Deck 19: Caring for the Newborn at Risk

Question 1

A nurse is assessing a newborn infant and notes cool skin,poor feeding attempts,and bradycardia.Which action by the nurse is best?

A) Obtain a rectal temperature.
B) Place the infant in a radiant warmer.
C) Provide a neutral thermal environment.
D) Put the infant on a warm pack.

Answer 1

Obtain a rectal temperature.

Question 2

A nurse explains to a student that which of the following is the mechanism by which circulation of oxygen is increased to the organs of a newborn?

A) Deeper respirations
B) Increased stroke volume
C) Increased tidal volume
D) Tachycardia

Answer 2

Tachycardia

Question 3

A nurse assesses an infant using the Premature Infant Pain Profile and gives the baby a score of 19.What action by the nurse is most appropriate?

A) Administer morphine (Astramorph).
B) Give an oral sucrose solution.
C) Provide nonnutritive sucking.
D) Swaddle and cuddle the infant.

Answer 3

Administer morphine (Astramorph).

Question 4

A nurse assesses a premature infant and finds shearing injuries to the infant's arms and legs.What action by the nurse is best?

A) Apply emollient lotion to the skin.
B) Assess the baby for pain.
C) Order hypoallergenic crib linens.
D) Place sheepskin under the baby.

Question 5

An infant in the NICU has persistent pulmonary hypertension.The nurse places highest priority on which of the following nursing diagnoses?

A) Ineffective tissue perfusion: cardiopulmonary
B) Ineffective tissue perfusion: cerebral
C) Ineffective tissue perfusion: peripheral
D) Ineffective tissue perfusion: neurovascular

Question 6

A 2-hour-old infant has ruddy skin and delayed capillary refill.What laboratory value best correlates with this condition?

A) Blood glucose is 38 mg/dL.
B) Blood glucose is 65 mg/dL.
C) Hematocrit is 42%.
D) Hematocrit is 72%.

Question 7

The pediatric nurse prepares a newborn for phototherapy.The nurse explains to the parents that certain organs need to be protected during treatment.Which organs are these?

A) Eyes and ears
B) Eyes and hands
C) Eyes and genitals
D) Genitals and hands

Question 8

A postterm baby is born,and the nurse notes that the baby has dirty-looking skin and nails.The baby has moderate respiratory distress with rales and rhonchi noted.What nursing care does the nurse anticipate providing for this infant?

A) Giving the baby oxygen via an oxygen hood
B) Increasing oxygenation by using CPAP
C) Providing chest physiotherapy every 8 hours
D) Sitting the infant upright to feed and sleep

Question 9

A preterm infant in the NICU is receiving oxygen,and the nurse notes that the oxygen saturation is 98%.Which action by the nurse is most appropriate?

A) Call respiratory therapy to draw an arterial blood gas.
B) Document the findings and continue to monitor.
C) Lower the infant's oxygen concentration and reassess.
D) See if the infant can tolerate more stimulation and activity.

Question 10

A nurse has given a premature hypoglycemic infant an IV glucose solution.How would the nurse best determine if the goals for this treatment have been met?

A) Blood glucose is 42 mg/dL.
B) Blood glucose is 58 mg/dL.
C) The baby has a normal-sounding cry.
D) The baby is sucking vigorously.

Question 11

The pediatric nurse is providing care to an infant diagnosed with phenylketonuria.What education is vital for this nurse to provide the parents?

A) Information available from the Centers for Disease Control and Prevention
B) High-protein, low-carbohydrate diet for the life of the baby
C) Special phenylalanine-free infant formula and diet restriction
D) Very-low-protein diet supplemented with thiamine during childhood

Question 12

An NICU nurse is caring for several infants who are being treated for hypothermia.Which baby can be dressed and taken out of the warmer?

A) Skin pale but pink
B) Sucks vigorously
C) Temperature 97.4°F (36.3°C)
D) Temperature 98.2°F (36.7°C)

Question 13

The pediatric nurse is receiving a morning report via phone call on an infant who will be arriving in the neonatal intensive care unit.The report indicates that shoulder dystocia may have occurred during the birth process.The nurse assesses the neonate as at risk for which additional condition?

A) Brachial plexus injury
B) Hyperbilirubinemia
C) Hypoglycemia
D) Intracranial hemorrhage

Question 14

A small-for-gestational-age (SGA)newborn is admitted to the NICU.The nurse notes that the baby's head circumference is in the 68th percentile for gestational age,but the baby's weight is under the 10th percentile.The baby also has a scaphoid abdomen and long fingernails.How does the nurse classify this baby in the handoff report?

