Ricci Chapter 23 - Test Bank - 4th Edition

1. The nurse is teaching a group of parents who have preterm newborns about the differences

between a full-term newborn and a preterm newborn. Which characteristic would the nurse

describe as associated with a preterm newborn but not a term newborn?

A. fewer visible blood vessels through the skin

B. more subcutaneous fat in the neck and abdomen

C. well-developed flexor muscles in the extremities

D. greater body surface area in proportion to weight

Answer: D

Rationale: Preterm newborns have large body surface areas compared to weight, which allows an

increased transfer of heat from their bodies to the environment. Preterm newborns often have

thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle

tone.

2. A nurse is assessing a postterm newborn. Which finding would the nurse correlate with this

gestational age variation?

A. moist, supple, plum skin appearance

B. abundant lanugo and vernix

C. thin umbilical cord

D. absence of sole creases

Answer: C

Rationale: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled

skin; limited vernix and lanugo; and creases covering the entire soles of the feet.

3. The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU)

are coming to visit for the first time. The newborn is receiving mechanical ventilation, intravenous fluids and medications and is being monitored electronically by various devices.

Which action by the nurse would be most appropriate?

A. Suggest that the parents stay for just a few minutes to reduce their anxiety.

B. Reassure them that their newborn is progressing well.

C. Encourage the parents to touch their preterm newborn.

D. Discuss the care they will be giving the newborn upon discharge.

Answer: C

Rationale: The NICU environment can be overwhelming. Therefore, the nurse should address

their reactions and explain all the equipment being used. On entering the NICU, the nurse should

encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the

parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment.

The parents should be allowed to stay for as long as they feel comfortable. Reassurance,

although helpful, may be false reassurance at this time. Discussing discharge care can be done

later once the newborn's status improves and plans for discharge are initiated.

4. Rapid assessment of a newborn indicates the need for resuscitation. The newborn has copious

secretiohs. The newborn is dried and placed under a radiant warmer. Which action would the

nurse do next?

A. Intubate with an appropriate-sized endotracheal tube.

B. Give chest compressions at a rate of 80 times per minute.

C. Administer epinephrine intravenously.

D. Clear the airway with a bulb syringe.

Answer: D

Rationale: After placing the newborn's head in a neutral position, the nurse would clear the

airway with a bulb syringe or suction. This is followed by assessment of breathing and bagging if

needed, placing a pulse oximeter, ventilating the newborn, assessing the heart rate and giving

chest compressions if needed, and then admnistering epinephrine and/or volume expansion if

needed.

5. The nurse prepares to assess a newborn who is considered to be large-for-gestational-age

(LGA). Which characteristic would the nurse correlate with this gestational age variation?

A. strong, brisk motor skills

B. difficulty in arousing to a quiet alert state

C. birthweight of 7 lb, 14 oz (3,572 g)

D. wasted appearance of extremities

Answer: B

Rationale: LGA newborns typically are more difficult to arouse to a quiet alert state. They have

poor motor skills, have a large body that appears plump and full-sized, and usually weigh more

than 8 lb, 13 oz (3,997 g) at term.

6. A preterm newborn has received large concentrations of oxygen therapy during a 3-month stay

in the NICU. As the newborn is prepared to be discharged home, the nurse anticipates a referral

for which specialist?

A. ophthalmologist

B. nephrologist

C. cardiologist

D. neurologist

Answer: A

Rationale: Use of large concentrations of oxygen and sustained oxygen saturations higher than

95% while on supplemental oxygen have been associated with the development of retinopathy of

prematurity (ROP) and further respiratory complications in the preterm newborn (Martin &

Deakins, 2020). For these reasons, oxygen should be used judiciously to prevent the

development of further complications. A guiding principle for oxygen therapy is it should be

targeted to levels appropriate to the condition, gestational age, and postnatal age of the newborn.

As a result, an ophthalmology consult for follow-up after discharge is essential for preterm

infants who have received extensive oxygen. Although referrals to other specialists may be

warranted depending on the newborn's status, there is no information to suggest that any would

be needed.

7. A nurse is developing the plan of care for a small-for-gestational-age newborn. Which action

would the nurse determine as a priority?

