Deck 28: The Newborn at Risk: Birth-Related Stressors

Question 1

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 polycythemia?

A)Venous hemoglobin level higher than 26 g/dL
B)Bilirubin level of 6 mg/dL
C)Venous hemoglobin level lower than 12 g/dL
D)Blood glucose level of 44 mg/dL

Answer 1

Venous hemoglobin level higher than 26 g/dL

Question 2

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates that she understands how to provide care for an infant undergoing intensive phototherapy?

A)Urine-specific gravity is assessed each voiding.
B)Eye coverings are left off to help keep the baby calm.
C)Temperature is checked every six hours.
D)The infant is taken out of the isolette for diaper changes.

Answer 2

Urine-specific gravity is assessed each voiding.

Question 3

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?

A)Begin chest compressions.
B)Deep suction the airways.
C)Begin bag-and-mask ventilation.
D)Assess blood pressure.

Answer 3

Begin bag-and-mask ventilation.

Question 4

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. His mother had preeclampsia. His respiratory rate is 80; he is grunting and has nasal flaring. What is the most likely cause of this infant's condition?

A)Meconium aspiration syndrome
B)Transient tachypnea of the newborn
C)Respiratory distress syndrome
D)Prematurity of the neonate

Question 5

The mother of a severely premature infant is being allowed to see her baby for the first time. The infant has an IV, a feeding tube, and is receiving phototherapy. He is also hooked up to cardiac and respiratory monitors. What information or instructions should the mother NOT receive before seeing her infant?

A)The mother should not touch her infant because the baby's skin is fragile and could be easily hurt.
B)The mother should not hold the infant before thoroughly washing her hands.
C)The mother should be told what her infant will look like.
D)The mother should receive a description of the equipment that is hooked up to her child.

Question 6

A mother called the maternity ward four days after the birth of her baby girl. She tells the nurse that she has noticed her infant's skin tone is yellow and asks if she should bring the infant to the hospital. What is the most likely cause of the infant's skin tone?

A)Pathologic jaundice
B)Acute bilirubin encephalopathy
C)Physiologic jaundice
D)Hemolytic disease of the newborn

Question 7

The newborn has been diagnosed with sepsis. What indications would lead the nurse to suspect this condition?

A)Respiratory distress syndrome developed 48 hours after birth.
B)Temperature of 97.0°F two hours after warming the infant from 97.4°F
C)Irritability and flushing of the skin at 8 hours of age
D)Bradycardia and tachypnea develop when the infant is 36 hours old.

Question 8

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 urine output
B)Increased pulmonary vascular resistance
C)Increased PCO₂
D)Increased urination

Question 9

A diabetic mother has just given birth to a baby boy. The baby appears lethargic and has a high-pitched cry. The initial plasma glucose level was 19 mg/dL. What is the proper nursing action for this infant?

A)Wait 30 minutes and re-test plasma glucose levels.
B)Have the mother breastfeed the infant.
C)Start an IV with D₅W dextrose solution.
D)Start an IV with D₁₀W dextrose solution.

Question 10

One day after giving birth vaginally, a patient develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex II infection. The expected care for her neonate includes:

A)Meticulous hand washing and antibiotic eye ointment administration.
B)Intravenous acyclovir (Zovirax) and contact precautions.
C)Cultures of blood and CSF and serial chest X-rays every 12 hours.
D)Parental rooming-in and four intramuscular injections of penicillin.

Question 11

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

A)Vasoconstriction and pallor
B)Blood glucose level of 45
C)Room temperature IV running
D)Positioned under radiant warmer