High-Risk Neonatal Nursing Care Olds Maternal-Newborn Exam 91 Questions with Verified Answers
What factors influence the outcomes of the at-risk
... [Show More] newborn? Select all that apply.
a. Type and length of newborn illness.
b. Maternal factors.
c. Gestational age.
d. Environmental factors.
e. Birth weight. - CORRECT ANSWER Birth weight.
Gestational age.
Types and length of newborn illness.
Environmental factors.
Maternal factors.
Rationale: All are correct. Maternal factors, such as age and parity; newborn weight; and gestational age also influence outcomes, as do environmental factors such as exposure to environmental dangers (toxic chemicals and illicit drugs).
The nurse informs the parents of a small-for-gestational-age newborn that complications can occur, including:
a. Hyperthermia.
b. Leukocytosis.
c. Hyperglycemia.
d. Cognitive difficulties. - CORRECT ANSWER Cognitive difficulties.
Rationale: SGA newborns often subsequently exhibit learning disabilities. The disabilities are characterized by hyperactivity, short attention span, and poor fine-motor coordination. Some hearing loss and speech defects also can occur. The SGA newborn does not exhibit symptoms of high blood sugar, increased temperature, and high white blood cell count.
In the transition from intrauterine to extrauterine life, what intervention is of high priority when working with an infant of a diabetic mother?
a. Administer IV fluids.
b. Obtain lab work to look for infection.
c. Keep under radiant warmer.
d. Check blood glucose frequently. - CORRECT ANSWER Check blood glucose frequently.
Rationale: Lab work, IV fluids, and the radiant warmer bed could be required for interventions if indicated, but frequent blood glucose checks are especially important in the infant of the diabetic mother to ensure that blood glucose levels are being maintained. The infant's temperature must be assessed before placing the infant under the warmer.
Which is the most appropriate nursing diagnosis for a newborn who has meconium aspiration syndrome?
a. Pain.
b. Hyperthermia.
c. Altered Nutrition: More than Body Requirements.
d. Impaired Gas Exchange (lungs and at the cellular level). - CORRECT ANSWER Impaired Gas Exchange (lungs and at the cellular level).
Rationale: Meconium aspiration syndrome causes respiratory issues. Pain, increased temperature, and nutritional status generally are not issues identified at the time the syndrome is diagnosed.
A 28-weeks'-gestation newborn experienced birth asphyxia at the time of delivery. What is a long-term complication of birth asphyxia?
a. Intraventricular hemorrhage.
b. Anemia of prematurity.
c. Retinopathy of prematurity.
d. Necrotizing enterocolitis. - CORRECT ANSWER Intraventricular hemorrhage.
Rationale: Birth asphyxia will cause an insult to the brain, and more often than not will cause a bleed or intraventricular hemorrhage. Birth asphyxia is not directly correlated with NEC, retinopathy of prematurity, or anemia of prematurity. These are common for the premature infant, but not necessarily birth asphyxia.
What is the best explanation as to why the nursing diagnosis, Risk for Infection, often is a complication for the preterm infant? Select all that apply.
a. Preterm newborns have immature immune systems.
b. Preterm babies have thin and permeable skin.
c. Preterm babies have immature cardiovascular systems.
d. Preterm babies have immature gastrointestinal systems. - CORRECT ANSWER Preterm babies have thin and permeable skin.
Preterm newborns have immature immune systems.
Rationale: The preterm newborn is susceptible to infection because of an immature immune system and thin, permeable skin. Invasive procedures, techniques such as umbilical catheterization, mechanical ventilation, and prolonged hospitalization place the infant at greater risk for infection.
What is the best intervention a nurse can utilize to promote parent-infant attachment with a preterm or high-risk newborn?
a. Provide an extensive handbook with information related to the preterm newborn.
b. Encourage rooming in.
c. Contact support families that have been through the same diagnosis with their own child and allow time to discuss the situation.
d. Allow for privacy. - CORRECT ANSWER Encourage rooming in.
Rationale: All will help strengthen the attachment bond, but the best answer would be to encourage rooming in. Rooming in can provide a great opportunity for the stable preterm infant and family to get acquainted; it offers both privacy and readily available help.
