High-Risk Neonatal Nursing Care Exam 63 Questions with Verified Answers
A nurse is assessing a preterm baby with a gestational age of 32 weeks and
... [Show More] birth weight of 1,389 grams. Which of the following signs if present would be a possible indication of RDS.
A. Expiratory grunting and intercostal retractions.
B. Respiratory rate of 46 breaths per minute and presence of acrocyanosis.
C. Mild nasal flaring and heart rate of 140 beats per minute.
D. Bradycardia and bounding pulse - CORRECT ANSWER A. Expiratory grunting and intercostal retractions
The primary risk factor for necrotizing enterocolitis is
A. Early oral feedings with formula
B. Passage of meconium during labor
C. Prematurity
D. Low birth weight - CORRECT ANSWER C. Prematurity
A common characteristic of a premature infant is
A. Absence lanugo
B. Dry skin
C. Increased flexion of arms and legs
D. Transparent and red skin - CORRECT ANSWER D. Transparent and red skin
When gavage feeding a preterm neonate, the nurse should
A. measure the tube before insertion from the mouth to the sternum
B. Check for placement by injecting a small amount of sterile water into the feeding tube and listen for a gurgling noise
C. Instill formula over a 20 minute period of time
D. Flush the tube at the end of feeding with dextrose water. - CORRECT ANSWER C. Instill formula over a 20 minute period of time
Which of the following statements is true regarding hyperbilirubinemia?
A. Jaundice covers the entire body in pathological jaundice versus only the face in physiological jaundice.
B. Jaundice occurs within the first 24 hours post birth in pathological jaundice versus after 24 hours in physiological jaundice.
C. Kernicterus only occurs in pathological jaundice.
D. Jaundice begins to appear in term neonates when the bilirubin level is 3 mg/dL. - CORRECT ANSWER B. Jaundice occurs within the first 24 hours post birth in pathological jaundice versus after 24 hours in physiological jaundice.
Clinical management strategies for prevention of retinopathy of prematurity focus on targeting appropriate ______ranges for infants at risk
A. Arterial pH
B. Oxygen saturation
C. Heart rate
D. Core temperature - CORRECT ANSWER B. Oxygen saturation
A neonate born at 37 weeks gestation is determined to be small for gestational age. The most common immediate problem for this infant would be
A. anemia
B. hypovolemia
C. hypoglycemia
D. Hypocalcemia - CORRECT ANSWER C. Hypoglycemia
Which of the following treatments is recommended for the infant experiencing drug withdrawal symptoms?
A. morphine
B. diluted formula
C. frequent awakening
D. well-lit room - CORRECT ANSWER A. morphine
Which is not a risk to the infant of a diabetic mother
A. hyperglycemia
B. poor feeding
C. Marcosomia
D. respiratory distress - CORRECT ANSWER A. hyperglycemia
If a pregnant woman is group beta strep positive, prophylactic antibiotics should be administered if
A. she is a planned c section
B. the gestational age of her baby is less than 37 weeks
C. she has vomiting and diarrhea during labor
D. her baby has a known congenital anomaly - CORRECT ANSWER B. the gestational age of her baby is less than 37 weeks
1. A neonate is born at 33 weeks' gestation with a birth weight of 2400 grams. This neonate would be classified as:
a. Low birth weight
b. Very low birth weight
c. Extremely low birth weight
d. Very premature - CORRECT ANSWER ANS: a
a. Neonates with a birth weight of less than 2500 grams but greater than 1500 grams are classified as low birth weight.
b. Neonates with birth weight less than 1500 grams but greater than 1000 grams are classified as very low birth weight.
c. Neonates with birth weight less than 1000 grams are classified as extremely low birth weight.
d. Neonates born less than 32 weeks' gestation are classified as very premature.
2. A nurse assesses that a 3-day-old neonate who was born at 34 weeks' gestation has abdominal distention and vomiting. These assessment findings are most likely related to:
a. Respiratory Distress Syndrome (RDS)
b. Bronchopulmonary Dysplasia (BPD)
c. Periventricular Hemorrhage (PVH)
d. Necrotizing Enterocolitis (NEC) - CORRECT ANSWER ANS: d
a. Assessment findings for RDS include tachypnea, intercostal retractions, respiratory grunting, and nasal flaring.
b. Assessment findings for BPD include chest retractions; audible wheezing, rales, and rhonchi; hypoxia; and bronchospasm.
c. Assessment findings for PVH include bradycardia, hypotonia, full and/or tense anterior fontanel, and hyperglycemia.
d. Assessment findings related to NEC include abdominal distention, bloody stools, abdominal distention, vomiting, and increased gastric residual. These signs and symptoms are related to the premature neonate's inability to fully digest stomach contents and limitation in absorptive function.
