Chapter 25: The High Risk Newborn Nursing School Test Banks

Chapter 25: The High Risk Newborn

MULTIPLE CHOICE

1. A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurses most appropriate action is to:

a.

Leave the infant in the room with the mother.

b.

Take the infant immediately to the nursery.

c.

Perform a gestational age assessment to determine whether the infant is large for gestational age.

d.

Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

ANS: D

This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mothers room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.

PTS: 1 DIF: Cognitive Level: Application REF: 668

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

2. Infants of mothers with diabetes (IDMs) are at higher risk for developing:

a.

Anemia.

c.

Respiratory distress syndrome.

b.

Hyponatremia.

d.

Sepsis.

ANS: C

IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 682

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

3. An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:

a.

Birth injury.

c.

Hypoglycemia.

b.

Hypocalcemia.

d.

Seizures.

ANS: C

Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 682

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

4. When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has:

a.

Few blood vessels visible through the skin.

b.

More subcutaneous fat.

c.

Well-developed flexor muscles.

d.

Greater surface area in proportion to weight.

ANS: D

Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

PTS: 1 DIF: Cognitive Level: Analysis REF: 685

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

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

a.

Parents are not allowed to hold infants who depend on oxygen.

b.

You may hold only your babys hand during the feeding.

c.

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

d.

You may hold your baby during the feeding.

ANS: D

You may hold your baby during the feeding is an accurate statement. Parental interaction via holding is encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions. The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant. Swaddling or kangaroo care during feedings provides positive interactions for the infant.

PTS: 1 DIF: Cognitive Level: Application REF: 700

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

6. A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?

a.

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

b.

The drug keeps your baby from requiring too much sedation.

c.

Surfactant is used to reduce episodes of periodic apnea.

d.

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

ANS: A

Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

PTS: 1 DIF: Cognitive Level: Application REF: 687

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

7. When providing an infant with a gavage feeding, which of the following should be documented each time?

a.

The infants abdominal circumference after the feeding

b.

The infants heart rate and respirations

c.

The infants suck and swallow coordination

d.

The infants response to the feeding

ANS: D

Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infants response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infants response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infants response to the feeding (including attempts to suck).

PTS: 1 DIF: Cognitive Level: Application REF: 700

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

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

a.

Rapid bolusing of the entire amount in 15 minutes

b.

Warm cloths to the abdomen for the first 10 minutes

c.

Slow, small, warm bolus feedings over 30 minutes

d.

Cold, medium bolus feedings over 20 minutes

ANS: C

Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions. Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Warm cloths to the abdomen for the first 10 minutes would not be appropriate because it is not a thermoregulated environment. Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

PTS: 1 DIF: Cognitive Level: Application REF: 700

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

9. An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurses most appropriate action would be to:

a.

Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

b.

Continue to observe and make no changes until the saturations are 75%.

c.

Continue with the admission process to ensure that a thorough assessment is completed.

d.

Notify the parents that their infant is not doing well.

ANS: A

Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.

PTS: 1 DIF: Cognitive Level: Application REF: 688

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

a.

Wait quietly at the newborns bedside until the parents come closer.

b.

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

c.

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

d.

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

ANS: B

The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant, rather than focus on the equipment. The importance and purpose of the apparatus that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infants condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infants appearance and condition. Encouragement from the nurse is instrumental in this process. Telling the parents only about the newborns physical condition and cautioning them to avoid touching their baby is an inappropriate action.

PTS: 1 DIF: Cognitive Level: Application REF: 705

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

11. Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:

a.

Hypertonia, tachycardia, and metabolic alkalosis.

b.

Abdominal distention, temperature instability, and grossly bloody stools.

c.

Hypertension, absence of apnea, and ruddy skin color.

d.

Scaphoid abdomen, no residual with feedings, and increased urinary output.

ANS: B

Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 693

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

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

a.

Your baby will develop exactly like your first child did.

b.

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

c.

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

d.

Your baby will need to be followed very closely.

ANS: C

The age of a preterm newborn is corrected by adding the gestational age and the postnatal age. The infants responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby does not appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.

PTS: 1 DIF: Cognitive Level: Application REF: 676

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

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

a.

Meconium aspiration, hypoglycemia, and dry, cracked skin.

b.

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

c.

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

d.

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

ANS: A

Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat. Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

PTS: 1 DIF: Cognitive Level: Analysis REF: 685

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

14. In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?

a.