A) Asymmetrical intrauterine growth restriction
B) Cold-stressed infant
C) Intrauterine growth retardation
D) Small for gestational age

Question 15

The pediatric nurse explains to the nursing student that respiratory distress syndrome results from a developmental lack of which substance?

A) Calcium
B) Lecithin
C) Magnesium
D) Surfactant

Question 16

A baby with brachial plexus injury is being discharged home.What information should the nurse include on the teaching plan?

A) Encourage the baby to move the arm by holding out toys to reach for.
B) Keep the baby's arm in the sling for 23 out of every 24 hours.
C) Perform passive range-of-motion exercises to affected extremity.
D) Return to the hospital on day 7 for microsurgical repair.

Question 17

An infant who is possibly infected with herpes simplex infection is being dismissed.What medication should the nurse anticipate instructing the parents on giving?

A) Acyclovir (Avirax)
B) Ampicillin (Omnipen)
C) Cephtriaxone (Rocephin)
D) Hydroxyzine (Atarax)

Question 18

A nurse has administered an analgesic to a premature infant in pain.What assessment would indicate to the nurse that the baby's pain is improving?

A) Crunching the forehead
B) Keeps eyes tightly closed
C) Shallow respirations
D) Sleeps after feeding

Question 19

A woman gave birth to an infant weighing 390 g.Which action by the NICU charge nurse is most appropriate?

A) Begin the discharge planning process when the child is admitted.
B) Consult social services to help make arrangements for home care.
C) Consult the palliative care team and admit the infant for comfort care.
D) Prepare for aggressive resuscitation and admission to the NICU.

Question 20

A nurse is preparing to admit a newborn to the NICU who weighs 1,750 g.What classification does the nurse use to describe this infant?

A) Extremely low birth weight
B) Low birth weight
C) Normal birth weight
D) Very low birth weight

Question 21

A newborn baby has a calcium level of 7.1 mg/dL.What information should the nurse provide the parents?

A) Low calcium can cause high blood sugars.
B) Postterm babies are most at risk for this condition.
C) The level will be rechecked at 72 hours.
D) Your baby needs to have a magnesium level check.

Question 22

A nurse sees a baby whose left arm is in a flexed position and is held in place by pinning the cuff of the baby's T-shirt sleeve to the opposite shoulder.What can the nurse conclude about this baby?

A) Broken clavicle
B) Broken wrist
C) Duchenne-Erb paralysis
D) Klumpke paralysis

Question 23

An infant is born with an encephalocele.Which action by the nurse takes priority?

A) Admit the baby to the NICU.
B) Consult the palliative care team.
C) Place warm sterile gauze on the defect.
D) Prepare the infant for surgery.

Question 24

A nurse is caring for a premature infant on oxygen.What action is critical for the infant's safety?

A) Educate the parents to care for an infant on oxygen.
B) Keep the infant in an incubator while on oxygen.
C) Obtain daily chest x-rays to monitor lung maturity.
D) Use the lowest amount of oxygen possible.

Question 25

An infant with gastroesophageal reflux disease (GERD)is being discharged home.Which of the following is the priority topic the nurse plans to include in the teaching plan?

A) Managing a multi-medication regime at home
B) Positioning the infant during feeding and sleeping
C) Type of formula to best prevent episode of GERD
D) When to return for surgical correction of the bowel

Question 26

A premature infant has apnea of prematurity accompanied by bradycardia and desaturation.The infant was started on caffeine citrate (Cafcit),and the results from a blood level have just now returned.The infant's blood level of Cafcit is 2.3 mg/mL.What action by the nurse is most appropriate?

A) Allow infant to grow out of the current Cafcit dose.
B) Document results; maintain cardiorespiratory monitor.
C) Inform parents that this blood level is therapeutic.
D) Prepare for immediate intubation and ventilation.

Question 27

A nurse is seeing a baby with a diagnosed cleft lip.What assessment finding indicates to the nurse that a priority outcome has been met?

A) Absence of infection
B) Appropriate weight gain
C) Interacts at developmental age
D) Normal cranial nerve function

Question 28

A baby has just been born with anencephaly.Which action by the labor and delivery charge nurse takes priority?

A) Admit the baby to the NICU.
B) Consult the palliative care team.
C) Place the infant in protective isolation.
D) Prepare the infant for surgery.

Question 29

A preterm infant was born at 31 weeks and has been admitted to the NICU.The nurse notes expiratory grunting,nasal flaring,and cyanosis on room air.Which laboratory findings would correlate with this condition?

