Ricci Chapter 24 - Test Bank - 4th Edition

1. A newborn with severe meconium aspiration syndrome (MAS) is not responding to

conventional treatment. Which measure would the nurse anticipate as possibly necessary for this

newborn?

A. extracorporeal membrane oxygenation (ECMO)

B. respiratory support with a ventilator

C. insertion of a laryngoscope for deep suctioning

D. replacement of an endotracheal tube via X-ray

Answer: A

Rationale: If conventional measures are ineffective, then the nurse would need to prepare the

newborn for ECMO. Hyperoxygenation, ventilatory support, and direct tracheal suctioning are

typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO

would be the next step.

2. A nurse is providing care to a newborn. The nurse suspects that the newborn is developing

sepsis based on which assessment finding?

A. increased urinary output

B. interest in feeding

C. temperature instability

D. wakefulness

Answer: C

Rationale: Manifestations of sepsis are typically nonspecific and may include hypothermia

(temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy.

3. A nurse is providing care to a newborn who is receiving phototherapy. Which action would

the nurse most likely include in the plan of care?

A. keeping the newborn in the supine position

B. covering the newborn's eyes while under the bililights

C. ensuring that the newborn is covered or clothed

D. reducing the amount of fluid intake to 8 ounces daily

Answer: B

Rationale: During phototherapy, the newborn's eyes are covered to protect them from the lights.

The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept

undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid

intake is increased to allow for added fluid, protein, and calories.

4. A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The

nurse understands that the newborn most likely acquired this infection from which cause?

A. improper hand washing

B. contaminated formula

C. nonsterile catheter insertion

D. mother's birth canal

Answer: D

Rationale: Most often, a newborn develops a group B streptococcus infection during the birthing

process when the newborn comes into contact with an infected birth canal. Improper hand

washing, contaminated formula, and nonsterile catheter insertion would most likely lead to a

late-onset infection, which typically occurs in the nursery due to horizontal transmission.

5. Which action would be most appropriate for the nurse to take when a newborn has an

unexpected anomaly at birth?

A. Show the newborn to the parents as soon as possible while explaining the defect.

B. Remove the newborn from the birthing area immediately.

C. Inform the parents that there is nothing wrong at the moment.

D. Tell the parents that the newborn must go to the nursery immediately.

Answer: A

Rationale: When an anomaly is identified at or after birth, parents need to be informed promptly

and given a realistic appraisal of the severity of the condition, the prognosis, and treatment

options so that they can participate in all decisions concerning their child. Removing the

newborn from the area or telling them that the newborn needs to go to the nursery immediately is

inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is

wrong is inappropriate because it violates their right to know.

6. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea

based on the understanding that this type of feeding is necessary because:

A. lactase enzymatic activity is not adequate.

B. oxygen demands need to be reduced.

C. renal solute lead must be considered.

D. hyperbilirubinemia is likely to develop.

Answer: B

Rationale: For the newborn with transient tachypnea, the newborn's respiratory rate is high,

increasing the oxygen demand. Thus, measures are initiated to reduce this demand. Gavage

feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are

not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is

not increased.

7. Which information would the nurse include when teaching a new mother about the difference

between pathologic and physiologic jaundice?

A. Physiologic jaundice results in kernicterus.

B. Pathologic jaundice appears within 24 hours after birth.

C. Both are treated with exchange transfusions of maternal O- blood.

D. Physiologic jaundice requires transfer to the NICU.

Answer: B

Rationale: Pathologic jaundice appears within 24 hours after birth whereas physiologic jaundice

commonly appears around the third or fourth days of life. Kernicterus is more commonly

associated with pathologic jaundice. An exchange transfusion is used only if the total serum

bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's

blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic

jaundice often is treated at home.

8. A nurse is teaching the mother of a newborn experiencing cocaine withdrawal about caring for

the neonate at home. The mother stopped using cocaine near the end of her pregnancy. The nurse

determines that additional teaching is needed when the mother identifies which action as

appropriate for her newborn?

A. wrapping the newborn snugly in a blanket

B. waking the newborn every hour

C. checking the newborn's fontanels

D. offering a pacifier

Answer: B

Rationale: Stimuli need to be decreased. Waking the newborn every hour would most likely be

too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to

decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive

sucking. Checking the fontanels provides evidence of hydration.

