Make sure the pulse oximeter is correlating to the heart rate

The Post-Term Neonate

2. Make sure the pulse oximeter is correlating to the heart rate

3. Assess the neonate for color.

4. Assess the neonate for respiratory effort.

1. Increase the FIO₂.

74.

A neonate with heart failure is being dis- charged home. In teaching the parents about the neo- nate’s nutritional needs, the nurse should explain that:

■ 1. Fluids should be restricted.

■ 2. Decreased activity level should reduce the need for additional calories.

■ 3. The formula should be low in sodium.

■ 4. The neonate may need a formula with higher calories per fl uid ounce.

75.

During an assessment of a neonate born at 33 weeks’ gestation, a nurse fi nds and reports a heart murmur. An echocardiogram reveals patent ductus arteriosis, for which the neonate received indo- methacin. An expected outcome after the admin- istration of indomethacin to a neonate with patent ductus arteriosis is:

■ 1. Closure of a patent ductus arteriosus.

■ 2. Decreased bleeding time.

■ 3. Increased gastrointestinal function.

■ 4. Increased renal output.

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85.

The nurse determines that a newborn is hypoglycemic based on which of the following fi nd- ings? Select all that apply.

■ 1. Glucometer reading of 40 mg/dL.

■ 2. Family history of insulin-dependent diabetes.

■ 3. Internal fetal monitor tracing.

■ 4. Irregular respirations, tremors, and hypothermia.

■ 5. Large for gestational age.

86.

The nurse is caring for an infant of an insulin- dependent diabetic primiparous client. When the mother visits the neonate at 1 hour after birth, the nurse explains to the mother that the neonate is being closely monitored for symptoms of hypoglyce- mia because of which of the following?

■ 1. Increased use of glucose stores during a dif- fi cult labor and delivery process.

■ 2. Interrupted supply of maternal glucose and continued high neonatal insulin production.

■ 3. A normal response that occurs during transi- tion from intrauterine to extrauterine life.

■ 4. Increased pancreatic enzyme production caused by decreased glucose stores.

87.

When caring for the neonate of a diabetic mother weighing 4,564 g (10 lb, 1 oz) who was delivered vaginally, the nurse should assess the neo- nate for fracture of the:

■ 1. Clavicle.

■ 2. Skull.

■ 3. Wrist.

■ 4. Rib cage.

88.

While caring for a neonate of a diabetic mother soon after delivery, the nurse has fed the newborn formula to prevent hypoglycemia. The nurse checks the neonate’s blood glucose level and it is 60 mg/dL, but the neonate continues to exhibit jitteriness and tremors. The nurse should fi rst:

■ 1. Inform the physician of the neonate’s glucose levels and tremors and request an order for blood calcium levels.

■ 2. Administer glucose intravenously based on infant glucose level.

■ 3. Take the neonate’s temperature and place him in the radiant warmer.

■ 4. Refeed the infant to continue to increase the blood glucose level.

89.

The nurse is caring for a neonate weighing 4,536 g (10 lb) who was born via cesarean delivery 1 hour ago. The mother is a class B insulin- dependent diabetic primipara. She asks the nurse, “Why is my baby in the neonatal intensive care unit?” The nurse bases a response on the understanding that neonates of class B diabetic mothers commonly develop which of the following conditions?

■ 1. Anemia.

■ 2. Persistent pulmonary hypertension.

■ 3. Hemolytic disease.

■ 4. Hypoglycemia.

80.

After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitiza- tion, the nurse determines that the client under- stands why she was not sensitized during her other pregnancy when she says which of the following?

■ 1. “My other baby had a different father.”

■ 2. “Like most women, I have immunity against the Rh factor.”

■ 3. “Antibodies are not usually formed until after exposure to an antigen.”

■ 4. “My blood couldn’t neutralize antibodies formed from my fi rst pregnancy.”

81.

After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following?

■ 1. Cardiac decompensation.

■ 2. Polycythemia.

■ 3. Anemia.

■ 4. Splenic enlargement.

82.

After delivery, a direct Coombs test is per- formed on the umbilical cord blood of a neonate with Rh-positive blood born to a mother with Rh- negative blood. The nurse explains to the client that this test is done to detect which of the following?

■ 1. Degree of anemia in the neonate.

■ 2. Electrolyte imbalances in the neonate.

■ 3. Antibodies coating the neonate’s red blood cells.

■ 4. Antigens coating the neonate’s red blood cells.

83.

After teaching the mother of a neonate with erythroblastosis fetalis who is to receive an exchange transfusion, which of the following, if stated by the mother as the purpose of the transfu- sion, indicates effective teaching?

■ 1. To replenish the neonate’s leukocytes.

■ 2. To restore the fl uid and electrolyte balance.

■ 3. To correct the neonate’s anemia.

■ 4. To replace Rh-negative blood with Rh-positive blood.

84.

The nurse explains to the mother of a neo- nate diagnosed with erythroblastosis fetalis that the exchange transfusion is necessary to prevent dam- age primarily to which of the following organs in the neonate?

■ 1. Kidneys.

■ 2. Brain.

■ 3. Lungs.

