Question 1

The nurse is caring for a newborn with full fontanelles and "setting sun" eyes. Which nursing interventions should be included in the care plan?

Accepted Answer

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

Question 2

The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings would be typical for this newborn?

Accepted Answer

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

Question 3

Parents have been told their child has fetal alcohol syndrome. Which statement by a parent indicates that additional teaching is required?

Accepted Answer

Fetal alcohol syndrome (FAS) is a condition in a child that results from alcohol exposure during the mother's pregnancy. FAS causes brain damage and growth problems. The problems caused by fetal alcohol syndrome vary from child to child, but defects caused by fetal alcohol syndrome are not reversible. A statement that cuddling and rocking will help the child stay calm does not reflect an understanding of the complexities and challenges of managing symptoms of FAS. While physical comfort measures like cuddling and rocking can be soothing to many babies, this statement suggests a lack of understanding of the potential behavioral and neurological issues associated with FAS that may require more specialized interventions beyond typical soothing techniques.

Question 4

The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents do not seem to understand the explanation given by the physician. What statement by the nurse is best?

Accepted Answer

Option A explains the condition in the simplest possible terms, using language that is easy to understand. It also highlights the key consequence of the defect, which is a lack of oxygen. Options B, C, and D use medical jargon that may be confusing, and do not provide a clear picture of the condition or its impacts.

Question 5

The nurse is analyzing assessment findings on four newborns. Which finding might suggest a congenital heart defect?

Accepted Answer

Cyanosis of the buccal membranes can be a sign of decreased oxygenation and could indicate a congenital heart defect.

Question 6

The nurse is assessing a drug-dependent newborn. Which symptom would require further assessment by the nurse?

Accepted Answer

Unrelieved irritability in a drug-dependent newborn can be a sign of withdrawal and would require further assessment and possible intervention. Occasional watery stools and spitting up after feeding are common in newborns and may not indicate a significant issue. Positive Babinski's reflex is a normal finding in newborns.

Question 7

Which assessment findings would lead the nurse to suspect that a newborn might have a congenital heart defect?

Accepted Answer

Cyanosis, heart murmur, diaphoresis, and tachypnea are common signs of congenital heart defects in newborns. Cyanosis indicates poor oxygenation, a heart murmur can suggest abnormal blood flow, diaphoresis may occur due to increased effort to circulate blood, and tachypnea indicates respiratory distress. Bradycardia is less commonly associated with congenital heart defects in newborns.

Question 8

The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for the newborn at home. Which instructions should the nurse emphasize?

Accepted Answer

Proper hand-washing technique is important to prevent the spread of infection. Placing soiled diapers in a sealed plastic bag will limit the potential spread of infectious materials. Cleansing the diaper changing area with a 1:10 bleach solution after each diaper change will help to further prevent the spread of infection. Providing three feedings per day is not an appropriate instruction, as newborns typically require frequent feedings. Taking the temperature rectally is not necessary for routine care and may increase the risk of exposure to infectious materials.

Question 9

Which nursing diagnoses would the nurse apply to a newborn exposed to HIV/AIDS?

Accepted Answer

The answer of Which nursing diagnoses would the nurse apply...

Question 10

An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The nurse is planning discharge teaching for the foster parents on how to care for the newborn at home. Which instructions should the nurse include?

Accepted Answer

Soiled diapers should be placed in a sealed plastic bag to prevent the spread of infection and ensure proper hygiene.

Question 11

The nurse is preparing an educational session on phenylketonuria for a family whose neonate has been diagnosed with the condition. Which statement by a parent indicates that teaching was effective?

Accepted Answer

Phenylketonuria (PKU) is a genetic disorder characterized by the inability to break down the amino acid phenylalanine, which is found in proteins. Consuming too much phenylalanine can lead to brain damage in individuals with PKU. Therefore, a diet low in phenylalanine is essential to prevent this outcome, which is correctly understood by the parent's statement in option B.

Question 12

In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would the nurse include?

Accepted Answer

Infants with FAS may have difficulty with feeding due to irritability or poor coordination, so allowing extra time for feedings can improve intake and growth. Assigning different personnel each day can be unsettling for the infant, who may benefit from consistency in care providers. Placing the newborn in a well-lit room may increase stimulation and agitation, which can exacerbate FAS symptoms. Monitoring for hyperthermia is important for all newborns but is not specific to FAS care. Therefore, the best intervention to include in planning care for the FAS newborn is allowing extra time with feedings.

Question 13

During discharge planning for a drug-dependent newborn, the nurse explains to the mother how to:

Accepted Answer

Placing the infant supine and operating a home apnea-monitoring system is the best choice for discharge planning for a drug-dependent newborn. These infants are at risk for sudden infant death syndrome (SIDS) and apnea, so monitoring the infant's breathing is important. Placing the newborn in a prone position increases the risk of SIDS, and limiting feedings and weaning off the pacifier are not specific to the needs of a drug-dependent newborn.

Question 14

The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus, and is positioned in a prone position. The nurse is especially careful to cleanse all stool after bowel movements. This care is most appropriate for an infant born with:

Accepted Answer

Myelomeningocele is a neural tube defect that often results in hydrocephalus. The prone position is recommended to promote spinal cord development, and careful cleansing is necessary to prevent infection and potential complications. Oomphalocele and gastroschisis are both abdominal wall defects, and a diaphragmatic hernia is a defect in the diaphragm muscle. These conditions do not typically result in hydrocephalus or require prone positioning and special care for fecal cleansing.

Question 15

A mother who is HIV-positive has given birth to a term female. What plan of care is most appropriate for this infant?

Accepted Answer

Beginning prophylactic AZT (Zidovudine) administration is the most appropriate plan of care for an infant born to an HIV-positive mother. The medication can reduce the risk of mother-to-child transmission of HIV. Testing with an anti-HIV-1 antibody assay at 8 months may miss early infection, and providing 4-5 large feedings throughout the day or encouraging the mother to breastfeed the child can increase the chances of transmission.

Quiz 33: The Newborn at Risk: Conditions Present at Birth