose of which is 1015 mg/kg/day. The other dose is too high. Avoiding fish, milk, and meat-based broths is part of the diet for homocystinuria. Regular eye exams are not part of the treatment plan for hypothyroidism.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

36. A baby has just been born with anencephaly. Which action by the labor and delivery charge nurse takes priority?
A. Admit the baby to the NICU.
B. Consult the palliative care team.
C. Place the infant in protective isolation.
D. Prepare the infant for surgery.
ANS: B
Anencephaly is a condition in which the child is born with a malformed skull and cerebrum. Some children with anencephaly are born alive, but the condition is fatal, as most of the skull is not present. The priority for the charge nurse is to initiate spiritual and palliative care for the family. There is no indication for admission to the NICU, protective isolation, or surgery.

Cognitive Level: Applying /Application
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

37. An infant is born with an encephalocele. Which action by the nurse takes priority?
A. Admit the baby to the NICU.
B. Consult the palliative care team.
C. Place warm sterile gauze on the defect.
D. Prepare the infant for surgery.
ANS: C
The priority action is to place sterile gauze over the open defect to prevent infection. The infant will need surgery and admission to the NICU, but the first action to take is to protect the babys safety. The mortality rate is fairly high, but the first choice would not be to consult the palliative care team, as surgery is usually attempted to repair the defect.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

38. A pediatric nurse sees a baby with microcephaly. What action is most important for this nurse to do?
A. Assess the babys feeding abilities with an adapted nipple.
B. Document head circumference at each visit.
C. Document weight gain at each visit.
D. Review medication administration with parents.
ANS: B
A baby with microcephaly has a head circumference 2 standard deviations below the mean for gestational age. It is crucial for the nurse to accurately and consistently measure and document the babys head circumference at each visit. The baby does not need a special nipple. Documenting weight gain is important for every baby, but is not specific for this condition. There are no medications used to treat this condition.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

39. A nurse is seeing a baby with a diagnosed cleft lip. What assessment finding indicates to the nurse that a priority outcome has been met?
A. Absence of infection
B. Appropriate weight gain
C. Interacts at developmental age
D. Normal cranial nerve function
ANS: B
Maintaining adequate nutrition is a priority concern in a child with cleft lip or palate, because these defects interfere with feeding. An appropriate weight gain signifies that feeding is adequate. Infection would be a concern in a recent defect repair. Interacting appropriately and having normal cranial nerve function are not specifically related to this defect.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

40. A baby is being discharged home to await surgery to correct a cleft palate. What information do the parents need as the priority?
A. Correct use of the Pavlik harness
B. Dressing changes and wound care
C. Feeding techniques and special nipples
D. How to explain the defect to others
ANS: C
Cleft lip and cleft palate usually are accompanied by feeding problems. Breastfeeding is possible for some babies, whereas others will need specially adapted nipples. There are resources for parents to deal with the emotional aspects of the defect, including how to word birth announcements, but this is not the priority. The Pavlik harness is used with long-bone fractures. Dressing changes and/or wound care would be a priority after surgical correction.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

41. A nurse is assessing a newborn and hears bowel sounds in the infants chest area. What other finding should the nurse specifically assess for?
A. Clubbed fingernails
B. Cyanosis
C. Genital abnormalities
D. Normal stools
ANS: B
Bowel sounds in the thoracic cavity could indicate a congenital diaphragmatic hernia. The nurse should assess for other signs, including cyanosis, bradycardia, barrel chest, and scaphoid abdomen. The other findings are not related to this condition.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

42. A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours. The infants weight is 6 lb, 1 oz (2.75 kg). What assessment finding would require the nurse to intervene immediately?
A. Blood pressure reading of 60/35 mm Hg
B. Skin temperature reading of 96.8F (36C)
C. Unconjugated bilirubin level of 1.0 mg/dL
D. White blood cell count of 12,500/mm3
ANS: B
This infant is at risk for neonatal sepsis. Signs of this condition include hyperthermia or hypothermia, lethargy, hypoglycemia, and poor feeding. This childs skin temperature reading is below normal, requiring the nurse to intervene. The blood pressure reading is normal for a child of this weight. The two laboratory values are also normal.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

43. A nurse is explaining to a student that sudden infant death syndrome (SIDS) has been reduced due mostly to what trend?
A. A decrease in preterm births
B. Decreased maternal smoking
C. Fewer drug-addicted mothers
D. The Back to Sleep campaign
ANS: D
The Back to Sleep campaign of the American Academy of Pediatrics aims for all infants to sleep on their backs, every time. Since initiation of this campaign, there a has been a 50% reduction in SIDS deaths. The other factors are not as firmly related to SIDS as is sleeping supine.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

