Deck 29: The Newborn at Risk: Birth-Related Stressors

Question 1

The nurse is planning care for four infants who were born on this shift.Which infant will require the most detailed assessment? The infant whose mother:

A)Has a history of obsessive-compulsive disorder (OCD).
B)Has Chlamydia.
C)Has delivered six other children by cesarean section.
D)Has a urinary tract infection (UTI).

Answer 1

Has Chlamydia.

Question 2

The nurse is caring for a newborn with jaundice.The parents question why the newborn is not under the phototherapy lights.The nurse explains that the fiberoptic blanket is beneficial because: (Select all that apply. )

A)Lights can stay on all of the time.
B)The eyes do not need to be covered.
C)The lights will need to be removed for feedings.
D)Newborns do not get overheated.
E)Weight loss is not a complication of this system.

Answer 2

Lights can stay on all of the time.
The eyes do not need to be covered.
Newborns do not get overheated.
Weight loss is not a complication of this system.

Question 3

A client in labor is found to have meconium-stained amniotic fluid upon rupture of membranes.At delivery,the nurse finds the infant to have depressed respirations and a heart rate of 80.The nurse anticipates which of the following to occur?

A)Deliver the neonate on its side with head up,to facilitate drainage of secretions.
B)Direct tracheal suctioning by specially trained personnel.
C)Prepare for the immediate use of positive pressure to expand the lungs.
D)Suction the oropharynx when the newborn's head is delivered.

Answer 3

Direct tracheal suctioning by specially trained personnel.

Question 4

The nurse assesses that a newborn's skin has a ruddy appearance and the peripheral pulses are decreased.The nurse suspects polycythemia.Which of the following lab reports might indicate that the newborn has polycythemia?

A)Central venous hematocrit level greater than 65%
B)Bilirubin level of 6 mg/dL
C)Venous hemoglobin level lower than 12 g/dL
D)Blood glucose level of 44 mg/dL

Question 5

A nursing instructor is demonstrating how to perform a heel stick on a newborn.To obtain an accurate capillary hematocrit reading,the nursing instructor tells the students to:

A)Warm the heel prior to obtaining blood.
B)Use a previous puncture site.
C)Cool the heel prior to obtaining blood.
D)Use a sterile needle and aspirate.

Question 6

A newborn is receiving phototherapy.Which intervention would be most important?

A)Measurement of head circumference
B)Encouraging the mother to stop breastfeeding
C)Stool guaiac testing
D)Assessment of hydration status

Question 7

During newborn resuscitation,effectiveness of bag-and-mask ventilations can be determined by:

A)The rise and fall of the chest.
B)Sudden wakefulness.
C)Urinary output.
D)Adequate thermoregulation.

Question 8

Antibiotics have been ordered for a newborn with an infection.Which of the following interventions would the nurse prepare to implement? Select all that apply.

A)Obtain skin cultures.
B)Restrict parental visits.
C)Evaluate bilirubin levels.
D)Administer oxygen as ordered.
E)Observe for signs of hypoglycemia.

Question 9

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS).The nurse informs the parents that the newborn is improving.Which of the following data supports the nurse's assessment?

A)Decreased urination
B)Pulmonary vascular resistance increases.
C)Increased Pco2
D)Increased urination

Question 10

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid.The nurse knows this newborn might require:

A)Initial resuscitation.
B)Vigorous stimulation at birth.
C)Phototherapy immediately.
D)An initial feeding of iron-enriched formula.

Question 11

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dL to 16.6 mg/dL in an 8-hour period.What nursing intervention would be included in the plan of care for this newborn?

A)Continue to observe.
B)Begin phototherapy.
C)Begin blood exchange transfusion.
D)Stop breastfeeding.

Question 12

The nurse is evaluating the effectiveness of phototherapy on a newborn.Which of the following evaluations indicates a therapeutic response to phototherapy?

A)Normal temperature is maintained by the newborn.
B)Bilirubin level of 14 mg/dL
C)Decreased reflexes
D)Skin blanches yellow.

Question 13

Which of the following assessment findings by the nurse would require obtaining a blood glucose level on the newborn?

A)Jitteriness of the newborn
B)Newborn sucking on fingers
C)Lusty cry
D)Axillary temperature of 98

Question 14

The parents of a preterm newborn desire to visit their baby in the NICU.All of the following statements by the nurse will support the parents as they visit their newborn except:

A)"Your newborn likes to be touched."
B)"Stroking the newborn will help with stimulation."
C)"Visits must be scheduled between feedings."
D)"Your baby loves her pink blanket."

Question 15

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS).The nurse bases this assessment on all of the following data except:

A)Grunting respirations.
B)Nasal flaring.
C)Respiratory rate of 40 during sleep.
D)Chest retractions.