A. Preventing hypoglycemia with early feedings

B. Observing for newborn reflexes

C. Promoting bonding between the parents and the newborn

D. Monitoring vital signs every 2 hours

Answer: A

Rationale: The nurse must consider the implications of a small-for-gestational-age newborn.

With the loss of the placenta at birth, the newborn must now assume control of glucose

homeostasis. This is achieved by early oral intermittent feedings. Observing for newborn

reflexes, promoting bonding, and monitoring vital signs, although important, are not the priority

for this newborn.

8. The nurse is providing care to a newborn who was born at 36 weeks' gestation. Based on the

nurse's understanding of gestational age, the nurse identifies this newborn as:

A. preterm.

B. late preterm.

C. term.

D. postterm.

Answer: B

Rationale: Gestational age is typically measured in weeks: a newborn born before completion of

37 weeks is classified as a preterm newborn, and one born after completion of 42 weeks is

classified as a postterm newborn. An infant born from the first day of the 38th week through 42

weeks is classified as a term newborn. The late preterm newborn (near term) is one who is born

between 34 weeks and 36 weeks, 6 days of gestation.

9. Which intervention would be most appropriate for the nurse to do when assisting parents who

have experienced the loss of their preterm newborn?

A. Avoid using the terms "death" or "dying."

B. Provide opportunities for them to hold the newborn.

C. Refrain from initiating conversations with the parents.

D. Quickly refocus the parents to a more pleasant topic.

Answer: B

Rationale: When dealing with grieving parents, nurses should provide them with opportunities to

hold the newborn if they desire. In addition, the nurse should provide the parents with as many

memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn.

These interventions help to validate the parents' sense of loss, relive the experience, and attach

significance to the meaning of loss. The nurse should use appropriate terminology, such as

"dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to

demonstrate empathy and to respect the parents' feelings, responding to them in helpful and

supportive ways. Active listening and allowing the parents to vent their frustrations and anger

help validate the parents' feelings and facilitate the grieving process.

10. A nurse is reviewing the maternal history of a large-for-gestational-age (LGA) newborn.

Which factor, if noted in the maternal history, would the nurse identify as possibly contributing

to the birth of this newborn?

A. substance use disorder

B. diabetes

C. preeclampsia

D. infection

Answer: B

Rationale: Maternal factors that increase the chance of having an LGA newborn include maternal

diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant,

postdate gestation, maternal obesity, male fetus, and genetics. Substance use disorder is

associated with small-for-gestational-age (SGA) newborns and preterm newborns. A maternal

history of preeclampsia and infection would be associated with preterm birth.

11. A nurse is assessing a preterm newborn. Which finding would alert the nurse to suspect that a

preterm newborn is in pain?

A. bradycardia

B. oxygen saturation level of 94%

C. decreased muscle tone

D. sudden high-pitched cry

Answer: D

Rationale: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry,

oxygen desaturation, tachycardia, and increased muscle tone.

12. A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking

pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks' gestation,

a blood pressure of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few

times. The client has been pregnant before and indicates she "loses them early." What

characteristic(s) place the client in the high-risk pregnancy category? Select all that apply.

A. BMI 17.5

B. blood pressure 110/70 mm Hg

C. prenatal history

D. homelessness

E. age

F. prenatal care

Answer: A, C, D, F

Rationale: The key to identifying a newborn with special needs related to birthweight or

gestational age variation is an awareness of the factors that could place a newborn at risk. These

factors are similar to those that would suggest a high-risk pregnancy and include maternal

nutrition (malnutrition or overweight), substandard living conditions or low socioeconomic

status, maternal age of less than 20 or more than 35 years, lack of prenatal care, and history of

previous preterm birth.

13. A neonate born at 40 weeks' gestation, weighing 2300 grams (5 lb, 1 oz) is admitted to the

newborn nursery for observation only. What is the nurse's first observation about the infant?

A. The neonate is average for its gestational age.

B. The neonate is small for its gestational age.

C. The neonate is large for its gestational age.

D. The neonate is fetal growth restricted.

Answer: B

Rationale: Small for gestational age (SGA) describes newborns that typically weigh less than

2,500 g (5 lb, 8 oz) at term due to less growth than expected in utero. A newborn is also

classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with

the number of weeks of gestation. In some SGA newborns, the rate of growth does not meet the

expected growth pattern. These infants are considered to have fetal growth restriction resulting in

pathology.