3. A full-term neonate who is 30 hours old has a bilirubin level of 10 mg/dL. The neonate has a yellowish tint to the skin of the face. The mother is breastfeeding her newborn. The nurse caring for this neonate would anticipate which of the following interventions?
a. Phototherapy
b. Feeding neonate every 2 to 3 hours
c. Switch from breastfeeding to bottle feeding
d. Assess red blood cell count - CORRECT ANSWER ANS: b
a. Phototherapy is considered when the levels are 12 mg/dL or higher when the neonate is 25 to 48 hours old. Neonates re-absorb increased amounts of unconjugated bilirubin in the intestines due to lack of intestinal bacteria and decreased gastrointestinal motility.
b. Adequate hydration promotes excretion of bilirubin in the urine.
c. Colostrum acts as a laxative and assists in the passage of meconium.
d. Assessing RBC is not a treatment for hyperbilirubinemia.
4. A NICU nurse is caring for a full-term neonate being treated for group B streptococcus. The mother of the neonate is crying and shares that she cannot understand how her baby became infected. The best response by the nurse is:
a. "Newborns are more susceptible to infections due to an immature immune system. Would you like additional information on the newborn immune system?"
b. "The infection was transmitted to your baby during the birthing process. Do you have a history of sexual transmitted infections?"
c. "Approximately 10% to 30% of women are asymptomatic carries of group B streptococcus which is found in the vaginal area. What other questions do you have regarding your baby's health?"
d. "I see that this is very upsetting for you. I will come back later and answer your questions." - CORRECT ANSWER ANS: c
a. Correct information, but does not fully address the woman's concern.
b. Correct, but GBS is not a sexually transmitted disease.
c. Correct. This response answers her questions and allows her to ask additional questions about her baby's health.
d. Acknowledges that she is upset but does not provide immediate information.
5. A nursery nurse observes that a full-term AGA neonate has nasal congestion, hypertonia, and tremors and is extremely irritable. Based on these observations, the nurse suspects which of the following?
a. Hypoglycemia
b. Hypercalcemia
c. Cold stress
d. Neonatal withdrawal - CORRECT ANSWER ANS: d
a. Signs and symptoms of hypoglycemia are jitteriness, hypotonia, irritability, apnea, lethargy, and temperature instability, but not nasal congestion.
b. Signs and symptoms of hypercalcemia are vomiting, constipation, and cardiac arrhythmias.
c. Signs and symptoms of cold stress are decreased temperature, cool skin, lethargy, pallor, tachypnea, hypotonia, jitteriness, weak cry, and grunting.
d. These are common signs and symptoms of neonatal withdrawal.
6. The following four babies are in the neonatal nursery. Which of the babies should be seen by the neonatologist as soon as possible?
a. 1-day-old, HR 170 bpm, crying
b. 2-day-old, T 98.9°F, slightly jaundice
c. 3-day-old, breastfeeding q 2 h, rooting
d. 4-day-old, RR 70 rpm, dusky coloring - CORRECT ANSWER ANS: d
a. A slight tachycardia—170 bpm—is normal when a baby is crying.
b. Slight jaundice on day 2 is within normal limits.
c. It is normal for a breastfed baby to feed every 2 hours.
d. A dusky skin color is abnormal in any neonate, whether or not the respiration rate is normal, although this baby is also slightly tachypneic.
7. A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time?
a. Encourage the parents to pray for the baby's soul.
b. Advise the parents that it is better for the baby to have died than to have had to live with a defect.
c. Encourage the parents to hold the baby.
d. Advise the parents to refrain from discussing the baby's death with their other children. - CORRECT ANSWER ANS: c
a. It is inappropriate for the nurse to advise prayer. The parents must decide for themselves how they wish to express their spirituality.
b. This is an inappropriate suggestion.
c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during the grieving process.
d. This is an inappropriate suggestion. It is very important for the parents to clearly communicate the baby's death with their other children.
8. The nurse is assessing a baby girl on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
a. Intermittent strabismus
b. Startling
c. Grunting
d. Vaginal bleeding - CORRECT ANSWER ANS: c
a. Pseudostrabismus is a normal finding.
b. Startling is a normal finding.
c. Grunting is a sign of respiratory distress. The neonatologist should be notified.
d. Vaginal bleeding is a normal finding.
