12/6/2011 Maternal-Newborn Nursing Chapter 13: NCLEX RN® Review Practice Test

You got 14 out of 30 questions correct 1. The following neonates are admitted to the nursery. The nurse should wit hhold the scheduled initial feeding from which newborn? You answered incorrectly: A neonate with an axillary temperature of 97.5ºF. The correct answer was: A neonate with a sustained respiratory rate of 68 breath s/min. Rationale: Feeding a baby orally with a respiratory rate greater than 60 breaths /min increases the risk of aspiration. A heart rate of 118 is slightly below the normal range of 120-160 beats/min but it is not a contraindication to feeding t he infant. A hypothermic or small for gestational age infant are both at risk fo r hypoglycemia and require a consistent source of glucose. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Knowledge of the nutritional needs of infants and the infant at risk f or aspiration will help to answer the question correctly. Eliminate option 2 bec ause it is not a reason to withhold a feeding, and eliminate options 3 and 4 bec ause the infants need a consistent source of glucose. Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mate rnal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pe arson Education, Inc., pp. 773, 951. 2. The nurse hears the parents of a 26-week gestation newborn tell family m embers "we'll be ready to bring the baby home in a few weeks." The most therapeu tic response by the nurse is: You answered correctly: "He probably won't be ready to come home for a few month s." Rationale: Families are often in a state of denial with the birth of a sick newb orn. It is important for nurses to gently encourage the parents to be realistic. By agreeing with the parents statement (option 1), the nurse is prolonging the state of denial and making it more difficult for the parents to see the situatio n realistically. Some parents do benefit from professional counseling, but nurse s still need to provide support when working with families. It is not important if the nursery is ready yet (option 4) and this distracts from the real issues t his family is facing at this time. Cognitive Level: Application Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: Knowledge of therapeutic communication to provide realistic support to the parents will aid in choosing the correct answer. Focus on the critical word s in the stem of the question "26-week gestation." Compare this to the normal 40 -week gestational period to determine that this infant will require care for som e time. Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Ne wborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearso n Education, Inc. p. 913-916, 983.

. London. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: Eliminate options 1. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. S. Reference: Olds. P. 889-895. Cognitive Level: Analysis Client Need: Psychosocial Integrity Integrated Process: Teaching/Learning Content Area: Maternal-Newborn Strategy: Knowledge of the ways to promote parent-infant attachment will help to answer the question... Upper Saddle River. (2004). & Davidson. the nurse writes a goal that within one week the infant will: You answered incorrectly: Maintain body temperature in a bassinet.L.: Pearso . drink from a bottle or recognize parents at one week of age. 983. & Davidson. Upper Saddle River.R. Maternal-Ne wborn Nursing & Women's Health Care (7th ed. or m ake nursing decisions based on changes in a client's assessment. London. p. Ladewig. the n urse determines that teaching has been effective if which of the following is ob served? You answered incorrectly: The couple wear gloves every time they touch their bab y The correct answer was: The couple puts family pictures in the isolette Rationale: Taping family pictures to the sides of the isolette promotes bonding and infant stimulation. NJ: Pe arson Education. Which baby could be appropriatel y assigned to an LPN/LVN? You answered correctly: A stable premature infant being fed every two hours Rationale: An LPN/LVN is not qualified to admit a client. A 28 -week gestation infant cannot maintain body temperature.B.. M. Rationale: A normal respiratory rate for all newborns is 30-60 breaths/min. 822.. London. Inc. (2004). & Davidson. M. The nurse is making client assignments. Young childre n often harbor organisms that could be transmitted to vulnerable newborns and sh ould not have contact until the infant is moved out of the neonatal intensive ca re unit.. 5. While observing the parents interact with their high risk newborn. Parents should wash their hands when they enter the unit but do not need to wear gloves when in contact with their infant. P. (2004).3. N. M. pp. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. NJ: Pe arson Education.). 2.A. M. J.A. administer blood.. Cognitive Level: Application Client Need: Safe Effective Care Environment: Management of Care Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Knowledge of delegation and the roles and responsibilities of the LPN/ LVN will aid in determining the correct answer. An LPN/LVN is q ualified to perform certain procedures and care for stable clients (option 3).L. In formulating a plan of care for an infant born at 28 weeks' gestation. Inc.. Upper Saddle River. 913-916. Reference: Olds. 4.R. Ladewig. Ladewig. M.B.. S. Reference: Olds.). M. and 4 because they are not appropriate for a 2 8-week gestation infant at one week of age. S.). P. The correct answer was: Maintain respiratory rate between 30-60 breaths/minute.