A) PaCO₂: 56 mm Hg
B) PaO₂: 76 mm Hg
C) pH: 7.30
D) SaO₂: 94%

Question 30

A nurse is asked to record preductal and postductal oxygen saturations on an infant with possible persistent pulmonary hypertension.Where does the nurse assess the preductal saturation?

A) Earlobe
B) Left finger
C) Left great toe
D) Right finger

Question 31

A pediatric nurse sees a baby with microcephaly.What action is most important for this nurse to do?

A) Assess the baby's feeding abilities with an adapted nipple.
B) Document head circumference at each visit.
C) Document weight gain at each visit.
D) Review medication administration with parents.

Question 32

A child diagnosed with congenital hypothyroidism is being dismissed from the NICU.What information should the nurse plan to teach the parents?

A) Avoid foods such as fish, milk, or meat-based broth soups.
B) The correct dose of levothyroxine (Synthroid) is 10-15 mg/kg/day.
C) The Correct dose of levothyroxine (Synthroid) is 10-15 mg/kg/day.
D) Regular eye examinations should be undertaken every 6 months.

Question 33

A premature infant has not had a bowel movement,and the nurse assesses abdominal distention after the last feeding.What action by the nurse takes priority?

A) Document the findings in the chart.
B) Facilitate a bowel x-ray.
C) Notify the health-care provider.
D) Place the infant on NPO status.

Question 34

A baby is being discharged home to await surgery to correct a cleft palate.What information do the parents need as the priority?

A) Correct use of the Pavlik harness
B) Dressing changes and wound care
C) Feeding techniques and special nipples
D) How to explain the defect to others

Question 35

A premature infant in the NICU has a sudden increase in head circumference.Which drug does the nurse anticipate administering?

A) Betamethasone (Celestone)
B) Caffeine citrate (Cafcit)
C) Morphine sulfate (Astromorph)
D) Phenobarbital (Luminal Sodium)

Question 36

The nurse caring for small-for-gestational-age (SGA)infants assesses them for attainment of outcomes related to nursing diagnoses.Which assessment finding best demonstrates attainment of priority outcomes?

A) Body temperature of 97.5°F (36.4° C)
B) Gains weight regularly
C) Parents visit daily
D) Skin remains intact

Question 37

The nurse working in labor and delivery knows that which infant is at highest risk of having a long-bone fracture?

A) Intrauterine growth restriction
B) Mother with osteoporosis
C) Multiples with one breech presentation
D) Premature

Question 38

A newborn has a blood glucose level of 188 mg/dL.What further assessment on this baby takes priority?

A) Airway status
B) Breathing status
C) Circulatory status
D) Skin status

Question 39

A postterm newborn is being treated for persistent pulmonary hypertension.Which assessment finding best indicates that a priority outcome has been met?

A) Blood pressure in normal range for age
B) Maintains temperature
C) Oxygen saturation 95%
D) Weight gain

Question 40

A diabetic woman had a cesarean delivery and her baby is noted to have a respiratory rate of 82 breaths/minute with retractions.The baby's blood gas analyses are as follows: pH,7.20; PCO₂,52 mm Hg; PaO₃,80 mm Hg; PHCO₂-,21 mEq/L.What is an important safety measure the nurse should plan to implement when caring for this infant?

A) Ensure the CPAP pressures do not exceed 6 cm H₂O.
B) Maintain secure position of the endotracheal tube with tape.
C) Place the skin temperature sensor over the liver border.
D) Plan to check the baby's blood glucose every 2 hours.

Question 41

A nurse is caring for a baby with neonatal abstinence syndrome.Which of the following medications should the nurse be prepared to give?

A) Chlorpromazine (Thorazine)
B) Clonidine (Catapres)
C) Diazepam (Valium)
D) Phenobarbital (Luminal)
E) Naloxone (Narcan)

Question 42

A nurse is assessing a newborn and hears bowel sounds in the infant's chest area.What other finding should the nurse specifically assess for?

A) Clubbed fingernails
B) Cyanosis
C) Genital abnormalities
D) Normal stools

Question 43

An infant is born weighing 6 lb,1 oz and has gastroschisis.The nurse anticipates running this infant's IV fluids at a rate of ____________________ mL/hour.

Question 44

A preterm infant has been started on IV fluids.When assessing the patient,which findings would indicate to the nurse that goals for this therapy are being met?

A) Intake greater than output by 24 hours
B) Lack of tremors and irritability
C) Respiratory rate of 35 breaths/minute
D) Urine output of 2/5 mL/kg/hour
E) Urine specific gravity of < 1.012

Question 45

A nurse monitors all newborns in the NICU for hypoglycemia.Which manifestations could indicate hypoglycemia in one of the babies?