9. It is noted that the amniotic fluid of a 42-week gestation baby, born 30 seconds ago, is thick and green. Which of the following actions by the nurse is critical at this time?
a. Perform a gavage feeding immediately.
b. Assess the brachial pulse.
c. Assist a physician with intubation.
d. Stimulate the baby to cry. - CORRECT ANSWER ANS: c
a. This action is not appropriate. The baby needs tracheal suctioning.
b. The baby needs to have tracheal suctioning. The most important action to promote health for the baby is for the health-care team to establish an airway that is free of meconium.
c. This action is appropriate. The baby needs to be intubated in order for deep suctioning to be performed by the physician. A nurse would not intubate and suction but rather would assist with the procedures.
d. It is strictly contraindicated to stimulate the baby to cry until the trachea has been suctioned. The baby would aspirate the meconium-stained fluid, which could result in meconium-aspiration syndrome.
10. A 42-week gestation neonate is admitted to the NICU (neonatal intensive care unit). This neonate is at risk for which complication?
a. Meconium aspiration syndrome
b. Failure to thrive
c. Necrotizing enterocolitis
d. Intraventricular hemorrhage - CORRECT ANSWER ANS: a
a. Although there is nothing in the scenario that states that the amniotic fluid is green tinged, post-term babies are high risk for meconium aspiration syndrome.
b. Post-term babies often gain weight very quickly.
c. Preterm, not post-term, babies are high risk for necrotizing enterocolitis.
d. Preterm, not post-term, babies are high risk for intraventricular hemorrhages.
11. A 1-day-old neonate in the well-baby nursery is suspected of suffering from drug withdrawal because he is markedly hyperreflexic and is exhibiting which of the following additional sign or symptom?
a. Prolonged periods of sleep
b. Hypovolemic anemia
c. Repeated bouts of diarrhea
d. Pronounced pustular rash - CORRECT ANSWER ANS: c
a. Babies who are withdrawing from drugs have disorganized behavioral states and sleep very poorly.
b. There is nothing in the scenario that indicates that this child is hypovolemic or anemic.
c. Babies who are experiencing withdrawal often experience bouts of diarrhea.
d. A pustular rash is characteristic of an infectious problem, not of neonatal abstinence syndrome.
12. A baby boy was just born to a mother who had positive vaginal cultures for group B streptococci. The mother was admitted to the labor room 30 minutes before the birth. For which of the following should the nursery nurse closely observe this baby?
a. Grunting
b. Acrocyanosis
c. Pseudostrabismus
d. Hydrocele - CORRECT ANSWER ANS: a
a. This infant is high risk for respiratory distress. The nurse should observe this baby carefully for grunting.
b. Acrocyanosis is a normal finding.
c. Pseudostrabismus is a normal finding.
d. Hydrocele should be reported to the neonatologist. It is not, however, an emergent problem, and it is not related to group B streptococci colonization in the mother.
13. The laboratory reported that the L/S ratio (lecithin/sphingomyelin) results from an amniocentesis of a gravid client with preeclampsia are 2:1. The nurse interprets the result as which of the following?
a. The baby's lung fields are mature.
b. The mother is high risk for hemorrhage.
c. The baby's kidneys are functioning poorly.
d. The mother is high risk for eclampsia - CORRECT ANSWER ANS: a
a. An L/S ratio of 2:1 usually indicates that the fetal lungs are mature.
b. L/S ratios are unrelated to maternal blood loss.
c. L/S ratios are unrelated to fetal renal function.
d. L/S ratios are unrelated to maternal risk for becoming eclamptic.
14. Which of the following neonatal signs or symptoms would the nurse expect to see in a neonate with an elevated bilirubin level?
a. Low glucose
b. Poor feeding
c. Hyperactivity
d. Hyperthermia - CORRECT ANSWER ANS: b
a. Hypoglycemia is not a sign that is related to an elevated bilirubin level.
b. The baby is likely to feed poorly. An elevated bilirubin level adversely affects the central nervous system. Babies are often sleepy and feed poorly when the bilirubin level is elevated.
c. Hyperactivity is the opposite of the behavior one would expect the baby to exhibit.
d. Hyperthermia is not directly related to an elevated bilirubin level.
15. The perinatal nurse is assisting the student nurse with completion of documentation. The laboring woman has just given birth to a 2700 gram infant at 36 weeks' gestation. The most appropriate term for this is:
a. Preterm birth
b. Term birth
c. Small for gestational age infant
d. Large for gestational age infant - CORRECT ANSWER ANS: a
a. A preterm infant is an infant with gestational age of fewer than 36 completed weeks.
b. Term births are infants born between 37 and 40 weeks.
c. SAG infants at 36 weeks weigh less than 2000 grams.
d. LAG infants at 36 weeks weigh over 3400 grams.
