Chapter 17
A nursing student is preparing a presentation on minimizing heat loss in the newborn. Which of the following would the student include as a measure to prevent heat loss through convection?
A) Placing a cap on a newborn's head
B) Working inside an isolette as much as possible.
C) Placing the newborn skin-to-skin with the mother
D) Using a radiant warmer to transport a newborn
B) Working inside an isolette as much as possible.
During a physical assessment of a newborn, the nurse observes bluish markings across the newborn's lower back. The nurse documents this finding as which of
the following?
A) Milia
B) Mongolian spots
C) Stork bites
D) Birth Trauma
B) Mongolian spots
When planning the care for an SGA newborn, which action would the nurse determine as a priority?
A) Preventing hypoglycemia with early feedings
B) Observing for respiratory distress syndrome
C) Promoting bonding between the parents and the newborn
D) Monitoring vital signs every 2 hours
A) Preventing hypoglycemia with early feedings
After teaching the parents of a newborn with retinopathy of prematurity (ROP) about the disorder and treatment, which statement by the parents indicates that the teaching was successful?
A) Can we schedule follow-up eye examinations with the pediatric ophthalmologist now?
B) We can fix the problem with surgery.
C) We'll make sure to administer eye drops each day for the next few weeks.
D) I'm sure the baby will grow out of it.
A) Can we schedule follow-up eye examinations with the pediatric ophthalmologist now?
When making a home visit, the nurse observes a newborn sleeping on his back in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the other end is a bulb syringe. The nurse determines that the mother needs additional teaching because of which of the following?
A) The newborn should not be sleeping on his back.
B) Stuffed animals should not be in areas where infants sleep.
C) The bulb syringe should not be kept in the bassinet.
D) This newborn should be sleeping in a crib
B) Stuffed animals should not be in areas where infants sleep.
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:
A) Have a smaller body surface compared to body mass
B) Lose more body heat when they sweat than adults
C) Have an abundant amount of subcutaneous fat all over
D) Are unable to shiver effectively to increase heat production
D) Are unable to shiver effectively to increase heat production
The nurse strokes the lateral sole of the newborn's foot from the heel to the ball of the foot when evaluating which reflex?
A) Babinski
B) Tonic neck
C) Stepping
D) Plantar grasp
A) Babinski
An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do next?
A) Administer intravenous glucose immediately.
B) Feed the newborn 2 ounces of formula.
C) Initiate blow-by oxygen therapy.
D) Place the newborn under a radiant warmer.
A) Administer intravenous glucose immediately.
A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which of the following 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
A) Extracorporeal membrane oxygenation (ECMO)
The nurse administers vitamin K intramuscularly to the newborn based on which of the following rationales?
A) Stop Rh sensitization
B) Increase erythropoiesis
C) Enhance bilirubin breakdown
D) Promote blood clotting
D) Promote blood clotting
Which of the following would alert the nurse to the possibility of respiratory distress in a newborn?
A) Symmetrical chest movements
B) Periods of apnea
C) Respirations of 50 breaths/minute
D) Sternal retractions
D) Sternal retractions
The nurse places a newborn with jaundice under the phototherapy lights in the nursery to achieve which goal?
A) Prevent cold stress
B) Increase surfactant levels in the lungs
C) Promote respiratory stability
D) Decrease the serum bilirubin level
D) Decrease the serum bilirubin level
Which of the following 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
B) Provide opportunities for them to hold the newborn.
A newborn is diagnosed with meconium aspiration syndrome. When assessing this newborn, which of the following would the nurse expect to find? (Select all that apply.)
A) Pigeon chest
B) Prolonged tachypnea
C) Intercostal retractions
D) High blood pH level
E) Coarse crackles on auscultation
B) Prolonged tachypnea
C) Intercostal retractions
E) Coarse crackles on auscultation
After the birth of a newborn, which of the following would the nurse do first to assist in thermoregulation?
A) Dry the newborn thoroughly.
B) Put a hat on the newborn's head.
C) Check the newborn's temperature.
D) Wrap the newborn in a blanket
A) Dry the newborn thoroughly.
A new mother reports that her newborn often spits up after feeding. Assessment reveals regurgitation. The nurse responds by integrating the understanding that this most likely is due to which of the following?
A) Placing the newborn prone after feeding
B) Limited ability of digestive enzymes
C) Underdeveloped pyloric sphincter
D) Relaxed cardiac sphincter
D) Relaxed cardiac sphincter
A new mother who is breastfeeding her newborn asks the nurse, "How will I know if my baby is drinking enough?" Which response by the nurse would be most appropriate?
A) If he seems content after feeding, that should be a sign.
B) Make sure he drinks at least 15 minutes on each breast.
C) He should wet between 6 to 12 diapers each day.
D) If his lips are moist, then he's okay.
C) He should wet between 6 to 12 diapers each day.
A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at the lowest risk?
A) Small-for-gestational-age (SGA) newborns
B) Large-for-gestational-age (LGA) newborns
C) Appropriate-for-gestational-age (AGA) newborns
D) Low-birth-weight newborns
C) Appropriate-for-gestational-age (AGA) newborns
The nurse is assessing the newborn of a mother who had gestational diabetes. Which of the following would the nurse expect to find? (Select all that apply.)
A) Pale skin color
B) Buffalo hump
C) Distended upper abdomen
D) Excessive subcutaneous fat
E) Long slender neck
B) Buffalo hump
C) Distended upper abdomen
D) Excessive subcutaneous fat
Which of the following 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.
B) Pathologic jaundice appears within 24 hours after birth.
A newborn is experiencing cold stress. Which of the following would the nurse expect to assess? (Select all that apply.)
A) Respiratory distress
B) Decreased oxygen needs
C) Hypoglycemia
D) Metabolic alkalosis
E) Jaundice
A) Respiratory distress
C) Hypoglycemia
E) Jaundice
Assessment of a newborn reveals uneven gluteal. skin creases and a clunk when the Ortolanis maneuver is performed. Which of the following would the nurse suspect?
A) Slipping of the periosteal joint
B) Developmental hip dysplasia
C) Normal newborn variation
D) Overriding of the pelvic bone
B) Developmental hip dysplasia
A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborn's risk? (Select all that apply.)
A) Surfactant deficiency
B) Placental deprivation
C) Immaturity of the respiratory control centers
D) Decreased amounts of brown fat
E) Depleted glycogen stores
A) Surfactant deficiency
C) Immaturity of the respiratory control centers
The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.)
A) Tremors
B) Diminished sucking
C) Regurgitation
D) Shrill, high-pitched cry
E) Hypothermia
F) Frequent sneezing
A) Tremors
C) Regurgitation
D) Shrill, high-pitched cry
F) Frequent sneezing
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 which of the following?
A) Inability to clear fluids
B) Immature respiratory control center
C) Deficiency of surfactant
D) Smaller respiratory passages
C) Deficiency of surfactant