44. A premature newborn has a pulse pressure of 33 mm Hg. What action by the nurse takes priority?
A. Assess the infant for patent ductus arteriosus.
B. Ensure the blood pressure cuff is the right size.
C. Increase fluids to 1.5 times the maintenance rate.
D. Sedate the baby to prevent fighting the ventilator.
ANS: B
A normal pulse pressure in a premature infant is 1525 mm Hg. This widened pulse pressure could be indicative of a patent ductus, so the nurse should assess for this condition. However, the first action would be to ensure that the blood pressure cuff is the appropriate size and is calibrated correctly. Increasing IV fluids and sedating the baby are not indicated.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

45. A premature infant is born and admitted to the NICU. A student nurse questions why the primary nurse is starting to plan discharge teaching so early. Which response by the nurse is best?
A. All these babies have the same needs, so discharge planning here is pretty routine.
B. By starting early I can ensure that social work and specialty nurses can see the baby.
C. Im not really planning the babys discharge; Im just writing some notes about it.
D. The parents have so much to learn we have to start planning discharge on admission.
ANS: D
Discharge planning starts on admission to the NICU. Instructions are extensive and parents need time to absorb education and begin planning. Of course, changes in the babys condition warrant changes in plans, but by starting early, the nurse can ensure the best possible outcome for the family.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

MULTIPLE RESPONSE

1. A nurse preceptor of a student nurse explains that although a high-risk newborn can have complications in any body system, the systems most often impacted include which of the following? (Select all that apply.)
A. Circulatory
B. Integumentary
C. Neurological
D. Renal
E. Respiratory
ANS: A, C, E
The three systems most commonly affected in the high-risk newborn are the circulatory, respiratory, and neurological systems.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

2. A nurse is documenting the types of high-risk newborns on the unit. Which infants would be classified as preterm? (Select all that apply).
A. weeks
B. weeks
C. weeks
D. weeks
E. weeks
ANS: A, B
Infants born between 38 and 41 weeks gestation are considered term infants. Infants born before the completion of the 37th week are considered premature. Infants born on or after 42 weeks are considered postterm.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

3. A nurse monitors all newborns in the NICU for hypoglycemia. Which manifestations could indicate hypoglycemia in one of the babies? (Select all that apply.)
A. Apneic episodes
B. None (asymptomatic)
C. Eye rolling
D. Lethargy
E. Palmar sweating
ANS: A, B, C, D
Apneic episodes, eye rolling, and lethargy are among the manifestations of hypoglycemia. Hypoglycemic infants can also be asymptomatic. Palmar sweating is indicative of pain.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

4. A woman in labor takes high-dose steroids for a connective tissue disorder. She takes no other medications. The nurse educates her that her baby could be at risk for which of the following conditions? (Select all that apply.)
A. Cold stress
B. Hypoglycemia
C. Intrauterine growth restriction
D. Large for gestational age
E. Polycythemia
ANS: B, D
High-dose corticosteroids can lead to hyperglycemia. A woman with uncontrolled hyperglycemia is at risk of having a large-for-gestational-age newborn or a newborn with hypothermia. Maternal hyperglycemia does not lead to cold stress, intrauterine growth restriction, or polycythemia.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

5. A baby is admitted with a long-bone fracture. What nursing actions are appropriate in the care of this baby? (Select all that apply.)
A. Elevation of the extremity
B. Frequent neurovascular checks
C. Heat therapy to reduce muscle spasm
D. Immobilization while healing
E. Traction at 0.1 kg per 1 kg/babys weight
ANS: A, B, D
Nursing care appropriate for the newborn with a long-bone fracture includes immobilization (usually in a soft splint), frequent neurovascular checks, elevation of the extremity above the heart, cold therapy (not heat), and pain medication.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

6. A nurse is caring for a premature newborn. What interventions does the nurse include on the babys care plan? (Select all that apply.)
A. Bathe the baby daily with mild soap.
B. Cradle baby in a linen nest in flexed position.
C. Monitor response to warming measures.
D. Reposition the baby every 4 hours.
E. Weigh the baby once a week.
ANS: B, C, D
Cradling the baby with extremities flexed helps with ventilation and neuroevolutive development, and helps prevent flattening of the occiput. While the baby is being warmed, the nurse monitors the babys temperature continuously with a skin probe. Repositioning every 4 hours helps prevent skin breakdown. The skin of the preterm infant is fragile so bathing is not done daily and is done without soap products. Premature infants need to be weighed daily.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