16. The NICU nurse recognizes that respiratory distress syndrome results from a developmental lack of:
a. Lecithin
b. Calcium
c. Surfactant
d. Magnesium - CORRECT ANSWER ANS: c
a. The ratio of lecithin to sphingomyelin in the amniotic fluid is used to assess maturity of fetal lungs.
b. Calcium is needed to prevent undermineralization of bones.
c. Respiratory distress syndrome (RDS) is a developmental respiratory disorder that affects preterm newborns due to lack of lung surfactant. The pathology of RDS is that there is diffuse atelectasis with congestion and edema in the lung spaces. On deflation, the alveoli collapse, and there is decreased lung compliance.
d. Magnesium is needed to prevent undermineralization of bones.
17. The NICU nurse is providing care to a 35-week-old infant who has been in the neonatal intensive care unit for the past 3 weeks. His mother wants to breastfeed her son naturally but is currently pumping her breasts to obtain milk. His mother is concerned that she is only producing about 1 ounce of milk every 3 hours. The nurse's best response to the patient's mother would be:
a. "Pumping is hard work and you are doing very well. It is good to get about 1 ounce of milk every 3 hours."
b. "Natural breastfeeding will be a challenging goal for your baby. Beginning today, you will need to begin to pump your breasts more often."
c. "Your baby will not be ready to go home for at least another week. You can begin to pump more often in the next few days in preparation for taking your child home."
d. "You have been working hard to give your son your breast milk. We can map out a schedule to help you begin today to pump more - CORRECT ANSWER ANS: d
a. This is correct information but does not assist the women in producing more milk.
b. This does not provide her with a plan to increase her milk.
c. This does not provide her with a plan.
d. The mother should be praised for her efforts to breastfeed and encouraged to continue to pump her milk. A determined schedule for pumping the milk will help the mother keep her milk flow steady and provide enough nutrients for the infant after discharge.
18. A nurse is caring for a 2-day-old neonate who was born at 31 weeks' gestation. The neonate has a diagnosis of respiratory distress syndrome (RDS). Which of the following medical treatments would the nurse anticipate for this neonate? (Select all that apply.)
a. Exogenous surfactant
b. Corticosteroids
c. Continuous positive airway pressure (CPAP)
d. Bronchodilators - CORRECT ANSWER ANS: a, c
a. This is a common medical treatment for RDS.
b. Corticosteroids are given to women in preterm labor to decrease the risk of RDS.
c. CPAP is used to assist neonates with RDS.
d. Bronchodilators are given to neonates with bronchopulmonary dysplasia (BPD).
19. Which of the following factors increases the risk of necrotizing enterocolitis (NEC) in very premature neonates? (Select all that apply.)
a. Early oral feedings with formula
b. Prolonged use of mechanical ventilation
c. Hyperbilirubinemia
d. Nasogastic feedings - CORRECT ANSWER ANS: a, d
a. Preterm neonates have a decreased ability to digest and absorb formula. Undigested formula can cause a blockage in the intestines leading to necrosis of the bowel.
b. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response.
c. Preterm neonates are predisposed to NEC due to alteration in blood flow to the intestines, impaired gastrointestinal host defense, and alteration in inflammatory response.
d. Bacterial colonization in the intestines can occur from contaminated feeding tubes causing an inflammatory response in the bowel.
20. Nursing actions that decrease the risk of skin breakdown include which of the following? (Select all that apply.)
a. Using gelled mattresses
b. Using emollients in groin and thigh areas
c. Using transparent dressings
d. Drying thoroughly - CORRECT ANSWER ANS: a, b, c
a. Use of gelled mattresses decreases the risk of pressure sores.
b. Use of emollients reduces the risk of irritation from urine.
c. Use of transparent dressings reduces the risk of friction injuries.
d. Drying thoroughly is important in maintaining body heat.
21. Nursing actions that minimize oxygen demands in the neonate include which of the following? (Select all that apply.)
a. Providing frequent rest breaks when feeding
b. Placing neonate on back for sleeping
c. Maintaining a neutral thermal environment (NTE)
d. Clustering nursing care - CORRECT ANSWER ANS: c, d
a. A prolonged feeding session increases energy consumption that increases oxygen consumption.
b. Placing the neonate on the back for sleeping has no effect on oxygen consumption.
c. A decrease in environmental temperature leads to a decrease in the neonate's body temperature which leads to an increase in respiratory and heart rate that leads to an increase in oxygen consumption.
d. Clustering of nursing care decreases stress which decreases oxygen requirements. [Show Less]