Necrotizing enterocolitis (NEC)

c.

Bronchopulmonary dysplasia (BPD)

b.

Retinopathy of prematurity (ROP)

d.

Intraventricular hemorrhage (IVH)

ANS: B

ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 690

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

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

a.

Hypovolemia and/or shock.

c.

Central nervous system injury.

b.

A nonneutral thermal environment.

d.

Pending renal failure.

ANS: A

The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.

PTS: 1 DIF: Cognitive Level: Application REF: 680

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

16. Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:

a.

Suffering from sleep or wakeful apnea.

b.

Experiencing severe swings in blood pressure.

c.

Trying to maintain a neutral thermal environment.

d.

Breathing in a respiratory pattern common to premature infants.

ANS: D

This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 684

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

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

a.

Is adopted from classical British nursing traditions.

b.

Helps infants with motor and central nervous system impairment.

c.

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

d.

Gets infants ready for breastfeeding.

ANS: C

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

PTS: 1 DIF: Cognitive Level: Knowledge REF: 699

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

18. For clinical purposes, preterm and post-term infants are defined as:

a.

Preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA).

b.

Post-term after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA.

c.

Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth.

d.

Preterm, SGA before 38 to 40 weeks, and post-term, LGA beyond 40 to 42 weeks.

ANS: C

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

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

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

19. With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that:

a.

In the first trimester diseases or abnormalities result in asymmetric IUGR.

b.

Infants with asymmetric IUGR have the potential for normal growth and development.

c.

In asymmetric IUGR weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA.

d.

Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B

IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

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

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

20. As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that:

a.

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

b.

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

c.

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

d.

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

ANS: C

High risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby. Parents and their high risk infant should spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high risk infants are discharged does not mean that they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

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

OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity

21. Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC:

a.

Early enteral feedings

c.

Exchange transfusion

b.

Breastfeeding

d.

Prophylactic probiotics

ANS: B

A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohns disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

PTS: 1 DIF: Cognitive Level: Application REF: 693

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

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

a.

Decreased respiratory rate.

b.

Bradycardia followed by an increased heart rate.

c.

Mottled skin with acrocyanosis.

d.

Increased physical activity.

ANS: C

The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurses role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

PTS: 1 DIF: Cognitive Level: Analysis REF: 696

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

23. Because of the premature infants decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?

a.

Delayed growth and development

c.

Ineffective infant feeding pattern

b.

Ineffective thermoregulation

d.

Risk for infection

ANS: D

The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

PTS: 1 DIF: Cognitive Level: Application REF: 684

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

24. A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborns distress is most likely to be:

a.

Hypoglycemia.

c.

Respiratory distress syndrome.

b.

Phrenic nerve injury.

d.

Sepsis.

ANS: D

The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 666

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

25. The most important nursing action in preventing neonatal infection is:

a.

Good handwashing.

c.

Separate gown technique.

b.

Isolation of infected infants.

d.

Standard Precautions.

ANS: A

Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 669

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

26. A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infants physical findings, this woman should be questioned about her use of which substance during pregnancy?

a.

Alcohol

c.

Heroin

b.

Cocaine

d.

Marijuana

ANS: A

The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.

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

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

27. A plan of care for an infant experiencing symptoms of drug withdrawal should include:

a.

Administering chloral hydrate for sedation.

b.

Feeding every 4 to 6 hours to allow extra rest.

c.

Swaddling the infant snugly and holding the baby tightly.

d.

Playing soft music during feeding.

ANS: C

The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.

PTS: 1 DIF: Cognitive Level: Application REF: 675

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

28. Human immunodeficiency virus (HIV) may be perinatally transmitted:

a.

Only in the third trimester from the maternal circulation.

b.

By a needlestick injury at birth from unsterile instruments.

c.

Only through the ingestion of amniotic fluid.

d.

Through the ingestion of breast milk from an infected mother.

ANS: D

Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 676

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

29. The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States?

a.

Alcohol

c.

Marijuana

b.

Tobacco

d.

Heroin

ANS: A

Alcohol abuse during pregnancy is recognized as one of the leading causes of cognitive impairment in the United States.

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

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

30. During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurses best response would be:

a.

Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.

b.

You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats feces.

c.

Its just gross. You should make your husband clean the litter boxes.

d.

Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby.

