Question 1

At birth, an infant newborn has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?

Accepted Answer

The best nursing action in this situation is to begin bag-and-mask ventilation to provide oxygen to the newborn and stimulate breathing. Suctioning the airways may also be done, but it is not the best initial action. Chest compressions and assessing blood pressure are not indicated in this scenario.

Question 2

The day after a vaginal delivery, a client develops painful vesicular lesions on the perineum and vulva which are diagnosed as a primary herpes type 2 infection. What care should the newborn receive?

Accepted Answer

The newborn should receive intravenous acyclovir to treat and prevent herpes infection. Contact precautions should also be taken to prevent transmission of the virus to the newborn.

Question 3

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

Accepted Answer

Increased urination is a sign of improving respiratory status in a newborn with RDS. It suggests that the lungs are functioning better and the excess fluid in the body is being processed and eliminated through the kidneys. Increased PCO₂ and pulmonary vascular resistance are not necessarily indicators of improved respiratory status, and decreased urine output would suggest worsening respiratory distress and hypoperfusion.

Question 4

A student nurse is caring for a neonate undergoing intensive phototherapy. Which action indicates that the student understands how to provide care for an infant undergoing intensive phototherapy?

Accepted Answer

Assessing urine specific gravity with each voiding is important for monitoring hydration status during intensive phototherapy.

Question 5

During a home visit the nurse suspects that a newborn is experiencing chlamydial conjunctivitis. What did the nurse assess to make this clinical determination? Select all that apply.

Accepted Answer

The answer of During a home visit the nurse suspects...

Question 6

The nurse is caring for a newborn born to a client who experienced abruptio placentae. Which assessment findings suggest that the infant is experiencing anemia? Select all that apply.

Accepted Answer

Anemia in newborns can manifest as pallor (A) due to reduced hemoglobin levels, tachypnea (B) and tachycardia (C) as the body attempts to compensate for decreased oxygen carrying capacity, and delayed capillary refill (E) indicating poor perfusion. Elevated blood pressure (D) is not typically associated with anemia.

Question 7

Place the following nursing interventions related to resuscitation in the correct order according to complexity of the method and seriousness of the infant's condition.
A) Perform chest compressions.
B) Administer epinephrine.
C) Rub the infant's back with a blanket.
D) Administer 21% oxygen in a positive-pressure ventilator.
E) Administer 100% oxygen in a positive-pressure ventilator.

Accepted Answer

The answer of Place the following nursing interventions related to...

Question 8

The mother of a 4-day-old infant is concerned that the infant's skin tone is yellow and asks if the baby should be hospitalized. What should the nurse consider as being the cause of this infant's skin color change?

Accepted Answer

The answer of The mother of a 4-day-old infant is...

Question 9

An infant weighing 1500 g is prescribed intravenous normal saline 10 mL/kg. How many milliliters of fluid should the nurse expect to provide this infant? (Calculate to the nearest whole number.)

Accepted Answer

The answer of An infant weighing 1500 g is prescribed...

Question 10

An infant born to a client with type 2 diabetes mellitus is lethargic, has a high-pitched cry, and has an initial plasma glucose level of 19 mg/dL. What should the nurse do immediately?

Accepted Answer

The infant's plasma glucose level is critically low, and starting an IV with D10W dextrose solution is necessary to rapidly increase the blood glucose level and prevent potential complications.

Question 11

A newborn delivered via cesarean birth at 32 weeks to a mother who experienced placenta previa has a low pulse rate, low blood pressure, and a capillary filling time of 3.6 seconds. Which interventions are indicated for the care of this newborn? Select all that apply.

Accepted Answer

The answer of A newborn delivered via cesarean birth at...

Question 12

The mother of a severely premature infant is being prepared to see her baby for the first time. The infant has an IV and a feeding tube, is receiving phototherapy, and is being monitored for cardiac and respiratory functioning. What information would be the least supportive for the mother at this time?

Accepted Answer

It is important to provide the mother with information on how to handle and touch her infant, rather than advising her to avoid doing so. This will help her to bond with her baby and provide essential skin-to-skin contact for her infant's growth and development. All the other options provide important information to the mother that will help her care for her premature infant.

Question 13

A 2-hour-old newborn delivered by cesarean section at 38 weeks with clear amniotic fluid has a respiratory rate of 80 with grunting and nasal flaring. The mother experienced preeclampsia while pregnant. What is the most likely cause of this infant's condition?

Accepted Answer

Transient tachypnea of the newborn is the most likely cause of the infant's condition, characterized by rapid breathing, grunting, and nasal flaring. It is more common in infants delivered by cesarean section because of delayed absorption of fetal lung fluid.

Question 14

A newborn is admitted to the neonatal intensive care unit with suspected meconium aspiration. What care should the nurse expect to provide to this client? Select all that apply.

Accepted Answer

The answer of A newborn is admitted to the neonatal...

Question 15

The nurse is concerned that a new mother is going to have difficulty caring for her newborn once the baby is discharged from the neonatal intensive care unit. What client behaviors are consistent with nonadaptive responses? Select all that apply.

Accepted Answer

Refusing to touch the infant, grimacing when holding the infant, expressing fear of taking the infant home, and blaming others for the infant's health problems are all nonadaptive responses that may indicate difficulty caring for the newborn. Asking staff questions about the infant's care is a normal and adaptive response, showing an interest in learning and providing appropriate care for the infant.

Question 16

An infant with type O Rh-positive blood becomes visibly jaundiced at 12 hours of age. The mother with type O Rh-negative blood asks why this has occurred. How should the nurse respond?

Accepted Answer

The infant's visible jaundice is a result of an incompatible blood type between the mother and baby, leading to hemolytic disease of the newborn. The mother, being Rh-negative, may have developed antibodies against the Rh factor present in the baby's Rh-positive blood, causing the destruction of the baby's red blood cells and subsequent jaundice.

Question 17

A newborn is diagnosed with sepsis. What finding should the nurse use to suspect this health problem?

Accepted Answer

The answer of A newborn is diagnosed with sepsis. What...

Question 18

The nurse is caring for a newborn with hypoglycemia. Which areas on the diagram should the nurse use to obtain blood to assess this newborn's blood glucose levels? Select all that apply.

Accepted Answer

The answer of The nurse is caring for a newborn...

Question 19

A newborn weighing 8 lb, 4 oz is prescribed intravenous vancomycin 30 mg/kg/day in divided doses every 8 hours. How many milligrams of the medication should the nurse prepare to administer to this infant for every dose? (Calculate to the nearest tenth decimal point.)

Accepted Answer

The answer of A newborn weighing 8 lb, 4 oz...

Question 20

The nurse is caring for an infant who delivered in a car on the way to the hospital and has developed cold stress. Which finding requires immediate intervention?

Accepted Answer

Room temperature IV running can exacerbate cold stress in an infant. IV fluids should be warmed to prevent further heat loss and stabilize the infant's temperature.

Quiz 27: The Newborn at Risk: Birth-Related Stressors