41.
The nurse is discussing kangaroo care with the parents of a premature neonate. The nurse should tell the parents that the advantages of kanga- roo care include which of the following? Select all that apply.■ 1. Facilitate a positive bonding experience.
■ 2. Increased IQ.
■ 3. Physiologic stability.
■ 4. Shorten length of stay in the neonatal inten- sive care unit.
■ 5. Time to grow.
32.
After instructing a mother about normal refl exes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck refl ex as occurring when the neonate does which of the following?■ 1. Steps briskly when held upright near a fi rm, hard surface.
■ 2. Pulls both arms and does not move the chin beyond the point of the elbows.
■ 3. Turns head to the left, extends left extremi- ties, and fl exes right extremities.
■ 4. Extends and abducts the arms and legs with the toes fanning open.
33.
A primiparous client expresses concern, asking the nurse why her neonate’s eyes are crossed.Which of the following would the nurse include when teaching the mother about neonatal strabismus?
■ 1. The neonate’s eyes are unable to focus on light at this time.
■ 2. Neonates commonly lack eye muscle coordination.
■ 3. Congenital cataracts may be present.
■ 4. The neonate is able to fi xate on distant objects immediately.
34.
While performing a physical assessment on a term neonate shortly after birth, which of the follow- ing would cause the nurse to notify the pediatrician?■ 1. Deep creases across the soles of the feet.
■ 2. Frequent sneezing during the assessment.
■ 3. Single crease on each of the palms.
■ 4. Absence of lanugo on the skin.
35.
Metabolic screening of an infant revealed a high phenylketonuria (PKU) level. Which of the following statements by the infant’s mother indicates understanding of the disease and its management? Select all that apply.■ 1. “My baby can’t have milk-based formulas.”
■ 2. “My baby will grow out of this by the age of 2.”
■ 3. “This is a hereditary disease, so any future children will have it, too.”
■ 4. “ My baby will eventually become retarded because of this disease.”
■ 5. “We have to follow a strict phenylalanine diet.”
■ 6. “A dietitian can help me plan a diet that keeps a safe phenylalanine level but lets my baby grow.”
36.
Assessment of a term neonate at 2 hours after birth reveals a heart rate of 110 bpm, periods of apnea approximately 25 to 30 seconds in length, and mild cyanosis around the mouth. The nurse notifi es the pediatrician based on the interpretation that these fi ndings may lead to which condition?■ 1. Respiratory arrest.
■ 2. Bronchial pneumonia.
■ 3. Intraventricular hemorrhage.
■ 4. Epiglottitis.
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48.
Twenty-four hours after cesarean delivery, a neonate at 30 weeks’ gestation is diagnosed with respiratory distress syndrome (RDS). When explain- ing to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body’s secretion of which of the following?■ 1. Somatotropin.
■ 2. Surfactant.
■ 3. Testosterone.
■ 4. Progesterone.
49.
When caring for a neonate born at 30 weeks’gestation who is in an isolette and receiving con- tinuous oxygen, which of the following would the nurse use as the best method to determine the effec- tiveness of this treatment?
■ 1. Evidence of cyanosis on mouth, hands, and feet.
■ 2. Continuous pulse rate monitoring.
■ 3. Arterial blood gas levels.
■ 4. Percentage of oxygen delivered.
50.
A viable male neonate delivered to a 28-year-old multiparous client by cesarean deliv- ery because of placenta previa is diagnosed with respiratory distress syndrome (RDS). Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?■ 1. Mother’s development of placenta previa.
■ 2. Neonate delivered preterm.
■ 3. Mother receiving analgesia 4 hours before delivery.
■ 4. Neonate with sluggish respiratory efforts after delivery.
51.
While the nurse is caring for a neonate at 32 weeks’ gestation in an isolette with continuous oxygen administration, the neonate’s mother asks why the neonate’s oxygen is humidifi ed. The nurse should tell the mother?■ 1. “The humidity promotes expansion of the neonate’s immature lungs.”
■ 2. “The humidity helps to prevent viral or bacte- rial pneumonia.”
■ 3. “Oxygen is drying to the mucous membranes unless it is humidifi ed.”
■ 4. “Circulation to the baby’s heart is improved with humidifi ed oxygen.”
42.
A neonate at 37 weeks’ gestation is delivered by cesarean delivery because of placenta previa.Which of the following would the circulating nurse do fi rst as soon as the neonate is delivered?
■ 1. Stimulate the neonate to cry vigorously.
■ 2. Aspirate mucus from the mouth with a bulb syringe.
■ 3. Begin resuscitation procedures with a bag and mask.
■ 4. Hold the neonate upright for the mother to view.
43.
After a vaginal delivery, a preterm neonate is to receive oxygen via mask. While administering the oxygen, the nurse would place the neonate in which of the following positions?■ 1. Left side, with the neck slightly fl exed.
■ 2. Back, with the head turned to the left side.
■ 3. Abdomen, with the head down.
■ 4. Back, with the neck slightly extended.
44.
Which of the following actions should the nurse take when performing external cardiac mas- sage on a neonate born at 28 weeks’ gestation?■ 1. Alternate cardiac massage with ventilation.
■ 2. Compress the sternum with the palm of the hand.
■ 3. Compress the chest 70 to 80 times per minute.
■ 4. Displace the chest wall half the depth of the anterior-posterior diameter of the chest.
45.
A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following?■ 1. Humidify the air being delivered.
■ 2. Cover the neonate’s scalp with a warm cap.
■ 3. Record the neonate’s temperature every 3 to 4 minutes.
■ 4. Assess the neonate’s blood glucose level.