9. A newborn is suspected of having fetal alcohol syndrome. Which finding would the nurse

expect to assess?

A. bradypnea

B. hydrocephaly

C. flattened maxilla

D. hypoactivity

Answer: C

Rationale: A newborn with fetal alcohol syndrome exhibits characteristic facial features such as

microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened

or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median

portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine

and gross motor development is delayed, and the newborn shows poor hand-eye coordination but

not hypoactivity.

10. After teaching the parents of a newborn with periventricular hemorrhage about the disorder

and treatment, which statement by the parents indicates that the teaching was successful?

A. "We'll make sure to cover both of his eyes to protect them."

B. "Our newborn could develop a learning disability later on."

C. "Once the bleeding ceases, there won't be any more worries."

D. "We need to get family members to donate blood for transfusion."

Answer: B

Rationale: Periventricular hemorrhage has long-term sequelae such as seizures, hydrocephalus,

periventricular leukomalacia, cerebral palsy, learning disabilities, vision or hearing deficits, and

intellectual disability. Covering the eyes is more appropriate for the newborn receiving

phototherapy. The bleeding in the brain can lead to serious long-term effects. Blood transfusions

are not used to treat periventricular hemorrhage.

11. A newborn has an Apgar score of 6 at 5 minutes. Which action would be the priority?

A. initiating IV fluid therapy

B. beginning resuscitative measures

C. promoting kangaroo care

D. obtaining a blood culture

Answer: B

Rationale: An Apgar score below 7 at 1 or 5 minutes indicates the need for resuscitation.

Intravenous fluid therapy and blood cultures may be done once resuscitation is started. Kangaroo

care would be appropriate once the newborn is stable.

12. While reviewing a newborn's medical record, the nurse notes that the chest X-ray shows a

ground glass pattern. The nurse interprets this as indicative of:

A. respiratory distress syndrome.

B. transient tachypnea of the newborn.

C. asphyxia.

D. persistent pulmonary hypertension.

Answer: A

Rationale: The chest X-ray of a newborn with RDS reveals a reticular (ground glass) pattern. For

TTN, the chest X-ray shows lung overaeration and prominent perihilar interstitial markings and

streakings. A chest X-ray for asphyxia would reveal possible structural abnormalities that might

interfere with respiration, but the results are highly variable. An echocardiogram would be done

to evaluate persistent pulmonary hypertension.

13. A newborn is suspected of developing persistent pulmonary hypertension. The nurse would

expect to prepare the newborn for which procedure to confirm the suspicion?

A. chest X-ray

B. blood cultures

C. echocardiogram

D. stool for occult blood

Answer: C

Rationale: An echocardiogram is used to reveal right-to-left shunting of blood to confirm the

diagnosis of persistent pulmonary hypertension. Chest X-ray would be most likely used to aid in the diagnosis of RDS or TTN. Blood cultures would be helpful in evaluating for neonatal sepsis.

Stool for occult blood may be done to evaluate for NEC.

14. A preterm newborn is receiving enteral feedings. Which finding would alert the nurse to

suspect that the newborn is developing NEC?

A. irritability

B. sunken abdomen

C. clay-colored stools

D. feeding intolerance

Answer: D

Rationale: The newborn with NEC may exhibit feeding intolerance with lethargy, abdominal

distention and tenderness, and bloody stools.

15. The nurse frequently assesses the respiratory status of a preterm newborn based on the

understanding that the newborn is at increased risk for respiratory distress syndrome because of:

A. inability to clear fluids.

B. immature respiratory control center.

C. deficiency of surfactant.

D. smaller respiratory passages.

Answer: C

Rationale: A preterm newborn is at increased risk for respiratory distress syndrome (RDS)

because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung

expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An

inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead

to an increased risk for apnea. Smaller respiratory passages led to an increased risk for

obstruction.

16. At a preconception counseling class, a client expresses concern and wonders how Healthy

People 2030 will improve maternal-infant outcomes. Which response(s) by the nurse is

appropriate? Select all that apply.