ANS: A

Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their children. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the womans husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the clients question, and is not the nurses best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.

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

OBJ: Nursing Process: Planning

MSC: Client Needs: Safe and Effective Care Environment

31. A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infants eyes when the mother asks, What is that medicine for? The nurse responds:

a.

It is an eye ointment to help your baby see you better.

b.

It is to protect your baby from contracting herpes from your vaginal tract.

c.

Erythromycin is given prophylactically to prevent a gonorrheal infection.

d.

This medicine will protect your babys eyes from drying out over the next few days.

ANS: C

With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.

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

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

32. With regard to injuries to the infants plexus during labor and birth, nurses should be aware that:

a.

If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.

b.

Erb palsy is damage to the lower plexus.

c.

Parents of children with brachial palsy are taught to pick up the child from under the axillae.

d.

Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

ANS: A

If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.

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

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

33. As related to central nervous system injuries that could occur to the infant during labor and birth, nurses should be aware that:

a.

Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant.

b.

Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia.

c.

In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests.

d.

Spinal cord injuries almost always result from forceps-assisted deliveries.

ANS: C

Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography scan may reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 666

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

34. To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that:

a.

Congenital infection progresses more slowly than does nosocomial infection.

b.

Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.

c.

Infections occur with about the same frequency in boy and girl infants, although female mortality is higher.

d.

The clinical sign of a rapid, high fever makes infection easier to diagnose.

ANS: B

Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract and progress more rapidly than do nosocomial (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and are similar to those of noninfectious problems, thus making diagnosis difficult.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 672

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

35. Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of:

a.

Gonorrhea.

c.

Congenital syphilis.

b.

Herpes simplex virus infection.

d.

Human immunodeficiency virus.

ANS: C

The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities.

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

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

36. What bacterial infection is definitely decreasing because of effective drug treatment?

a.

Escherichia coli infection

c.

Candidiasis

b.

Tuberculosis

d.

Group B streptococcal infection

ANS: D

Penicillin has significantly decreased the incidence of group B streptococcal infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and Canada. Candidiasis is a fairly benign fungal infection.

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

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

37. In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:

a.

The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over.

b.

Two thirds of newborns with fetal alcohol syndrome (FAS) are boys.

c.

Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.

d.

Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

ANS: C

Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 676

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

38. A careful review of the literature on the various recreational and illicit drugs reveals that:

a.

More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.

b.

Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not.

c.

Mothers should discontinue heroin use (detox) any time they can during pregnancy.

d.

Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

ANS: A

Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More long-range studies are needed. Just about all these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore, detoxification from heroin is not recommended, particularly later in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.

PTS: 1 DIF: Cognitive Level: Analysis REF: 679

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

39. To provide optimal care of infants born to mothers who are substance abusers, nurses should be aware that:

a.

Infants born to addicted mothers are also addicted.

b.

Mothers who abuse one substance likely will use or abuse another, thus compounding the infants difficulties.

c.

The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself.

d.

No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

ANS: B

Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. Drug-exposed newborn is a more accurate description than addict. The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infants intrauterine drug exposure.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 676

OBJ: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

40. Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is:

a.

Pharmacologic treatment.

b.

Reduction of environmental stimuli.

c.

Neonatal abstinence syndrome scoring.

d.

Adequate nutrition and maintenance of fluid and electrolyte balance.

ANS: C

Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates central nervous system (CNS), metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays CNS disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

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

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

41. While completing a newborn assessment, the nurse should be aware that the most common birth injury is:

a.

To the soft tissues.

b.

Caused by forceps gripping the head on delivery.

c.

Fracture of the humerus and femur.

d.

Fracture of the clavicle.

ANS: D

The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.

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

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

42. The most common cause of pathologic hyperbilirubinemia is:

a.

Hepatic disease.

c.

Postmaturity.

b.

Hemolytic disorders in the newborn.

d.

Congenital heart defect.

ANS: B

Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 679

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

43. Which infant would be more likely to have Rh incompatibility?

a.

Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor

b.

Infant who is Rh negative and whose mother is Rh negative

c.

Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor

d.

Infant who is Rh positive and whose mother is Rh positive

ANS: A

If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the children will be Rh positive. Only Rh-positive children of an Rh-negative mother are at risk for Rh incompatibility. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 679

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

44. With regard to hemolytic diseases of the newborn, nurses should be aware that:

a.

Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother.

b.

ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.

c.