What risk factor, when combined with alcohol, enhances the likelihood of fetal alcohol syndrome?
a. Caffeine.
b. Chocolate.
c. Citrus fruits.
d. Peanuts. - CORRECT ANSWER Caffeine.
Rationale: The effects of other substances, such as nicotine, marijuana, and caffeine—as well as poor diet—combined with alcohol, often enhance the likelihood of FAS.
The preterm newborn of a mother who used cocaine during pregnancy is experiencing vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea. What is the best explanation for these symptoms?
a. Maternal substance abuse.
b. Traumatic birth.
c. Sepsis.
d. Gestational diabetes. - CORRECT ANSWER Maternal substance abuse.
Rationale: The severity of withdrawal that an infant experiences can be assessed by using a scoring system such as the Finnegan scale. This scale is based on observations and measurement of the responses to neonatal abstinence from substances. It evaluates the infant on potentially life-threatening signs such as vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea.
The primary goal for the drug-dependent newborn is to reduce withdrawal symptoms and promote adequate respiration, temperature, and nutrition. What intervention best reflects that goal?
a. N.P.O. status.
b. Administer medications such as methadone.
c. Proper positioning of the infant in the right side-lying or in semi-Fowler's position.
d. Monitor for hyperthermia. - CORRECT ANSWER Proper positioning of the infant in the right side-lying or in semi-Fowler's position.
Rationale: Proper positioning in the right side-lying or semi-Fowler's position to avoid possible aspiration of vomitus or secretions is the best choice. The nurse would monitor for hypothermia; the infant would not be made NPO because of the vomiting/diarrhea; and the infant would not be placed on methadone, because of its addictive qualities.
The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dL. What should the nurse include in the plan of care for this newborn?
1. Offer early feedings with formula or breast milk.
2. Provide glucose water exclusively.
3. Evaluate blood glucose levels at 12 hours after birth.
4. Assess for hypothermia. - CORRECT ANSWER Answer: 1
Explanation: 1. IDMs whose serum glucose falls below 40 mg/dL should have early feedings with formula or breast milk (colostrum).
The nurse is caring for several pregnant clients. Which client should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity?
1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical factory
2. 23-year-old of low socioeconomic status, unmarried
3. 16-year-old who began prenatal care at 30 weeks
4. 28-year-old with a history of gestational diabetes - CORRECT ANSWER Answer: 1
Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35, high parity, history of preterm birth, and exposure to chemicals that might be toxic.
) The nurse is caring for a prenatal client. Reviewing the client's pregnancy history, the nurse identifies risk factors for an at-risk newborn, including which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. The mother's low socioeconomic status
2. Maternal age of 26
3. Mother's exposure to toxic chemicals
4. More than three previous deliveries
5. Maternal hypertension - CORRECT ANSWER Answer: 1, 3, 4, 5
Explanation: 1. Low socioeconomic status is associated with at-risk newborns.
3. Exposure to environmental dangers, such as toxic chemicals is associated with at-risk newborns.
4. Maternal factors such as multiparity are associated with at-risk newborns.
5. Preexisting maternal conditions, such as heart disease, diabetes, hypertension, hyperthyroidism, and renal disease are associated with at-risk newborns.
The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart?
1. Preterm appropriate for gestational age, symmetrical IUGR
2. Term small for gestational age, symmetrical IUGR
3. Preterm small for gestational age, asymmetrical IUGR
4. Preterm appropriate for gestational age, asymmetrical IUGR - CORRECT ANSWER Answer: 3
Explanation: 3. The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant is small for gestational age. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical IUGR.
A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn?
1. Monitor for feeding difficulties.
2. Assess for facial paralysis.
3. Monitor for signs of hyperglycemia.
4. Maintain a warm environment. - CORRECT ANSWER Answer: 4
Explanation: 4. Hypothermia is a common complication in the SGA newborn; therefore, the newborn's environment must remain warm, to decrease heat loss.
The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority?
1. Obtain a blood calcium level.
2. Take the newborn's temperature.
3. Obtain a bilirubin level.
4. Place a pulse oximeter on the newborn. - CORRECT ANSWER Answer: 1
Explanation: 1. Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant.