A. Healthy People 2030 will reduce the rate of fetal and infant deaths.

B. Healthy People 2030 will decrease the number of all infant deaths (within 1 year).

C. Healthy People 2030 will decrease the number of neonatal deaths (within the first year).

D. Healthy People 2030 will foster early and consistent prenatal care.

Answer: A, B, C, D

Rationale: One of the leading health indicators as identified by Healthy People 2030 refers to

decreasing the number of infant deaths. Acquired and congenital conditions account for a

significant percentage of infant deaths. Specific objectives include reducing the rate of fetal

deaths at 20 or more weeks of gestation though the nursing action of fostering early and

consistent prenatal care; reducing the rate of all infant deaths (within 1 year) through the nursing

actions of including education to place infants on their backs for naps and sleep to prevent

sudden infant death syndrome (SIDS), avoiding exposing newborns to cigarette smoke, and

ensuring that infants with birth defects receive health care needed in order to thrive; and reducing

the occurrence of fetal alcohol syndrome (FAS) through the nursing actions or counseling girls

and women to avoid alcohol use during pregnancy, and participating in programs for at-risk

groups, including adolescents, about the effects of substance use, especially alcohol, during

pregnancy.

17. A neonate is exhibiting signs of neonatal abstinence syndrome. Which findings would

confirm this diagnosis? Select all that apply.

A. adequate rooting and sucking

B. frequent sneezing

C. persistant fever

D. shrill, high-pitched cry

E. hypotonic reflexes

F. frequent yawning

Answer: B, C, D, F

Rationale: Manifestations of neonatal abstinence syndrome include a shrill, high-pitched cry;

persistent fever; frequent yawning; and frequent sneezing. Rather than adequate rooting and

sucking, these actions will be frantic in a neonate with abstinence syndrome. In addition, these

neonates will have hypertonic muscle tone, not hypotonic reflexes.

18. A pregnant woman gives birth to a small for gestational age neonate who is admitted to the

neonatal intensive care unit with seizure activity. The neonate appears to have abnormally small

eyes and a thin upper lip. The infant is noted to be microcephalic. Based on these findings, which

substance would the nurse suspect the women of using during pregnancy?

A. alcohol

B. cocaine

C. heroin

D. methamphetamine

Answer: A

Rationale: This child's features match those of fetal alcohol syndrome, including microcephaly,

small palpebral (eyelid) fissures, abnormally small eyes, and fetal growth restriction.

19. The nurse is developing a plan of care for a neonate experiencing symptoms of drug

withdrawal. What should be included in this plan?

A. Administer glucose between feedings.

B. Schedule feedings every 4 to 6 hours.

C. Swaddle the infant between feedings.

D. Rock horizontally.

Answer: C

Rationale: Supportive interventions to promote comfort include swaddling, low lighting, gentle

handling, quiet environment with minimal stimulation, use of soft voices, pacifiers to promote "self-soothing," frequent small feedings, and vertical rocking, which will soothe the newborn's

neurological system.

20. A neonate born addicted to cocaine is now being treated with medication for acute neonatal

abstinence syndrome. Which medication will be prescribed to relieve withdrawal symptoms?

A. meperidine

B. adrenalin

C. naloxone

D. morphine sulphate

Answer: D

Rationale: Pharmacologic treatment is warranted if conservative measures are not adequate.

Common medications used in the management of newborn withdrawal include an opioid

(morphine or methadone) and phenobarbital as a second drug if the opiate does not adequately

control symptoms. The other drugs are not used in NAS treatment.

21. The pediatrician prescribes morphine sulphate 0.2 mg/kg orally q 4 hour for a neonate

suffering from drug withdrawal. The neonate weighs 3,800 grams. How much of drug will the

nurse give in 24 hours? Record your answer using two decimal places.

Answer: 4.56

Rationale: 3800 grams = 3.8 kg

3.8 kg/kg x 0.20 mg x 6 doses = 4.56 mg in 24 hours

22. The nurse is admitting a term, large-for-gestational-age neonate weighing 4,610 g (10 lb, 2

oz), born vaginally with a mid-forceps assist, to a 15-year-old primipara. What would the nurse

anticipate as a result of the birth?

A. fracture of the tibia

B. fracture of the femur

C. fracture of a rib

D. midclavicular fracture

Answer: D

Rationale: Trauma to the newborn may result from the use of mechanical forces, such as forceps

during birth. Primarily injuries are found in large babies and babies with shoulder dystocia.

Associated traumatic injuries include fracture of the clavicle or humerus or subluxations of the

shoulder or cervical spine.