Exchange transfusions frequently are required in the treatment of hemolytic disorders.

d.

The indirect Coombs test is performed on the mother before birth; the direct Coombs test is performed on the cord blood after birth.

ANS: D

An indirect Coombs test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 680

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

45. An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment?

a.

Extracorporeal membrane oxygenation

b.

Respiratory support with a ventilator

c.

Insertion of a laryngoscope and suctioning of the trachea

d.

Insertion of an endotracheal tube

ANS: A

Extracorporeal membrane oxygenation is a highly technical method that oxygenates the blood while bypassing the lungs, thus allowing the infants lungs to rest and recover. The infant is likely to have been first connected to a ventilator. Laryngoscope insertion and tracheal suctioning are performed after birth before the infant takes the first breath.

An endotracheal tube will be in place to facilitate deep tracheal suctioning and ventilation.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 693

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

46. The goal of treatment of the infant with phenylketonuria (PKU) is to:

a.

Cure mental retardation.

b.

Prevent central nervous system (CNS) damage, which leads to mental retardation.

c.

Prevent gastrointestinal symptoms.

d.

Cure the urinary tract infection.

ANS: B

CNS damage can occur as a result of toxic levels of phenylalanine. No known cure exists for mental retardation. Digestive problems are a clinical manifestation of PKU. PKU does not involve any urinary problems.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 711

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

47. HIV may be perinatally transmitted:

a.

Only in the third trimester from the maternal circulation.

b.

From the use of unsterile instruments.

c.

Only through the ingestion of amniotic fluid.

d.

Through the ingestion of breast milk from an infected mother.

ANS: D

Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. This is highly unlikely because most health care facilities must meet sterility standards for all instrumentation. Transmission of HIV may occur during birth from blood or secretions.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 676

OBJ: Nursing Process: Planning

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

MULTIPLE RESPONSE

48. Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (Select all that apply):

a.

Amphetamine.

b.

Heroin.

c.

Nicotine.

d.

PCP.

e.

Morphine.

ANS: A, B, C, D

Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 676

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

49. Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply):

a.

Polycythemia.

b.

Anemia.

c.

Congenital heart disease.

d.

Bronchopulmonary dysphasia.

e.

Retinopathy.

ANS: A, B, C

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

Bronchopulmonary dysphasia and retinopathy are not associated with NEC.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 693

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

50. Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply):

a.

Problems with thermoregulation

b.

Cardiac distress

c.

Hyperbilirubinemia

d.

Sepsis

e.

Hyperglycemia

ANS: A, C, D

Thermoregulation problems, hyperbilirubinemia, and sepsis are all conditions related to immaturity and warrant close observation. After discharge the infant is at risk for rehospitalization related to these problems. AWHONN launched the Near-Term Infant Initiative to study the problem and ways to ensure that these infants receive adequate care. The nurse should ensure that this infant is feeding adequately before discharge and that parents are taught the signs and symptoms of these complications.

Late-preterm infants are also at increased risk for respiratory distress and hypoglycemia.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 685

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

MATCHING

Car seat safety is an essential part of discharge planning, and infants younger than 37 weeks of gestation should have a period of observation in an appropriate car seat to monitor for possible apnea, bradycardia, and decreased SaO2. The nurse who is about to perform a car seat evaluation on a late-preterm infant will perform the sequence of the test in which order?

a.

Secure the infant in the car seat per guidelines using blanket rolls on the side.

b.

Leave the infant undisturbed for 90 to 120 minutes.

c.

Set the heart rate alarm at 80 bpm and the apnea alarm at 20 seconds.

d.

Document the infants tolerance to the test.

e.

Perform the evaluation 1 to 7 days before discharge.

f.

Use the parents car seat.

g.

Set the pulse oximeter low alarm at 88%.

51. Step 1

52. Step 2

53. Step 3

54. Step 4

55. Step 5

56. Step 6

57. Step 7

51. ANS: F PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

52. ANS: E PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

53. ANS: A PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

54. ANS: G PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

55. ANS: C PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

56. ANS: B PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

57. ANS: D PTS: 1 DIF: Cognitive Level: Application

REF: 708 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

NOT: An episode of desaturation, bradycardia or apnea (20 seconds or more) constitutes a failure, and evaluation by the practitioner must occur before discharge. A car bed with the infant supine may be considered, and similar testing should occur in the car bed.

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