■ 4. Liver.

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95.

While caring for the neonate of a human immunodefi ciency virus–positive mother, the nurse prepares to administer an ordered hepatitis B intra- muscular injection at 4 hours after birth. Which of the following actions should the nurse do fi rst?

■ 1. Bathe the neonate with an antibacterial soap.

■ 2. Place the neonate under a radiant warmer.

■ 3. Wash the injection site with povidone-iodine (Betadine) solution.

■ 4. Apply clean gloves before administering the medication.

96.

A male neonate born at 38 weeks’ gestation by cesarean delivery after prolonged rupture of the membranes and a maternal oral temperature of 102° F (38.8° C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the physician?

■ 1. Leukocytosis.

■ 2. Apical heart rate of 132 bpm.

■ 3. Behavioral changes.

■ 4. Warm, moist skin.

97.

The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following will the nurse need to instruct the parents to do because of the neonate’s infection?

■ 1. Use caution near the isolation incubator and equipment.

■ 2. Visit but do not touch the neonate.

■ 3. Wash their hands thoroughly before touching the neonate.

■ 4. Wear a mask when holding the neonate.

98.

A female neonate delivered vaginally at term with a cleft lip and cleft palate is admitted to the regular nursery. Which of the following actions should the nurse do the fi rst time that the parents visit the neonate in the nursery?

■ 1. Explain the surgical interventions that will be performed.

■ 2. Stress that this defect is not life-threatening.

■ 3. Emphasize the neonate’s normal characteris- tics.

■ 4. Reassure the parents about the success rate of the surgery.

99.

After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?

■ 1. “I should clean her mouth with soapy water after feeding.”

■ 2. “I should feed her in an upright position.”

■ 3. “I need to remember to burp her often.”

■ 4. “I may need to use a special nipple for feeding.”

90.

While assessing a neonate weighing 3,175 g (7 lb) who was born at 39 weeks’ gestation to a prim- iparous client who admits to cocaine use during pregnancy, which of the following would alert the nurse to possible cocaine withdrawal?

■ 1. Bradycardia.

■ 2. High-pitched cry.

■ 3. Sluggishness.

■ 4. Hypocalcemia.

91.

After teaching a primiparous client who used cocaine during pregnancy about possible gastroin- testinal signs and symptoms in her neonate, which of the following, if stated by the mother as common, indicates effective teaching?

■ 1. Hypotonia.

■ 2. Constipation.

■ 3. Vomiting.

■ 4. Abdominal distention.

92.

When teaching a primiparous client who used cocaine during pregnancy how to comfort her fussy neonate, the nurse can advise the mother to:

■ 1. Tightly swaddle the neonate.

■ 2. Feed the neonate extra, high-calorie formula.

■ 3. Keep the neonate in a brightly lit environ- ment.

■ 4. Touch the baby only when he is crying.

93.

A neonate born at 38 weeks’ gestation is admitted to the neonatal nursery for observation.

The neonate’s mother, who is positive for human immunodefi ciency virus (HIV) infection, has

received no prenatal care. The mother asks the nurse if her neonate is positive for HIV. The nurse can tell the mother which of the following?

■ 1. “More than 50% of neonates born to mothers who are positive for HIV will be positive at 18 months of age.”

■ 2. “An enlarged liver at birth generally means the neonate is HIV positive.”

■ 3. “A complete blood count analysis is the primary method for determining whether the neonate is HIV positive.”

■ 4. “Most neonates are asymptomatic at birth and usually test positive for the HIV antibody at this time.”

94.

When caring for a multiparous client who is human immunodefi ciency virus (HIV)–positive and asking to breast-feed her neonate as soon as possi- ble, which of the following instructions about breast milk should the nurse include in the teaching plan?

■ 1. It may help prevent the spread of the HIV virus.

■ 2. It contains antibodies that can protect the neonate from HIV.

■ 3. It can be benefi cial for the bonding process.

■ 4. It has been found to contain the retrovirus HIV.

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105.

The father of a neonate diagnosed with gastro- schisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teach- ing plan about feeding the neonate?

■ 1. The neonate will remain on nothing-by- mouth (NPO) status until after surgery.

■ 2. An iron-fortifi ed formula will be given before surgery.

■ 3. The neonate will need total parenteral nutri- tion for nourishment.

■ 4. The mother may breast-feed the neonate before surgery.

106.

The nurse is developing a plan of care for a neonate who is to undergo gastroschisis surgery.

What should be included? Select all that apply.

■ 1. Prevention of hypothermia.

■ 2. Maintenance of fl uid and electrolyte balance.

■ 3. Provision of time for parental bonding.

■ 4. Prevention of infection.

■ 5. Providing developmental care.

107.

While caring for a male neonate diagnosed with gastroschisis, the nurse observes that the parents seem hesitant to touch the neonate because of his appearance. The nurse determines that the parents are most likely experiencing which of the following stages of grief?

■ 1. Denial.

■ 2. Shock.

■ 3. Bargaining.

■ 4. Anger.

108.

Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?

■ 1. Keep the neonate’s eyes completely covered.

■ 2. Use a regular diaper on the neonate.