23. A 33 weeks' gestation neonate is being assessed for necrotizing enterocolitis (NEC). Which

nursing actions would the nurse implement? Select all that apply.

A. Perform hemoccult tests on stools.

B. Monitor abdominal girth.

C. Measure gastric residual before feeds.

D. Assess bowel sounds before each feed.

E. Assess urine output.

Answer: A, B, C, D

Rationale: Always keep the possibility of NEC in mind when dealing with preterm newborns,

especially when enteral feedings are being administered. Note feeding intolerance, diarrhea, bilestained

emesis, or grossly bloody stools. Perform hemoccult tests on the bloody stool. Assess the

neonate's abdomen for distention, tenderness, and visible loops of bowel. Measure the abdominal

circumference, noting an increase. Listen to bowel sounds before each feeding. Determine

residual gastric volume prior to feeding; when it is elevated, be suspicious for NEC. Assessing

urine output is not essential.

24. A 30 weeks' gestation neonate born with low Apgar scores is in the neonatal intensive care

unit with respiratory distress syndrome and underwent an exchange transfusion for anemia.

Which factors place the neonate at risk for necrotizing enterocolitis? Select all that apply

A. preterm birth

B. respiratory distress syndrome

C. low Apgar scores

D. hyperthermia

E. hyperglycemia

F. exchange transfusion

Answer: A, B, C, F

Rationale: The predisposing factors for the development of necrotizing enterocolitis include

preterm labor, respiratory distress syndrome, exchange transfusion, and low birth weight. Low

Apgar scores, hypothermia, and hypoglycemia are also risk factors.

25. A preterm newborn is admitted to the neonatal intensive care with the diagnosis of an

omphalocele. What nursing actions would the nurse perform? Select all that apply.

A. The abdominal contents are protected.

B. Fluid loss of the neonate will be minimized.

C. Perfusion to the exposed abdominal contents will be maintained.

D. Neonatal weight loss will be prevented.

E. Assessment of hyperbilirubinemia will be monitored.

Answer: A, B, C

Rationale: Nursing management of newborns with omphalocele or gastroschisis focuses on

preventing hypothermia, maintaining perfusion to the eviscerated abdominal contents by

minimizing fluid loss, and protecting the exposed abdominal contents from trauma and infection.

Weight loss at this point is not a priority, and neither is assessing bilirubin.

26. The nurse in the neonatal intensive care unit is caring for a neonate she suspects is at risk for

an intraventricular hemorrhage (IVH). Which nursing actions would be priorities? Select all that

apply.

A. Maintain fetal flexed position.

B. Administer fluids slowly.

C. Assess for bulging fontanel.

D. Measure head circumference daily.

E. Assess Moro reflex.

F. Measure intake and output.

Answer: A, B, C, D

Rationale: Care of the newborn with IVH is primarily supportive. Correct anemia, acidosis, and

hypotension with fluids and medications. Administer fluids slowly to prevent fluctuations in

blood pressure. Avoid rapid volume expansion to minimize changes in cerebral blood flow. Keep

the newborn in a flexed, contained position with the head elevated to prevent or minimize

fluctuations in intracranial pressure. Continuously monitor the newborn for signs of hemorrhage,

such as changes in the level of consciousness, bulging fontanel, seizures, apnea, and reduced

activity level. Also, measuring head circumference daily to assess for expansion in size is

essential in identifying complications early. Moro reflex and intake and output are routine and

not associated with IVH.

27. At the breech forceps birth of a 32 weeks' gestation neonate, the nurse notes

olygohydramnios with green thick amniotic fluid. The maternal history reveals a mother of

Hispanic ethnicity with marked hypertension, who admits to using cocaine daily. Which factor(s)

may contribute to meconium aspiration syndrome (MAS)? Select all that apply.

A. the preterm pregnancy

B. the forceps breech birth

C. maternal cocaine use

D. maternal hypertension

E. Hispanic ethnicity

F. oligohydramnios present

Answer: B, C, D, F

Rationale: The predisposing factors for meconium aspiration syndrome include postterm

pregnancy and breech presentation with forceps. Ethnicity (Pacific Islander, Indigenous

Australian, Black African) is a factor. Postterm neonates are at risk for MAS, but preterm

neonates are not. Exposure to drugs during pregnancy, especially tobacco and cocaine, predispose the neeonate to MAS. Maternal hypertension and oligohydramnios also contribute to

MAS.