7. A baby was born 4 days ago at 34 weeks gestation and is receiving phototherapy for neonatal jaundice. The baby has symptoms of temperature instability, dry skin, poor feeding, lethargy, and irritability. What are the nurses priority nursing interventions? (Select all that apply.)
A. Assess the babys temperature to check for hypothermia.
B. Check to make sure the infants face mask stays in place.
C. Educate the mother to feed the child every 2 hours.
D. Verify laboratory results to check for hypoglycemia.
E. Verify laboratory results to check for hypomagnesemia.
ANS: A, D
Priority nursing actions for the baby undergoing phototherapy include keeping the baby warm, as hypothermia can occur due to exposure, and ensuring the baby receives adequate nutrition. Bilirubin is excreted in the stool. Proper nutrition will also help maintain fluid status. Keeping the babys mask in place is an important safety action to prevent eye damage, but is not related to this babys signs. Hypoglycemia can occur with poor nutrition. Magnesium levels are not affected by jaundice.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment/Management of Care
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

8. An infant has been admitted to the neonatal intensive care unit because of meconium-aspiration syndrome and related complications. The pediatric nurse assesses the patient frequently for which complication? (Select all that apply.)
A. Hemothorax
B. Pneumomediastinum
C. Pneumonia
D. Pneumothorax
E. Respiratory distress syndrome.
ANS: B, D
Meconium-aspiration syndrome is often complicated by pneumothorax and/or pneumomediastinum. Hemothorax, pneumonia, and respiratory distress syndrome are not typical complications.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

9. A nurse is caring for a baby with neonatal abstinence syndrome. Which of the following medications should the nurse be prepared to give? (Select all that apply.)
A. Chlorpromazine (Thorazine)
B. Clonidine (Catapres)
C. Diazepam (Valium)
D. Phenobarbital (Luminal)
E. Naloxone (Narcan)
ANS: A, B, C, D
Several medications are used to treat the infants of drug-abusing mothers, including paregoric (camphorated tincture of opium), phenobarbital (Luminal), clonidine (Catapres), chlorpromazine (Thorazine), and diazepam (Valium). Naloxone (Narcan) is not used because it can increase the severity of drug withdrawal in the infant.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

10. An experienced NICU nurse is explaining to a new nurse why premature infants have such great nutritional needs. What information should the experienced nurse include? (Select all that apply.)
A. The pancreas doesnt produce enough insulin for food use.
B. Their guts are premature and dont absorb nutrients.
C. They havent built up stores in utero like term babies.
D. They have complications that increase their metabolic rate.
E. They lose 10% of their already-low weight at birth.
ANS: C, D, E
Several factors exist to cause increased nutritional demands in the premature infant. They havent have time in the uterus to build up nutritional stores like normal term babies do, their many complications increase their metabolic rate, and they lose 10% of their body weight after birth, which they can ill afford, Certainly some premature infants have intestinal and pancreatic problems, but this is not a true statement for all.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

11. A preterm infant has been started on IV fluids. When assessing the patient, which findings would indicate to the nurse that goals for this therapy are being met? (Select all that apply.)
A. Intake greater than output by 24 hours
B. Lack of tremors and irritability
C. Respiratory rate of 35 breaths/minute
D. Urine output of mL/kg/hour
E. Urine specific gravity of < 1.012
ANS: D, E
In the first few days of life, the goal for hydration is to maintain a urine output of 13 mL/kg/hour and a urine specific gravity of < 1.012. The other assessments are not related.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

COMPLETION

1. An infant is born at 35 weeks and 3 days. How would the nurse document this gestational age? ____________________

ANS:
35 3/7
Gestational age is written in weeks, with days indicated by a fraction.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

2. An infant weighing 3 lb, 7 oz has apnea of prematurity. The nurse needs to administer the loading dose of caffeine citrate (Cafcit). The dose for this is____________________ mg.

ANS:
31 mg
A weight of 3 lb, 7 oz = 1.55 kg. The loading dose for this drug is 20 mg/kg, which is 31 mg.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

3. An infant is born weighing 6 lb, 1 oz and has gastroschisis. The nurse anticipates running this infants IV fluids at a rate of ____________________ mL/hour.

ANS:
412.5 mL/hour
Maintenance fluids for a child this weight (2.75 kg) is 275 mL/hour. A child with gastroschisis has fluids run at 1.5 times the maintenance rate, which would equal 412.5 mL/hour.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

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