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

Question 1

The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest priority?

A) Risk for Impaired Elimination
B) Risk for Ineffective Airway Clearance
C) Impaired Oxygenation
D) Enhanced Family Coping

Answer 1

Impaired Oxygenation

Question 2

The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. Which nursing action has the highest priority?

A) Obtain a blood calcium level.
B) Take the newborn's temperature.
C) Obtain a bilirubin level.
D) Place a pulse oximeter on the newborn.

Answer 2

Obtain a blood calcium level.

Question 3

The nurse is caring for the newborn of a diabetic mother. Which of the following should be included in the nurse's plan of care for this newborn?

A) Offer more frequent feedings.
B) Administer an intravenous infusion of glucose.
C) Assess for hypercalcemia.
D) Assess for hyperbilirubinemia immediately after birth.

Answer 3

Offer more frequent feedings.

Question 4

Type: SEQ The nurse is preparing to gavage-feed a preterm infant. Put the steps in the correct order, creating a five-digit number. Standard Text: Click and drag the options below to move them up or down.

A) Check pH of the gastric aspirate.
B) Elevate the syringe 6-8 inches above the infant's head.
C) Measure from the tip of the nose to the earlobe to the xyphoid process.
D) Clear the tubing with 2-3 ml of sterile water.
E) Lubricate the tube by dipping it into sterile water.
F) non of the above

Question 5

A 38-week newborn is found to be small for gestational age (SGA). Which nursing intervention should be included in the care of this newborn?

A) Monitor for feeding difficulties.
B) Assess for facial paralysis.
C) Monitor for signs of hyperglycemia.
D) Maintain a warm environment.

Question 6

A NICU nurse plans care for a preterm newborn that will provide opportunities for development. Which interventions support development in a preterm newborn in a NICU?

A) Schedule care throughout the day.
B) Silence alarms quickly.
C) Place a blanket over the top portion of the incubator.
D) Do not offer a pacifier.
E) Dim the lights.

Question 7

The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39 mg/dl. What should the nurse include in the plan of care for this newborn?

A) Offer early feedings with formula or breast milk.
B) Provide glucose water exclusively.
C) Evaluate blood glucose levels at 12 hours after birth.
D) Assess for hypothermia.

Question 8

The nurse assesses the gestational age of a newborn and informs the parents that the newborn is premature. All of the following assessment findings are congruent with prematurity except:

A) Cry is weak and feeble.
B) Clitoris and labia minora are prominent.
C) Strong sucking reflex.
D) Lanugo is plentiful.

Question 9

The nurse is caring for an infant of a diabetic mother. Which potential complications would the nurse consider in planning care for this newborn? Note: Credit will be given if all correct choices and no incorrect choices are selected. Standard Text:

A) Tremors
B) Hyperglycemia
C) Hyperbilirubinemia
D) Respiratory distress syndrome
E) Birth trauma

Question 10

The mother of a premature newborn questions why a gavage feeding catheter is placed in the mouth of the newborn and not in the nose. The nurse's best response is:

A) "Most newborns are nose breathers."
B) "The tube will elicit the sucking reflex."
C) "A smaller catheter is preferred for feedings."
D) "Most newborns are mouth breathers."

Question 11

In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include:

A) Volume of urine output.
B) Weight.
C) Blood pH.
D) Head circumference.
E) Bowel sounds.

Question 12

A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago. The infant's blood sugar is 47 mg/dl. The best nursing action is to:

A) Recheck the blood sugar in 4 hours.
B) Begin an IV of 10% dextrose.
C) Feed the baby 1 ounce of formula.
D) Document the findings in the chart.

Question 13

The nurse caring for a postterm newborn would not perform the intervention of:

A) Providing warmth.
B) Frequently monitoring blood glucose.
C) Observing respiratory status.
D) Restricting breastfeeding.

Question 14

The nurse is caring for several pregnant patients. Which patient should the nurse anticipate is most likely to have a newborn at risk for mortality or morbidity?

A) 37-year-old G8 P2323, works in a chemical factory
B) 23-year-old primip, low socioeconomic status, unmarried
C) 16-year-old primip, began prenatal care at 30 weeks.
D) 28-year-old G2 P1001, history of gestational diabetes

Question 15

The neonatal special care unit nurse is overseeing the care provided by a nurse new to the unit. Which action requires immediate intervention? The new nurse:

A) Holds the infant after giving a gavage feeding.
B) Auscultates lung sounds bilaterally.
C) Provides care when the baby is awake.
D) Gives the feeding with room-temperature formula.