46.
Two hours ago, a neonate at 38 weeks’ gesta- tion and weighing 3,175 g (7 lb) was born to a prim- iparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician?■ 1. Alkalosis.
■ 2. Increased muscle tone.
■ 3. Temperature instability.
■ 4. Positive Babinski’s refl ex.
47.
Assessment of a 2-day-old neonate delivered at 34 weeks’ gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should fi rst:■ 1. Consult with health care provider to obtain a chest x-ray.
■ 2. Reposition the neonate and then assess if the grunting and cyanosis resolve.
■ 3. Begin oxygen administration at 6-8 L via mask.
■ 4. Obtain a complete blood count to determine infection.
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57.
Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks’gestation who is diagnosed with intraventricular hemorrhage (IVH)?
■ 1. Increased muscle tone.
■ 2. Hyperbilirubinemia.
■ 3. Bulging fontanels.
■ 4. Hyperactivity.
58.
An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifi er in the infant’s mouth during these feedings. The nurse replies that the pacifi er helps in what ways? Select all that apply.■ 1. Teaches the infant to suck and swallow.
■ 2. Provides oral stimulation.
■ 3. Keeps oral mucus membranes moist while the tube is in place.
■ 4. Reminds the infant how to suck.
■ 5. Stimulates secretions that help gastric emptying.
59.
While caring for a neonate delivered at 32 weeks’ gestation, the nurse assesses the neonate daily for symptoms of necrotizing enterocolitis (NEC). Which of the following would alert the nurse to notify the neonatologist?■ 1. The presence of 1 mL of gastric residual before a gavage feeding.
■ 2. Jaundice appearing on the face and chest.
■ 3. An increase in bowel peristalsis.
■ 4. Abdominal distention.
60.
Which of the following statements by the mother of a neonate diagnosed with bronchopulmo- nary dysplasia (BPD) indicates effective teaching?■ 1. “BPD is an acute disease that can be treated with antibiotics.”
■ 2. “My baby may require permanent assisted ventilation.”
■ 3. “Bronchodilators can cure my baby’s condi- tion.”
■ 4. “My baby may have seizures later on in life because of this condition.”
61.
A preterm infant delivered 2 hours ago at 34 weeks’ gestation is experiencing rapid respira- tions, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?■ 1. Placement of the neonate on a ventilator.
■ 2. Administration of bronchodilators through the nares.
■ 3. Suctioning of the neonate’s nares with wall suction.
■ 4. Insertion of a chest tube into the neonate.
52.
A preterm neonate admitted to the neonatal intensive care unit at about 30 weeks’ gestation is placed in an oxygenated isolette. The neonate’s mother tells the nurse that she was planning to breast-feed the neonate. Which of the following instructions about breast-feeding would be most appropriate?■ 1. Breast-feeding is not recommended because the neonate needs increased fat in the diet.
■ 2. Once the neonate no longer needs oxygen and continuous monitoring, breast-feeding can be done.
■ 3. Breast-feeding is contraindicated because the neonate needs a high-calorie formula every 2 hours.
■ 4. Gavage feedings using breast milk can be given until the neonate can coordinate suck- ing and swallowing.
53.
Which of the following best identifi es the reason for assessing a neonate weighing 1,500 g at 32 weeks’ gestation for retinopathy of prematurity (ROP)?■ 1. The neonate is at risk because of multiple factors.
■ 2. Oxygen is being administered at a level of 21%.
■ 3. The neonate was alkalotic immediately after birth.
■ 4. Phototherapy is likely to be ordered by the pediatrician.
54.
Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks’ gestation who weighs 2,000 g?■ 1. Sunken orbital sockets.
■ 2. Strabismus.
■ 3. Reaction to bright light.
■ 4. Constricted retinal vessels.
55.
Which of the following subjects should the nurse include when teaching the mother of a neo- nate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications?■ 1. Laser therapy.
■ 2. Cromolyn sodium (Intal) eye drops.
■ 3. Frequent testing for glaucoma.
■ 4. Corneal transplants.
56.
Three days after admission of a neonate delivered at 30 weeks’ gestation, the neonatologist plans to assess the neonate for periventricular- intraventricular hemorrhage (PIVH). The nurse should plan to assist the neonatologist by preparing the neonate for which of the following?■ 1. Computed tomography scan.
■ 2. Arterial blood specimen collection.
■ 3. Radiographs of the skull.
■ 4. Complete blood count specimen collection.
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67.
A neonate is admitted to the neonatal inten- sive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS).The neonate weighs 10 lb, 4 oz (4,650 g) and is at 41 weeks’ gestation. Which of the following nursing diagnoses would be the priority for this neonate?
■ 1. Impaired skin integrity related to post-term status.
■ 2. Imbalanced nutrition: More than body requirements related to large size.
■ 3. Risk for impaired parent-infant-child attach- ment related to transfer to the intensive care unit.
■ 4. Impaired gas exchange related to the effects of respiratory distress.
68.
When developing the initial plan of care for a neonate who was born at 41 weeks’ gestation, was diagnosed with meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse include?■ 1. Care of an umbilical arterial line.
■ 2. Frequent ultrasound scans.
■ 3. Orogastric feedings as soon as possible.
■ 4. Assessment for symptoms of hyperglycemia.
69.
A post-term neonate diagnosed with persis- tent pulmonary hypertension is prescribed intrave- nous tolazoline (Priscoline). While administering this drug, the nurse should monitor the neonate for?■ 1. Feeding behaviors.
■ 2. Temperature.
■ 3. Skin color.
■ 4. Blood pressure.