Question 1

A patient in labor is found to have meconium-stained amniotic fluid upon rupture of membranes. At delivery, the nurse finds the infant to have depressed respirations and a heart rate of

Accepted Answer

Direct tracheal suctioning by specially trained personnel is recommended for infants with meconium-stained amniotic fluid who are born with depressed respirations and heart rate, to prevent meconium aspiration syndrome.

Question 2

The patient with blood type O Rh-negative has given birth to an infant with blood type O Rh-positive. The infant has become visibly jaundiced at 12 hours of age. The mother asks why this is happening. The best response by the nurse is:

Accepted Answer

The mother's body has made antibodies against the baby's blood because of incompatibility between the mother's O Rh-negative blood and the baby's O Rh-positive blood. This causes the destruction of the baby's red blood cells, leading to jaundice. This is known as hemolytic disease of the newborn.

Question 3

The nurse assesses a 12-hour-old newborn's serum bilirubin level and finds it to be 14 mg/dl. What nursing intervention would be included in the plan of care for this newborn?

Accepted Answer

A serum bilirubin level of 14 mg/dl in a 12-hour-old newborn indicates the need for phototherapy to prevent complications from hyperbilirubinemia. Continuing to observe without intervention could lead to further elevation of the bilirubin level and possible neurotoxic effects. Blood exchange transfusion is a treatment option for severe cases of hyperbilirubinemia, but it is not typically necessary at a bilirubin level of 14 mg/dl. There is no need to stop breastfeeding unless other interventions have failed or there is an underlying issue causing the hyperbilirubinemia.

Question 4

The nurse is caring for a jaundiced infant receiving bank light phototherapy in an isolette. Which finding requires an immediate intervention?

Accepted Answer

Monitoring the infant's temperature is an essential aspect of care during phototherapy. Hyperthermia can occur due to dehydration or the effect of light sources, while hypothermia may occur from inattention to environmental temperature. Therefore, any temperature changes out of the normal range require immediate intervention. The normal axillary temperature for infants ranges from 36.5°C to 37.5°C (97.7°F–99.5°F). The other options listed are appropriate aspects of care for an infant receiving phototherapy, and therefore do not require immediate intervention.

Question 5

The nurse prepares to admit to the nursery a newborn whose mother had meconium-stained amniotic fluid. The nurse knows this newborn might require:

Accepted Answer

Meconium-stained amniotic fluid increases the risk of aspiration, which can lead to airway obstruction and respiratory distress. Therefore, initial resuscitation may be necessary to ensure the newborn is stable and breathing adequately.

Question 6

The nurse is observing a student nurse care for a neonate undergoing intensive phototherapy. Which action by the student nurse indicates an understanding of how to provide this care?

Accepted Answer

Monitoring urine-specific gravity helps assess hydration status, which is crucial during intensive phototherapy as it can lead to dehydration.

Question 7

The nurse is caring for a newborn with jaundice. The parents why the newborn is not under phototherapy lights. The nurse explains that the fiber optic blanket is beneficial because:

Accepted Answer

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

Question 8

A nursing instructor is demonstrating how to perform a heel stick on a newborn. To obtain an accurate capillary hematocrit reading, the nursing instructor tells the students to:

Accepted Answer

The answer of A nursing instructor is demonstrating how to...

Question 9

The nurse is caring for an infant who was delivered in a car on the way to the hospital and who has developed cold stress. Which finding requires immediate intervention?

Accepted Answer

Room-temperature IV fluids can exacerbate cold stress in an infant by further lowering the body temperature. Immediate intervention is required to warm the fluids to help stabilize the infant's temperature.

Question 10

During newborn resuscitation, the nurse evaluates the effectiveness of bag-and-mask ventilations by:

Accepted Answer

The most reliable way to evaluate the effectiveness of bag-and-mask ventilations during newborn resuscitation is by assessing the rise and fall of the chest. This indicates that air is reaching the lungs and the baby is being adequately ventilated. Sudden wakefulness, urinary output, and adequate thermoregulation are not reliable indicators of effective ventilation.

