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51 Cards in this Set
- Front
- Back
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A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurse’s most appropriate action is to
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Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
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Infants of mothers with diabetes (IDMs) are at higher risk for developing
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Respiratory distress syndrome.
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An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of
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Hypoglycemia
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When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has
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Greater surface area in proportion to weight.
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On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give?
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“You may hold your baby during the feeding.”
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A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?
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“Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide.”
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When providing an infant with a gavage feeding, which of the following should be documented each time?
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The infant’s response to the feeding
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An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory compromise?
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Slow, small, warm bolus feedings over 30 minutes
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An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse’s most appropriate action would be to:
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Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.
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A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborn’s parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurse’s most appropriate action would be to:
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Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn.
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Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include:
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Abdominal distention, temperature instability, and grossly bloody stools.
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An infant is being discharged from the neonatal intensive care unit after 70 days of hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infant’s mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurse’s most appropriate response is:
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“Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-week-old infant would be doing.”
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A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetrician’s office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate:
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Meconium aspiration, hypoglycemia, and dry, cracked skin.
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In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?
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Retinopathy of prematurity (ROP)
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In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:
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Hypovolemia and/or shock.
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Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:
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Breathing in a respiratory pattern common to premature infants.
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The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infant’s gestational age. This intervention:
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Helps infants to interact directly with their parents and enhances their temperature regulation.
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For clinical purposes, preterm and post-term infants are defined as:
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Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth.
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With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that:
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Infants with asymmetric IUGR have the potential for normal growth and development.
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As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that:
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Parents of high risk infants need special support and detailed contact information.
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Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC:
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Breastfeeding
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As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:
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Mottled skin with acrocyanosis.
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Because of the premature infant’s decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?
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Risk for infection
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A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn’s distress is most likely to be:
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Sepsis
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The most important nursing action in preventing neonatal infection is:
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Good handwashing.
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A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant’s physical findings, this woman should be questioned about her use of which substance during pregnancy?
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Alcohol
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A plan of care for an infant experiencing symptoms of drug withdrawal should include:
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Swaddling the infant snugly and holding the baby tightly.
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Human immunodeficiency virus (HIV) may be perinatally transmitted:
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Through the ingestion of breast milk from an infected mother.
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The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States?
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Alcohol
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During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse’s best response would be:
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“Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child.”
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A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant’s eyes when the mother asks, “What is that medicine for?” The nurse responds:
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“Erythromycin is given prophylactically to prevent a gonorrheal infection.”
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With regard to injuries to the infant’s plexus during labor and birth, nurses should be aware that:
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If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months.
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As related to central nervous system injuries that could occur to the infant during labor and birth, nurses should be aware that:
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In many infants signs of hemorrhage in a full-term infant are absent and are diagnosed only through laboratory tests.
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To care adequately for infants at risk for neonatal bacterial infection, nurses should be aware that:
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Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot.
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Near the end of the first week of life, an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of:
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Congenital syphilis.
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What bacterial infection is definitely decreasing because of effective drug treatment?
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Group B streptococcal infection
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In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that:
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Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school.
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A careful review of the literature on the various recreational and illicit drugs reveals that:
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More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs.
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To provide optimal care of infants born to mothers who are substance abusers, nurses should be aware that:
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Mothers who abuse one substance likely will use or abuse another, thus compounding the infant’s difficulties.
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Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is:
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Neonatal abstinence syndrome scoring.
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While completing a newborn assessment, the nurse should be aware that the most common birth injury is:
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Fracture of the clavicle.
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The most common cause of pathologic hyperbilirubinemia is:
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Hemolytic disorders in the newborn.
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Which infant would be more likely to have Rh incompatibility?
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Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
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With regard to hemolytic diseases of the newborn, nurses should be aware that:
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The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.
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An infant with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which highly technical method of treatment may be necessary for an infant who does not respond to conventional treatment?
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Extracorporeal membrane oxygenation
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The goal of treatment of the infant with phenylketonuria (PKU) is to:
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Prevent central nervous system (CNS) damage, which leads to mental retardation.
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HIV may be perinatally transmitted:
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Through the ingestion of breast milk from an infected mother.
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Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (Select all that apply):
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Amphetamine Heroin Nicotine PCP ABCD |
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Risk factors associated with necrotizing enterocolitis (NEC) include (Select all that apply):
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Polycythemia Anemia Congenital heart disease ABC |
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Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for (Select all that apply):
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Problems with thermoregulation Hyperbilirubinemia Sepsis ACD |
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a. Secure the infant in the car seat per guidelines using blanket rolls on the side. b. Leave the infant undisturbed for 90 to 120 minutes. c. Set the heart rate alarm at 80 bpm and the apnea alarm at 20 seconds. d. Document the infant’s tolerance to the test.e. Perform the evaluation 1 to 7 days before discharge. f. Use the parent’s car seat. g. Set the pulse oximeter low alarm at 88%. 51. Step 1 52. Step 2 53. Step 3 54. Step 4 55. Step 5 56. Step 6 57. Step 7 |
51. F 52. E 53. A 54. G 55. C 56. B 57. D |