Question 16

The pregnant patient at 41 weeks is scheduled for labor induction. She asks the nurse whether induction is really necessary. What response by the nurse is best?

A) "Babies can develop postmaturity syndrome, which increases their chances of having complications after birth."
B) "When infants are born 2 or more weeks after their due date, they have meconium in the amniotic fluid."
C) "Sometimes the placenta ages excessively, and we want to take care of that problem before it happens."
D) "The doctor wants to be proactive in preventing any problems with your baby if he gets any bigger."

Question 17

The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces). The head circumference and length are in the 25th percentile. What statement would the nurse expect to find in the chart?

A) Preterm appropriate for gestational age, symmetrical IUGR
B) Term small for gestational age, symmetrical IUGR
C) Preterm small for gestational age, asymmetrical IUGR
D) Preterm appropriate for gestational age, asymmetrical IUGR

Question 18

The nurse is working with parents who have just experienced the birth of their first child at 34 weeks. Which statements by the parents indicate that additional teaching is needed?

A) "Our baby will be in an isolette to keep him warm."
B) "Breathing might be harder for our baby because he is early."
C) "The growth of our baby will be faster than if he were term."
D) "Tube feedings will be required because his stomach is small."
E) "Because he came early, he will not produce urine for 2 days."

Question 19

A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk for:

A) Visual impairment.
B) Hypercalcemia.
C) Cerebral palsy.
D) Sensitive gag reflex.

Question 20

The nurse is teaching the parents of an infant with an inborn error of metabolism how to care for the infant at home. Teaching includes information about:

A) Specially prepared formulas.
B) Cataract problems.
C) Respiratory problems.
D) Administration of thyroid medication.

Question 21

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

A) Measure head circumference daily.
B) Assess for bulging fontanelles.
C) Avoid position changes.
D) Watch for signs of infection.
E) Use a sheepskin in pillow under the head.

Question 22

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

A) Hyperirritability
B) Decreased muscle tone
C) Exaggerated reflexes
D) Depressed respiratory effort
E) Transient tachypnea

Question 23

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

A) "Our baby's heart murmur is from this syndrome."
B) "He might be a fussy baby because of this."
C) "His face looks like it does due to this problem."
D) "Cuddling and rocking will help him stay calm."

Question 24

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?

A) "With this defect, not enough of the blood circulates through the lungs, leading to a lack of oxygen in the baby's body."
B) "The baby's aorta has a narrowing in a section near the heart that makes the left side of the heart work harder."
C) "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides of the heart."
D) "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner than normal."

Question 25

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

A) Apical heart rate of 140 beats per minute
B) Respiratory rate of 40
C) Acrocyanosis
D) Cyanosis of the buccal membranes

Question 26

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

A) Occasional watery stools
B) Spitting up after feeding
C) Unrelieved irritability
D) Positive Babinski's reflex

Question 27

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

A) Cyanosis
B) Heart murmur
C) Bradycardia
D) Diaphoresis
E) Tachypnea

Question 28

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?

A) Use proper hand-washing technique.
B) Provide three feedings per day.
C) Place soiled diapers in a sealed plastic bag.
D) Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change.
E) Take the temperature rectally.

Question 29

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

A) Altered Nutrition: More than Body Requirements
B) Risk for Impaired Skin Integrity
C) Risk for Infection
D) Impaired Physical Mobility
E) Sleep Pattern Disturbance

Question 30

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?

A) Do not add food supplements to the baby's diet.
B) Place soiled diapers in a sealed plastic bag.
C) Wash soiled linens in cool water with bleach.
D) Put the infant in sunlight through a window.

Question 31

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?

A) "This condition occurs more frequently among Japanese people."
B) "We must be very careful to avoid most proteins, to prevent brain damage."
C) "Carbohydrates can cause our baby to develop cataracts and liver damage."
D) "Our baby's thyroid gland isn't functioning properly."

Question 32

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

A) Allow extra time with feedings.
B) Assign different personnel to the newborn each day.
C) Place the newborn in a well-lit room.
D) Monitor for hyperthermia.

Question 33

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

A) Place the newborn in a prone position.
B) Limit feedings to three a day to decrease diarrhea.
C) Place the infant supine and operate a home apnea-monitoring system.
D) Wean the newborn off the pacifier.

Question 34

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:

A) Oomphalocele.
B) Gastroschisis.
C) Diaphragmatic hernia.
D) Myelomeningocele.

Question 35

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

A) Test with an anti-HIV-1 antibody assay at 8 months.
B) Begin prophylactic AZT (Zidovudine) administration.
C) Provide 4-5 large feedings throughout the day.
D) Encourage the mother to breastfeed the child.