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

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?
1) Assess blood pressure.
2) Deep suction the airways.
3) Begin chest compressions.
4) Begin bag-and-mask ventilation.

Answer 1

4

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?
1) Intravenous acyclovir (Zovirax) and contact precautions
2) Cultures of blood and cerebrospinal fluid and serial chest x-rays every 12 hours
3) Parental rooming-in and four intramuscular injections of penicillin
4) Meticulous hand washing and antibiotic eye ointment administration

Answer 2

1

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?
1) Increased PCO₂
2) Increased urination
3) Decreased urine output
4) Increased pulmonary vascular resistance

Answer 3

2

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?
1) Assesses temperature every 6 hours
2) Assesses urine specific gravity with each voiding
3) Removes eye coverings to help keep the baby calm
4) Removes the infant from the Isolette for diaper changes

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.
1) Eyelid swelling
2) Yellow discharge
3) Eye inflammation
4) Purulent discharge
5) Corneal ulcerations

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.
1) Pallor
2) Tachypnea
3) Tachycardia
4) Elevated blood pressure
5) Capillary refill 6 seconds

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.
1) Perform chest compressions.
2) Administer epinephrine.
3) Rub the infant's back with a blanket.
4) Administer 21% oxygen in a positive-pressure ventilator.
5) Administer 100% oxygen in a positive-pressure ventilator.

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?
1) Pathologic jaundice
2) Physiologic jaundice
3) Acute bilirubin encephalopathy
4) Hemolytic disease of the newborn

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.)

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?
1) Have the mother breastfeed the infant.
2) Start an IV with D₅W dextrose solution.
3) Start an IV with D₁₀W dextrose solution.
4) Wait 30 minutes and retest plasma glucose levels.

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

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?
1) Wash hands before holding the infant.
2) The infant has tubes and monitoring equipment in place.
3) The appearance of the different machines and tubes attached to the infant.
4) Avoid touching the infant because the baby's skin is fragile and could be easily hurt.

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?
1) Prematurity of the neonate
2) Respiratory distress syndrome
3) Meconium aspiration syndrome
4) Transient tachypnea of the newborn

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.
1) Dopamine infusion
2) High-pressure ventilation
3) High-level oxygen therapy
4) Surfactant replacement therapy
5) High-volume intravenous fluids

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.
1) Refusing to touch the infant
2) Grimacing when holding the infant
3) Expressing fear of taking the infant home
4) Asking staff questions about the infant's care
5) Blaming spouse for the infant's health problems

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?
1) "The RhoGAM you received at 28 weeks' gestation did not prevent alloimmunization."
2) "Your body has made antibodies against the baby's blood that are destroying her red blood cells."
3) ""The red blood cells of your baby are breaking down because you both have type O blood."
4) "Your baby's liver is too immature to eliminate the red blood cells that are no longer needed."

Question 17

A newborn is diagnosed with sepsis. What finding should the nurse use to suspect this health problem?
1) Irritability and flushing of the skin at 8 hours of age
2) Respiratory distress syndrome developed 48 hours after birth
3) Bradycardia and tachypnea develop when the infant is 36 hours old
4) Temperature of 97.0°F 2 hours after warming the infant from 97.4°F

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.

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.)

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?
1) Blood glucose level of 45
2) Vasoconstriction and pallor
3) Room temperature IV running
4) Positioned under radiant warmer