14. A thin newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retractions,

a heart rate of 120 beats/min, temperature of 36° C (96.8° F) and persisting oxygen saturation of

<87%. The nurse interprets these findings as:

A. cardiac distress.

B. respiratory alkalosis.

C. bronchial pneumonia.

D. respiratory distress.

Answer: D

Rationale: Ineffective breathing pattern related to immature respiratory system and respiratory

distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation

less than 87 %. These assessment findings do not indicate bronchial pneumonia respiratory

alkalosis or cardiac distress at this time.

15. A one-day-old neonate born at 32 weeks' gestation is in the neonatal intensive care unit under

a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 degrees F

(35 degrees C). What could explain the assessment finding?

A. Conduction heat loss is a problem in the baby.

B. The supply of brown adipose tissue is not developed.

C. Axillary temperatures are not accurate.

D. This is a normal temperature.

Answer: B

Rationale: Typically newborns use nonshivering thermogenesis for heat production by

metabolizing their own brown adipose tissue. However, this preterm newborn has an inadequate

supply of brown fat because he or she left the uterus early before the supply was adequate.

Conduction heat loss allows an increased transfer of heat from their bodies to the environment,

but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and

the mode of taking temperatures for neonates.

16. A 42-year-old woman is 26 weeks' pregnant. She lives at a shelter for female victims of

intimate partner violence. Her blood pressure is 170/90 mm Hg, the fetal heart rate is 140 bpm,

TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of

giving birth to a small-for-gestational-age (SGA) infant? Select all that apply.

A. the age of the client

B. living in a shelter for victims of intimate partner violence

C. vaginal bleeding

D. fetal heart rate

E. blood pressure

F. positive test for TORCH

Answer: A, B, C, E, F

Rationale: Some factors contributing to the birth of SGA newborns include maternal age of 20 or

35 years old, low socioeconomic status, and preeclampsia with increased blood pressure. The

vaginal bleeding indicates placental problems, and she tests positive for sexually transmitted

diseases by TORCH group infections.

17. A term neonate has been admitted to the observational newborn nursery with the diagnosis of

being small for gestational age. Which factors would predispose the neonate to this diagnosis?

Select all that apply.

A. The mother had chronic placental abruption.

B. At birth the placenta was noted to be decreased in weight.

C. On assessment the placenta had areas of infarction.

D. At birth the placenta was a shiny Schultz presentation.

E. Placental talipes was present at birth.

Answer: A, B, C, D

Rationale: Placental factors that can contribute to a small for gestational age infant include

chronic placental abruption, infarction on surface of placenta, and a decreased placental weight.

A shiny Schultz placenta is a normal description because the fetal side of the placenta comes out

first, which is shiny. Placenta talipes does not exist.

18. A small-for-gestational age infant is admitted to the observational care unit with the nursing

diagnosis of ineffective thermoregulation related to lack of fat stores as evidenced by persistent

low temperatures. Which are appropriate nursing interventions? Select all that apply.

A. Assess the axillary temperature every hour.

B. Review maternal history.

C. Assess environment for sources of heat loss.

D. Bathe the neonate with warmer water.

E. Minimize kangaroo care.

F. Encourage skin-to-skin contact.

Answer: A, B, C, F

Rationale: Proper care to promote thermoregulation include assessing the axillary temperature

every hour, reviewing the maternal history to identify risk factors contributing to problem,

assessing the environment for sources of heat loss, avoiding bathing and exposing newborn to

prevent cold stress, and encouraging kangaroo care (mother or father holds preterm infant

underneath clothing skin-to-skin and upright between breasts) to provide warmth.

19. A couple has just given birth to a baby who has low Apgar scores due to asphyxia from

prolonged cord compression. The neonatologist has given a poor prognosis to the newborn, who

is not expected to live. Which interventions are appropriate at this time? Select all that apply.

A. Advise the parents that the hospital can make the arrangements.

B. Offer to pray with the family if appropriate.

C. Leave the parents to talk through their next steps.

D. Initiate spiritual comfort by calling the hospital clergy, if appropriate.

E. Respect variations in the family's spiritual needs and readiness.

Answer: B, D, E

Rationale: When assisting the parents to cope with a perinatal loss, the nurse must respect

variations in the family's spiritual needs and readiness. The nurse will also initiate spiritual

comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if

appropriate.

