Deck 26: Nursing Care of a Family With a High-Risk Newborn

Question 1

The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient?

A) Glucose water
B) 20 calories per ounce
C) 22 calories per ounce
D) Iron supplemented

Answer 1

22 calories per ounce

Question 2

The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered?

A) Alveolar collapse on expiration
B) Bronchial constriction from room air
C) Wheezing from excess fluid accumulation
D) Inspiratory constriction from air contaminants

Answer 2

Alveolar collapse on expiration

Question 3

Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which nursing diagnosis is this intervention addressing?

A) Ineffective thermoregulation related to immaturity
B) Risk for imbalanced nutrition, less than body requirements
C) Risk for deficient fluid volume related to insensible water loss
D) Impaired gas exchange related to immature pulmonary functioning

Answer 3

Ineffective thermoregulation related to immaturity

Question 4

The nurse manager of a labor and delivery unit is reviewing the skill set needed for the nursing staff to meet the 2020 National Health Goals regarding preterm births. Which skills should the manager validate that the nursing staff has to meet these goals? (Select all that apply.)

A) Resuscitation at birth
B) Actions to prevent apnea
C) Identify characteristics of preterm labor
D) Actions to prevent maternal hypotension
E) Interventions to prevent intraventricular hemorrhage

Question 5

The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.)

A) Provide audio stimulation with the use of music.
B) Stop procedures if the infant shows signs of distress.
C) Provide a nest with blankets to provide a sense of security.
D) Provide tactile stimulation by tickling the bottom of the feet.
E) Provide care consistently so the infant develops sleep/wake cycles.

Question 6

While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply.)

A) Grunting
B) Nasal flaring
C) Intercostal retractions
D) Oxygen saturation 96%
E) Increasing respiratory rate

Question 7

The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant?

A) To detect rebound hypoglycemia
B) To determine insulin dosage to administer
C) To explain the effects of maternal hyperglycemia on the baby
D) To estimate the amount of calories to provide the infant through formula

Question 8

A preterm infant is receiving oxygen to maintain respiratory status. When assessing this patient, at which level should the nurse maintain oxygenation to prevent retinopathy of prematurity?

A) 40 mmHg
B) 50 mmHg
C) 100 mmHg
D) 180 mmHg

Question 9

The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective?

A) Newborn is placed on the back to sleep.
B) Mother removes a pacifier from the baby's mouth.
C) The baby is on an every-2-hour formula-feeding schedule.
D) Parents signed a waiver refusing routine immunizations after birth.

Question 10

A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid balance. What did the nurse assess that supports this nursing diagnosis? (Select all that apply.)

A) Specific gravity of 1.022
B) Respiratory rate of 40 breaths/min
C) Urine output less than 2 ml/kg/hr
D) Heart rate of 135 beats/min
E) Abdominal skin temperature of 96.9°F

Question 11

The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem?

A) "Once the infection clears up, the baby will be fine."
B) "We will need to plan for special care to help with learning disabilities."
C) "In a few months, more brain tissue will grow to fill in the hollow areas in the brain."
D) "In a few months, the baby will need to have physical therapy to train muscles to work."

Question 12

The nurse is caring for a small-for-gestational-age infant born to a drug-dependent patient. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? (Select all that apply.)

A) Tremors
B) Convulsions
C) High-pitched cry
D) Constant movement
E) Sluggish respiratory rate

Question 13

The nurse is instructing the parents of a preterm infant about the care the infant will receive within the neonatal intensive care unit. What should the nurse include when teaching the parents at this time? (Select all that apply.)

A) Bring in a small toy to be placed in the baby's bassinette.
B) Coordinate the times to visit the baby with the primary nurse.
C) Ask the nurse to explain equipment and the purpose for their use.
D) Write down the name of the baby's primary nurse and primary care provider.
E) Limit telephone calls to the care area since the nurses will not be able to respond.

Question 14

In which position should the nurse place a newborn to administer oxygen by bag and mask?

A) Trendelenburg
B) On the back with the neck slightly flexed
C) On the back with the head slightly extended
D) Position is unimportant as long as the tongue is pulled forward.

Question 15

The nurse is preparing to administer surfactant (Survanta) 4 mg/kg every 12 hours for 2 days. The newborn weighs 2,300 g. How many milligram of the medication will the newborn receive for all of the doses? (Numeric value only. Round to the nearest tenth decimal point.)