A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dL. What is the best nursing action?
1. To recheck the blood sugar in 6 hours
2. To begin an IV of 10% dextrose
3. To feed the baby 1 ounce of formula
4. To document the findings in the chart - CORRECT ANSWER Answer: 4
Explanation: 4. A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action.
The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn?
1. Offer early feedings.
2. Administer an intravenous infusion of glucose.
3. Assess for hypercalcemia.
4. Assess for hyperbilirubinemia immediately after birth. - CORRECT ANSWER Answer: 1
Explanation: 1. Newborns of diabetic mothers may benefit from early feeding as they are extremely valuable in maintaining normal metabolism and lowering the possibility of such complications as hypoglycemia and hyperbilirubinemia.
The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn?
Note: Credit will be given if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Tremors
2. Hyperglycemia
3. Hyperbilirubinemia
4. Respiratory distress syndrome
5. Birth trauma - CORRECT ANSWER Answer: 1, 3, 4, 5
Explanation: 1. Tremors are a clinical sign of hypocalcemia.
3. Hyperbilirubinemia is caused by slightly decreased extracellular fluid volume, which increases the hematocrit level.
4. Respiratory distress syndrome (RDS) is a complication that occurs more frequently in newborns of diabetic mothers whose diabetes is not well controlled.
5. Because most IDMs are macrosomic, trauma may occur during labor and vaginal birth resulting in shoulder dystocia, brachial plexus injuries, subdural hemorrhage, cephalohematoma, and asphyxia.
The nurse caring for a postterm newborn would not perform what intervention?
1. Providing warmth
2. Frequently monitoring blood glucose
3. Observing respiratory status
4. Restricting breastfeeding - CORRECT ANSWER Answer: 4
Explanation: 4. Breastfeeding is an appropriate means of feeding for the postterm newborn.
The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best?
1. "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth."
2. "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid."
3. "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens."
4. "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger." - CORRECT ANSWER Answer: 1
Explanation: 1. The term postmaturity applies to the infant who is born after 42 completed weeks of gestation and demonstrates characteristics of postmaturity syndrome.
The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. What is the nurse's best response?
1. "Most newborns are nose breathers."
2. "The tube will elicit the sucking reflex."
3. "A smaller catheter is preferred for feedings."
4. "Most newborns are mouth breathers." - CORRECT ANSWER Answer: 1
Explanation: 1. Orogastric insertion is preferable to nasogastric because most infants are obligatory nose breathers.
A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for which of the following?
1. Visual impairment
2. Hyperthermia
3. Central cyanosis
4. Sensitive gag reflex - CORRECT ANSWER Answer: 1
Explanation: 1. Extremely premature newborns are particularly susceptible to injury of the delicate capillaries of the retina causing characteristic retinal changes known as retinopathy of prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has become the norm.
A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Schedule care throughout the day.
2. Silence alarms quickly.
3. Place a blanket over the top portion of the incubator.
4. Do not offer a pacifier.
5. Dim the lights. - CORRECT ANSWER Answer: 2, 3, 5
Explanation: 2. Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly.
3. Dimmer switches should be used to shield the baby's eyes from bright lights with blankets over the top portion of the incubator.
5. Dimming the lights may encourage infants to open their eyes and be more responsive to their parents.
The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. Which of the following assessment findings is not congruent with prematurity?
1. Cry is weak and feeble
2. Clitoris and labia minora are prominent
3. Strong sucking reflex
4. Lanugo is plentiful - CORRECT ANSWER Answer: 3
Explanation: 3. Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn.
The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. "Our baby will be in an incubator to keep him warm."
2. "Breathing might be harder for our baby because he is early."
3. "The growth of our baby will be faster than if he were term."
4. "Tube feedings will be required because his stomach is small."
5. "Because he came early, he will not produce urine for 2 days." - CORRECT ANSWER Answer: 3, 4, 5
Explanation: 3. Preterm infants grow more slowly than do term infants because of difficulty in meeting high caloric and fluid needs for growth due to small gastric capacity.