28. A 2-hour-old neonate born via caesarean birth has begun having a respiratory rate of 110

breaths/min and is in respiratory distress. What intervention(s) is a priority for the nurse to

include in this neonates's care? Select all that apply.

A. Keep the head in a "sniff" position

B. Administer oxygen

C. Insert an orogastric tube

D. Ensure thermoregulation

E. Obtain an arterial blood gas

Answer: A, B, D

Rationale: This neonate is experiencing manifestations of transient tachypnea of the newborn

(TTN). It occurs from delayed clearing of the lungs from fluid, and can be seen in neonates born

via cesarean birth, because they have not had the experience of the compression on the thorax

during vaginal delivery. This starts within the first 6 hours of life and can last up to 72 hours.

The priority interventions for this neonate are oxygen, thermoregulation and minimal

stimulation. Keeping the head in a neutral or "sniff " position allows for optimal airway. If the

neonate becomes cold, then respiratory distress and or sepsis can develop. Minimal stimulation

conserves the neonate's respiratory and heat requirements. The neonate may need placement of a

peripheral IV for hydration and/or a feeding tube for formula or breast milk. The neonate should

not be nipple fed until the respirations are under 60 breaths/min. A chest x-ray and an arterial

blood gas may be needed also, but they would only be necessary if the neonate is in severe

distress. The arterial blood gas results would show mild hypoxemia, a midly elevated CO2 level,

and a normal pH.

29. A newborn infant has been diagnosed with persistent pulmonary hypertension of the newborn

(PPHN). In providing care for this newborn what intervention should be the nurse's priority?

A. Measure blood pressure

B. Obtain arterial blood gases

C. Monitor oxygen saturation

D. Suction the newborn

Answer: A

Rationale: PPHN occurs when there is persistent fetal circulation after birth. The pulmonary

pressures do not decrease at birth when the newborn begins breathing causing hypoxemia,

acidosis and vasoconstriction of the pulmonary artery. This newborn requires much care and

possibly extracorporeal membrane oxygenation (ECMO). The nurse should monitor the

newborn's blood pressure regularly, because hypotension can occur from ensuing heart failure

and the persistent hypoxemia. Vasopressors may be needed for this newborn. The newborn

should not be suctioned. Doing so causes more stimulation and worsens respiratory issues.

Arterial blood gases will be obtained regularly, but they are not a priority nursing intervention.

Oxygen saturation should always be monitored in a newborn with respiratory distress.

30. A newborn is exhibiting symptoms of withdrawal and toxicology test have been prescribed.

Which type of specimen should the nurse collect to obtain the most accurate results?

A. Meconium

B. Blood

C. Urine

D. Sputum

Answer: A

Rationale: Toxicology screening of a newborn can include testing from blood, urine and

meconium. These tests identify which drugs the newborn has been exposed to in utero. A

meconium sample can detect which drugs the mother has been using from the second trimester

of pregnancy until birth. It is the preferred method of testing. A urine screen identifies only the

drugs the mother has used recently. The nurse should be careful not to mix the meconium sample

with urine as it alters the results of the test. Blood samples can be taken and they will yield

results of current drugs in the newborn's system, but they are invasive and noninvasive testing

will provide the same results. If possible, testing on the mother is preferred. This testing provides

quick results of what drugs the mother has been exposing the fetus to in utero. This will help in

planning and providing care for the drug-exposed newborn. Sputum is not used for toxicology

studies.

31. A neonate is diagnosed with Erb's palsy after birth. The parents are concerned about their

neonate's limp arm. The nurse explains the neonate will be scheduled to receive what

recommended treatment for this condition first?

A. Physical therapy to the joint and extremity

B. Nothing but time and let nature take its course

C. Surgery to correct the joint and muscle alignment

D. Immobilization of the shoulder and arm

Answer: D

Rationale: Treatment for a neonate with Erb palsy usually involves immobilization of the upper

arm across the upper abdomen/chest to protect the shoulder from excessive motion for the first

week; then gentle passive range-of-motion exercises are performed daily to prevent contractures.

Surgery is not needed to regain function since there is no structural injury. Doing nothing will

not help the neonate regain function in the extremity.