■ 3. Offer feedings every 4 hours.

■ 4. Check the oral temperature every 8 hours.

109.

While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?

■ 1. Bronze-colored skin.

■ 2. Maculopapular chest rash.

■ 3. Urine specifi c gravity of 1.018.

■ 4. Absent Moro refl ex.

110.

The nurse is caring for a neonate at 38 weeks’

gestation when the nurse observes marked peri- staltic waves on the neonate’s abdomen. After this observation, the neonate exhibits projectile vomit- ing. The nurse notifi es the pediatrician because these signs are indicative of which of the following?

■ 1. Esophageal atresia.

■ 2. Pyloric stenosis.

■ 3. Diaphragmatic hernia.

■ 4. Hiatal hernia.

100.

A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?

■ 1. Use an appropriate nipple and bottle set.

■ 2. Encourage the mother to breast-feed.

■ 3. Assess daily weights and wet diapers to monitor intake.

■ 4. Allow unlimited length of time for each feed- ing.

101.

A male neonate born at 36 weeks’ gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instruc- tions should the nurse expect to include when developing the teaching plan for the mother about FAS?■ 1. Withdrawal symptoms usually do not occur

until 7 days postpartum.

■ 2. Large-for-gestational-age size is common with this condition.

■ 3. Facial deformities associated with FAS can be corrected by plastic surgery.

■ 4. Symptoms of withdrawal include tremors, sleeplessness, and seizures.

102.

Which of the following characteristics should the nurse teach the mother about her neonate diag- nosed with fetal alcohol syndrome (FAS)?

■ 1. Neonates are commonly listless and lethargic.

■ 2. The IQ scores are usually average.

■ 3. Hyperactivity and speech disorders are com-

■ 4. The mortality rate is 70% unless treated.mon.

103.

A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruc- tion when she says which of the following?

■ 1. “The way my baby’s face looks now will stay that way.”

■ 2. “My baby may be irritable as a newborn.”

■ 3. “I may need some help coping with my new- born.”

■ 4. “My baby will be fi ne soon after we are home.”

104.

When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse expect to do fi rst?

■ 1. Weigh the neonate.

■ 2. Insert an orogastric tube.

■ 3. Prepare for immediate blood transfusion.

■ 4. Cover the abdomen with a moistened sterile gauze.

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Managing Care Quality and Safety

115.

The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?

■ 1. A neonate born at 36 weeks’ gestation.

■ 2. A neonate born by Cesarean section.

■ 3. A neonate experiencing apneic episodes.

■ 4. A neonate who is 42 weeks’ gestation

116.

The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients fi rst?

■ 1. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes.

■ 2. A newborn delivered at 36-weeks’ gestation weighing 5 lb who is due to breast-feed for the fi rst time in 15 minutes.

■ 3. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago.

■ 4. A newborn who had a borderline low temperature and was double-wrapped with a hat on ½ hour ago to bring up the temperature.

117.

The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One new- born is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis.

The SCN cannot accept a transfer for 30 minutes.

The nurse has been notifi ed that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine follow-up. There can be no other addi- tions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?

■ 1. Ask the nurses in SCN if they can take the newborn with possible sepsis now.

■ 2. Ask the primary staff nurses to take their babies back to the sleeping mothers’

rooms.

■ 3. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave.

■ 4. Ask the nurse with the infant who is breath- ing at 80 bpm to wait ½ hour.

111.

The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following?

■ 1. Decreased cardiac output with faint periph- eral pulses.

■ 2. Profound cyanosis over most of the body.

■ 3. Loud cardiac murmurs through systole and diastole.

■ 4. Harsh systolic murmurs with a palpable thrill.

112.

Assessment of a term neonate at 8 hours after birth reveals tachypnea, dyspnea, sternal retrac- tions, diminished femoral pulses, poor lower body perfusion, and cyanosis of the lower body and extremities, with a pink upper body. The nurse notifi es the pediatrician based on the interpretation that these symptoms are associated with which of the following?

■ 1. Coarctation of the aorta.

■ 2. Atrioventricular septal defect.

■ 3. Pulmonary atresia.

■ 4. Transposition of the great arteries.

113.

The nurse is caring for a 2-day-old neonate in the recovery room 30 minutes after surgical cor- rection for the cardiac defect, transposition of the great vessels. Which of the following would alert the nurse to notify the physician?

■ 1. Oxygen saturation of 90%.

■ 2. Pale pink extremities.

■ 3. Warm, dry skin.

■ 4. Femoral pulse of 90 bpm.

114.

After the physician explains the progno- sis and medical management for atrial septal defect to a primiparous client whose 2-day-old female neonate was diagnosed with this condi- tion, the nurse determines that the mother needs further instructions when she says which of the following?

■ 1. “As my child grows, she may have increased fatigue and diffi culty breathing.”

■ 2. “My child may need to have antibiotics if she develops an infection.”

■ 3. “This condition occurs more commonly in females than in males.”

■ 4. “About half of the children born with this defect heal spontaneously.”

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Answers, Rationales, and Test Taking Strategies

The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.

For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.