A) Apneic episodes
B) None (asymptomatic)
C) Eye rolling
D) Lethargy
E) Palmar sweating

Question 46

A baby was born 4 days ago at 34 weeks' gestation and is receiving phototherapy for neonatal jaundice.The baby has symptoms of temperature instability,dry skin,poor feeding,lethargy,and irritability.What are the nurse's priority nursing interventions?

A) Assess the baby's temperature to check for hypothermia.
B) Check to make sure the infant's face mask stays in place.
C) Educate the mother to feed the child every 2 hours.
D) Verify laboratory results to check for hypoglycemia.
E) Verify laboratory results to check for hypomagnesemia.

Question 47

A woman in labor takes high-dose steroids for a connective tissue disorder.She takes no other medications.The nurse educates her that her baby could be at risk for which of the following conditions?

A) Cold stress
B) Hypoglycemia
C) Intrauterine growth restriction
D) Large for gestational age
E) Polycythemia

Question 48

A nurse preceptor of a student nurse explains that although a high-risk newborn can have complications in any body system,the systems most often impacted include which of the following?

A) Circulatory
B) Integumentary
C) Neurological
D) Renal
E) Respiratory

Question 49

A nurse is caring for a premature newborn.What interventions does the nurse include on the baby's care plan?

A) Bathe the baby daily with mild soap.
B) Cradle baby in a linen nest in flexed position.
C) Monitor response to warming measures.
D) Reposition the baby every 4 hours.
E) Weigh the baby once a week.

Question 50

An infant is born at 35 weeks and 3 days.How would the nurse document this gestational age? ____________________

Question 51

A premature infant was delivered after a prolonged labor with rupture of the maternal membranes >18 hours.The infant's weight is 6 lb,1 oz (2.75 kg).What assessment finding would require the nurse to intervene immediately?

A) Blood pressure reading of 60/35 mm Hg
B) Skin temperature reading of 96.8°F (36°C)
C) Unconjugated bilirubin level of 1.0 mg/dL
D) White blood cell count of 12,500/mm3

Question 52

A premature newborn has a pulse pressure of 33 mm Hg.What action by the nurse takes priority?

A) Assess the infant for patent ductus arteriosus.
B) Ensure the blood pressure cuff is the right size.
C) Increase fluids to 1.5 times the maintenance rate.
D) Sedate the baby to prevent fighting the ventilator.

Question 53

An infant weighing 3 lb,7 oz has apnea of prematurity.The nurse needs to administer the loading dose of caffeine citrate (Cafcit).The dose for this is____________________ mg.

Question 54

A premature infant is born and admitted to the NICU.A student nurse questions why the primary nurse is starting to plan discharge teaching so early.Which response by the nurse is best?

A) "All these babies have the same needs, so discharge planning here is pretty routine."
B) "By starting early I can ensure that social work and specialty nurses can see the baby."
C) "I'm not really planning the baby's discharge; I'm just writing some notes about it."
D) "The parents have so much to learn we have to start planning discharge on admission."

Question 55

An experienced NICU nurse is explaining to a new nurse why premature infants have such great nutritional needs.What information should the experienced nurse include?

A) The pancreas doesn't produce enough insulin for food use.
B) Their guts are premature and don't absorb nutrients.
C) They haven't built up stores in utero like term babies.
D) They have complications that increase their metabolic rate.
E) They lose 10% of their already-low weight at birth.

Question 56

A nurse is explaining to a student that sudden infant death syndrome (SIDS)has been reduced due mostly to what trend?

A) A decrease in preterm births
B) Decreased maternal smoking
C) Fewer drug-addicted mothers
D) The "Back to Sleep" campaign

Question 57

An infant has been admitted to the neonatal intensive care unit because of meconium-aspiration syndrome and related complications.The pediatric nurse assesses the patient frequently for which complication?

A) Hemothorax
B) Pneumomediastinum
C) Pneumonia
D) Pneumothorax
E) Respiratory distress syndrome.

Question 58

A baby is admitted with a long-bone fracture.What nursing actions are appropriate in the care of this baby?

A) Elevation of the extremity
B) Frequent neurovascular checks
C) Heat therapy to reduce muscle spasm
D) Immobilization while healing
E) Traction at 0.1 kg per 1 kg/baby's weight

Question 59

A nurse is documenting the types of high-risk newborns on the unit.Which infants would be classified as preterm? (Select all that apply).

A) weeks
B) weeks
C) weeks
D) weeks
E) weeks