4. Although tube feedings might be required, it would be because preterm babies have a marked danger of aspiration and its associated complications due to the infant's poorly developed gag reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex.
5. Although preterm babies have diminished kidney function due to incomplete development of the glomeruli, they can produce urine. Preterm infants usually have some urine output during the first 24 hours of life.
The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention?
1. The new nurse holds the infant after giving a gavage feeding.
2. The new nurse provides skin-to-skin care.
3. The new nurse provides care when the baby is awake.
4. The new nurse gives the feeding with room-temperature formula. - CORRECT ANSWER Answer: 4
Explanation: 4. Preterm babies have little subcutaneous fat, and do not maintain their body temperature well. Formula should be warmed prior to feedings to help the baby maintain its temperature.
Benefits of skin-to-skin care as a developmental intervention include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Routine discharge
2. Stabilization of vital signs
3. Increased periods of awake-alert state
4. Decline in the episodes of apnea and bradycardia
5. Increased growth parameters - CORRECT ANSWER Answer: 2, 4, 5
Explanation: 2. Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention.
4. Decline in the episodes of apnea and bradycardia is a benefit of skin-to-skin care as a developmental intervention.
5. Increased growth parameters are a benefit of skin-to-skin care as a developmental intervention.
In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include which of the following?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Volume of urine output
2. Weight
3. Blood pH
4. Head circumference
5. Bowel sounds - CORRECT ANSWER Answer: 1, 2
Explanation: 1. In order to assess hydration status, volume of urine output must be evaluated.
2. In order to assess hydration status, the infant's weight must be evaluated.
The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority?
1. Tissue Integrity, Impaired
2. Infection, Risk for
3. Gas Exchange, Impaired
4. Family Processes, Dysfunctional - CORRECT ANSWER Answer: 3
Explanation: 3. Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate surfactant production and has the highest priority.
The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. What information does teaching include?
1. Specially prepared formulas
2. Cataract problems
3. Low glucose concentrations
4. Administration of thyroid medication - CORRECT ANSWER Answer: 1
Explanation: 1. An afflicted PKU infant can be treated by a special diet that limits ingestion of phenylalanine. Special formulas low in phenylalanine, such as Lofenalac, Minafen, and Albumaid XP, are available.
The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with which of the following?
1. Omphalocele
2. Gastroschisis
3. Diaphragmatic hernia
4. Myelomeningocele - CORRECT ANSWER Answer: 4
Explanation: 4. Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent infection. The infant is positioned on abdomen or on side and restrain (to prevent pressure and trauma to sac). Hydrocephalus often is present.
The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Measure head circumference daily.
2. Assess for bulging fontanelles.
3. Avoid position changes.
4. Watch for signs of infection.
5. Use a gel pillow under the head. - CORRECT ANSWER Answer: 1, 2, 4, 5
Explanation: 1. The infant has congenital hydrocephalus. The nurse should measure and plot occipital-frontal baseline measurements, then measure head circumference once a day.
2. The infant has congenital hydrocephalus. Fontanelles should be checked for bulging and sutures for widening.
4. Infants with hydrocephalus are prone to infection.
5. The infant has congenital hydrocephalus. The enlarged head should be supported with a gel pillow.
During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to do which of the following?
1. Place the newborn in a prone position.
2. Limit feedings to three a day to decrease diarrhea.
3. Place the infant supine and operate a home apnea-monitoring system.
4. Wean the newborn off the pacifier. - CORRECT ANSWER Answer: 3
Explanation: 3. Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should sleep in a supine position, and home apnea monitoring should be implemented.
The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse?
1. Occasional watery stools
2. Spitting up after feeding
3. Jitteriness and irritability
4. Nasal stuffiness - CORRECT ANSWER Answer: 3
Explanation: 3. Jitteriness and irritability can be an indicator of drug withdrawal.
Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a parent indicates that additional teaching is required?
1. "Our baby's heart murmur is from this syndrome."
2. "He might be a fussy baby because of this."
3. "His face looks like it does due to this problem."
4. "Cuddling and rocking will help him stay calm." - CORRECT ANSWER Answer: 4
Explanation: 4. The FASD baby is most comfortable in a quiet, minimally stimulating environment. [Show Less]