Question 11

A nurse is caring for a newborn on a ventilator who has respiratory distress syndrome (RDS). The nurse informs the parents that the newborn is improving. Which data support the nurse's assessment?

Accepted Answer

Increased urination is a sign of improving respiratory distress syndrome as it indicates that the newborn is able to excrete excess fluids, which is often a sign of decreasing pulmonary edema. Decreased urine output (A), increased pulmonary vascular resistance (B), and increased PCO2 (C) are all signs of worsening respiratory distress syndrome.

Question 12

Which nursing intervention is appropriate in the management of the preterm infant with hypothermia?

Accepted Answer

Warming the baby slowly and maintaining a neutral thermal environment are appropriate interventions for managing hypothermia in preterm infants.

Question 13

The nurse notes that a 36-hour-old newborn's serum bilirubin level has increased from 14 mg/dl to 16.6 mg/dl in an 8-hour period. What nursing intervention would be included in the plan of care for this newborn?

Accepted Answer

An increase in serum bilirubin level of more than 5 mg/dl in an 8-hour period is significant and requires immediate intervention. Phototherapy is the initial treatment for hyperbilirubinemia in newborns. Continuing to observe is not sufficient in this case, and a blood exchange transfusion is typically reserved for severe cases. There is no indication to stop breastfeeding without further assessment and intervention.

Question 14

Which assessment findings by the nurse would require obtaining a blood glucose level on the newborn?

Accepted Answer

Jitteriness can be a sign of hypoglycemia, which is a condition where the newborn's blood glucose level is low. Therefore, obtaining a blood glucose level is necessary to assess for and treat hypoglycemia. Sucking on fingers and a lusty cry are normal newborn behaviors and an axillary temperature of 98°F is within the normal range.

Question 15

The nurse is assessing a 2-hour-old newborn delivered by cesarean at 38 weeks. The amniotic fluid was clear. The mother had preeclampsia. The newborn has a respiratory rate of 80, is grunting, and has nasal flaring. What is the most likely cause of this infant's condition?

Accepted Answer

Transient tachypnea of the newborn is the most likely cause of the infant's condition, characterized by rapid breathing, grunting, and nasal flaring, often seen in infants delivered by cesarean section due to delayed absorption of fetal lung fluid.

Question 16

The nurse is assessing a newborn diagnosed with physiologic jaundice. Which findings would the nurse expect? Note; Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text:

Accepted Answer

Physiologic jaundice typically appears after 24 hours of life and manifests as yellowish coloration of the sclera of the eyes. Cephalhematoma or excessive bruising and cyanosis are not typically associated with physiologic jaundice. Jaundice may be present within the first 24 hours of life in the case of pathological jaundice, which would require further investigation and treatment.

Question 17

A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). The nurse bases this assessment on all of the following data except:

Accepted Answer

While a respiratory rate of 40 during sleep may be a sign of respiratory distress, it is not specific to RDS and can be present in other respiratory conditions. The presence of grunting respirations, nasal flaring, and chest retractions are all classic signs of RDS.

Question 18

A laboring mother has recurrent late decelerations. At birth, the infant has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?

Accepted Answer

The infant is showing signs of respiratory distress and requires immediate intervention to begin breathing. The best nursing action is to begin bag-and-mask ventilation.

Question 19

When planning care for the premature newborn diagnosed with respiratory distress syndrome, which potential complications would the nurse anticipate?

Accepted Answer

The answer of When planning care for the premature newborn...

Question 20

A newborn is receiving phototherapy. Which intervention by the nurse would be most important?

Accepted Answer

Phototherapy can increase the risk of dehydration in a newborn, so it is important for the nurse to assess the hydration status regularly and intervene as needed to maintain adequate hydration. Measuring head circumference and testing stool guaiac are important interventions but are not specific to phototherapy. Encouraging the mother to stop breastfeeding is not recommended as breast milk is the best source of nutrition for the newborn.

Quiz 34: The Newborn at Risk: Birth-Related Stressors