20. A neonate is born at 42 weeks' gestation weighing 4.4 kg (9 lb, 7 oz) with satisfactory Apgar

scores. Two hours later birth the neonate's blood sugar indicates hypoglycemia. Which

symptoms would the baby demonstrate? Select all that apply.

A. poor sucking

B. respiratory distress

C. weak cry

D. jitteriness

E. blood glucose >40 mg/dl

Answer: A, B, C, D

Rationale: Some of the common problems associated with newborns experiencing a variation in

gestational age, such as a postterm newborn, are respiratory distress, jitteriness, feeble sucking,

weak cry, and a blood glucose of 40 mg/dl.

21. A premature, 36-week-gestation neonate is admitted to the observational nursery and placed

under bili-lights with evidence of hyperbilirubinemia. Which assessment findings would the

neonate demonstrate? Select all that apply.

A. increased serum bilirubin levels

B. clay-colored stools

C. tea-colored urine

D. cyanosis

E. Mongolian spots

Answer: A, B, C

Rationale: Hyperbilirubinemia is indicated when the newborn presents with elevated serum

bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis would not be seen in infants

in this scenario. Mongolian spots are not associated with newborn jaundice.

22. A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment

findings would indicate that the neonate is in pain? Select all that apply.

A. There is flaccid muscle tone of the affected limb.

B. Respiration rate is 52 breaths per minute.

C. Heart rate is 180 beats per minutes.

D. Oxygen saturation level is 88%.

E. The infant has facial grimacing and quivering chin.

Answer: C, D, E

Rationale: Suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is

noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when

disturbed. Oxygen desaturation will be noted with an increase in heart rate. Increase in the

normal blood pressure, pulse, and respiration are noted.

23. During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV

epinephrine (adrenaline) in a 1:10,000 concentration to be given stat. The neonate weighs 3000

grams and is 38 centimeters long. How many millimeters (mL) should the nurse administer?

Record your answer using one decimal place.

Answer: 0.3

Rationale: Epinephrine should be given if heart rate is 60 after 30 seconds of compressions and

ventilation.

24. A macrosomic infant in the newborn nursery is being observed for a possible fractured

clavicle. For which would the nurse assess? Select all that apply.

A. facial grimacing with movement

B. bruising over area

C. asymmetrical movement

D. edema present

E. positive Babinski reflex

Answer: A, B, C, D

Rationale: Birth trauma for LGA newborns would be demonstrated by an obvious deformity,

with bruising at the site and edema noted. There would be asymmetrical movement when the

newborn moves the limb. Babinski reflex is a neurological test and would be normal to be

positive.

25. A set of newborn twins has been admitted to the neonatal intensive care unit with the

diagnosis of fetal growth restriction (FGR). Which maternal factors would predispose the

newborn to this diagnosis? Select all that apply.

A. hemoglobin 15 g/dl (150 g/l)

B. A1C levels of 8% (0.08)

C. heroin use disorder

D. blood pressure baseline of 170/90 mm Hg

E. age 39 years

F. multiple gestation

Answer: B, C, D, E, F

Rationale: Assessment of the small-for-gestational-age (SGA) or FGR infant begins by

reviewing the maternal history to identify risk factors such as maternal age over 30 years, a

substance use disorder, hypertension, multiple gestation. Gestational diabetes or diabetes

mellitus is also a factor. Normal A1C level is 5.7% (0.57) for a person without diabetes.

Hemoglobin is normal for pregnant woman in third trimester.

26. A neonate is admitted to the newborn observation nursery with the possible diagnosis of

polycythemia. The nurse would be observing for which findings? Select all that apply.

A. ruddy skin color

B. respiratory distress

C. cyanosis

D. pink gums and tongue

E. jitteriness

Answer: A, B, C, E

Rationale: Observe for clinical signs of polycythemia (respiratory distress, cyanosis, jitteriness,

jaundice, ruddy skin color, and lethargy) and monitor blood results.

27. A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s)

will the nurse utilize to provide care for this neonate? Select all that apply.

A. Obtain hemoglobin and hematocrit laboratory tests

B. Provide early feedings to prevent hypoglycemia

C. Maintain oxygen saturation parameters

D. Monitor urinary output

E. Insert a peripheral IV

Answer: A, B, C, D

Rationale: Polycythemia in a neonate is defined as a hematocrit above 65% (0.65) and a

hemoglobin level above 20 g/dl (200 g/l). The hematocrit and hemoglobin peak between 6 and

12 hours of life and then start to decrease. If these values do not decrease as expected, then

hypoperfusion will occur and polycythemia will develop. In the beginning, the nurse may assess

feeding difficulties, hypoglycemia, jitteriness and respiratory distress. As the condition worsens,

a ruddy skin color could be seen, cyanosis could develop, the neonate could become lethargic

and seizures could develop. Nursing care for this neonate requires obtaining hematocrit and

hemoglobin laboratory tests at 2 hours, 12 hours and 24 hours. Feeding should be started to

provide fluid, nutrition and prevent hypoglycemia. The oxygen saturation should be monitored.

If the levels are below the established parameters from the health care provider, oxygen therapy

will be needed. The urine output should be monitored continuously because polycythemia can cause real failure. A peripheral IV may or may not be needed. This would depend on the

neonate's condition and if IV fluids would be required.

28. A client has given birth to a full-term infant weighing 10 pounds 5 ounces (4678 grams).

What priority assessment should be completed by the nurse?

A. Blood glucose

B. Temperature control

C. Feeding difficulty

D. Perfusion

Answer: A

Rationale: Hypoglycemia is a common concern with a large-for-gestational age (LGA) infant.

This infant will deplete the glucose stores very rapidly. Therefore, it is important to assess the

glucose level within 30 minutes of birth and to repeat every hour until stable. Hypoglycemia is

defined as a gluose level less than 35 to 45 mg/dl (1.94 to 2.50 mmol/l) in the first 4 hours of life,

and intervention should occur when the glucose is less than 40 mg/dl (2.22 mmol/l). Intervention

should also occur if the blood glucose is less than 45 mg/dl (2.50 mmol/l) at 4 and 24 hours of

life respectively. Generally the nurse assesses symptoms of jitteriness, irritability and tachypnea

first. These symptoms can progress to temperature instability, lethargy, bradycardia, hyponia and

seizures.

29. A client expresses concerns that her grandmothers had complicated pregnancies. What

principle(s) should the nurse discuss to allay the fears of the client? Select all that apply.

A. "We work to ensure that birth of high-risk infants happens in settings where we are able to

care for them."

B. "We will work with you to identify prenatal risk factors early and take actions to reduce their

impact."

C. "We support those at risk of having a preterm births with the goal of delaying early births."

D. "We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and

death."

E. "We allow families to grieve the loss of a newborn, should it occur."

Answer: A, B, C, D

Rationale: The nurse will attempt to allay the client's fears by discussing the actions the facility

enacts to promote a healthy brith and infant. This includes ensuring the birth of high-risk infants

takes place in settings that have the technological capacity to care for them, identifying risk

factors early and taking action to reduce their impact, working to delay the birth of those

pregancies identified at risk of preterm birht, and promoting an overall reduction in infant illness,

disability, and death to proper care of the mother and infant. Although allowing a family to

greive in instances of infant death, discussing this factor with the client is likely to create more

fear.

30. A late preterm newborn is being prepared for discharge to home after being in the neonatal

intensive care unit for 4 days. The nurse instructs the parents about the care of their newborn and

emphasizes warning signs that should be reported to the pediatrician immediately. The nurse

determines that additional teaching is needed based on which parental statement?

A. "We will call 911 if we start to see that our newborn's lips or skin are looking bluish."

B. "If our newborn's skin turns yellow, it is from the treatments and our newborn is okay."

C. "If our newborn does not have a wet diaper in 12 hours, we will call our pediatrician."

D. "We will let the pediatrician know if our newborn's temperature goes above 100.4°F (38°C)."

Answer: B

Rationale: The parents of a preterm newborn need teaching about when to notify their

pediatrician or nurse practitioner. These include: displaying a yellow color to the skin (jaundice);

having difficulty breathing or turning blue (call for emergency services in this case); having a

temperature below 97°F (36.1°C) or above 100.4°F (38°C); and failing to void for 12 hours.