A..). The infant should be unclothed to allow as mu ch skin exposure to the high intensity light as possible and to be turned every two hours. P. & Davidson.. The other three answers may warrant furt her investigation. breathing and circulation.n Education. Inc. but the priority at delivery is to establish and maintain an airway. Reference: Olds. Reference: Olds.. 7-13. Ladewig. The light sources affect the surfaces of the body.L. S. Think also about other measures that protect the skin. Eliminate options 1. Upper Saddle River. S. p.A. Inc. M. Inc. A newborn is receiving phototherapy for the treatment of hyperbilirubine mia. 8. Rationale: Preterm infants have minimal adipose tissue so they tend to lose heat faster through their skin. 2.R.B. The nurse concludes that client teaching has been effective when the parent s are observed doing which of the following? Select all that apply. 889.R. Breastfeeding is not contraindicated with hyperbilirubinemia. P. Which of the following would be most important for the nurse to note as part of the initial assessment of a newborn's history? You answered incorrectly: Mother's blood type is O negative The correct answer was: Mother received meperidine (Demerol) 50 mg IV 20 minutes before delivery Rationale: Narcotics cross the placenta and if given close to delivery can cause respiratory depression in the newborn. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Remember airway. M. 7. NJ: Pe arson Education.. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Content Area: Maternal-Newborn Strategy: Knowledge of phototherapy and the necessary nursing care will help to choose the correct answer. London. pp. & Davidson. 6. You answered incorrectly: Cover the infant's eyes before placing under the high intensity light The correct answers were: Cover the infant's eyes before placing under the high intensity light. Because they are weak and neurologically immature. 965-970. 667-668. Ladewig. they aren't able to lay in a tight fetal posit ion allowing a greater percentage of their body to be exposed to the air and los ..L. use eye protection as a key guiding principl e. Their skin is thin with blood vessels near the surfa ce which increases the amount of heat lost through their skin. Wh en thinking about sources of light. (2004). a nd 4 because these findings may warrant further investigation. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. Loose g reen stools are a side effect of bilirubin excretion through the intestines.B.). Turn the infant every two hours Rationale: It is important to protect the infant's eyes from the high intensity light to prevent permanent damage. M. M.. The parents of a preterm neonate ask why their baby gets cold so easily. (2004). pp. The nurse explains that preterm neonates: You answered correctly: Have minimal body fat to retain body heat. but the priority at delivery is to establish and maintain an airway. London. Upper Saddle River. NJ: Pe arson Education.

).. S.B. Reference: Olds. Which of the following data would alert the nurse that the infant is exp eriencing dehydration? You answered incorrectly: Low serum sodium The correct answer was: Sunken anterior fontanelle Rationale: Signs of dehydration in an infant include dry mucus membranes.). NJ: Pe arson Education.R. The other assessment data are expected finding s in an infant. While feeding an infant the nurse notices white adherent patches on the infant's gums and buccal cavity.. infants are not able to shiver to produce body heat whe n they are cold. and is wrapped in a blanket . The highest priority of the nurse is to assess: You answered correctly: Patent airway. In general. he is active.. Eliminate option 1 because this is not a normal findi ng. 10. Upper Saddle River. Elimina te option 4 because this finding would not be indicative of herpes infection. A newborn is admitted to the nursery 15 minutes after delivery. NJ: Pe arson Education. . The nurse should take which of the following ac tions? You answered correctly: Further evaluate for yeast infection Rationale: The primary sign of an oral yeast infection. Ladewig.R. Ladewig.e more heat. M. and 3 because th ese assessment findings are expected in an infant. & Davidson. P. Mate rnal-Newborn Nursing & Women's Health Care (7th ed.L. Inc. M. P.A. M. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Knowledge of the signs of oral yeast infection or thrush will help to choose the correct answer. (2004). Use this information to eliminate each incorrect option systemat ically. London. Ladewig. Reference: Olds. Inc. S. p. sunken fontanelle. is white patc hes in the mouth that tend to bleed if they are touched. (2004). London. (2004). 806-807. Eliminate option 3 because vitamin K is not related to this finding. M.. 974. Eliminate options 1.L.. Upper Saddle River. His skin is mottled. & Davidson..R. pp. and dry skin turgor. M.. or thrush. 2. S. 11.). p. Reference: Olds.. 901. London. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. & Davidson. 9. mucus membranes are blue. Inc. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Analysis Content Area: Maternal-Newborn Strategy: Knowledge of the signs and symptoms of dehydration in the newborn will aid in identifying the correct answer. P. 825. M.A. NJ: Pe arson Education. Upper Saddle River. Mate rnal-Newborn Nursing & Women's Health Care (7th ed.B.A.. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Content Area: Maternal-Newborn Strategy: Knowledge of heat loss for preterm infants is necessary to choose the correct answer. The other answers are b ased on incorrect conclusions about the significance of the symptom.L.B.

(2004). You answered correctly: Expiratory grunting sounds. The nurse should plan for which of the following interventions? You answered incorrectly: Administer surfactant via the endotracheal tube The correct answer was: Schedule eye exam by ophthalmologist prior to discharge Rationale: This infant has been receiving high levels of oxygen for several week s and is at risk for retinopathy of prematurity (ROP). P. Ladewig.).R.B. (2004). nasal flaring. This infant is demonstrating initial signs of respiratory defici ency. include hypoxia with respiratory and meta bolic acidosis. 945-946. P. M. A 26-week gestation neonate has received 80-100% oxygen via mechanical v entilation for two weeks and has received several blood transfusions for anemia. pp. Inc. NJ: Pe arson Education. Substernal re traction with inspiration Rationale: The physiologic changes that occur with respiratory distress syndrome . tachypnea. Follow the ABC's of resuscitation: airway. substernal. & Davidson. Ladewig. 13. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Recall the characteristics of normal newborn respiratory function to i dentify abnormal assessment findings. 942-946. Eliminate option 3 because the skin c olor would change from pink to pale. Eliminate opt ion 6 because symmetrical and diaphragmatic respiratory movement characterizes n ormal breathing. Inc... Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Knowledge of the signs and symptoms of respiratory distress and the pr iority intervention of maintaining a patent airway is needed to choose the corre ct answer.L. Eliminate option 1 because the respiratory rate would increase rather than decrease. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. It is important to administer the minimum amount of oxygen to infa nts to decrease the risk that this condition will develop.. Which of the followi ng assessment findings would support the nurse's judgment? Select all that appl y. grunting respirations. Oxygen should be wean ed and not withdrawn suddenly..L. S. London. re spirations are labored with suprasternal. mottled or bluish (cyanotic). M. All preterm infants who r eceived oxygen should have a thorough eye exam done by an ophthalmologist prior to discharge. Upper Saddle River. pp.R. London. breathing and circulation.A. M. grunting sounds and nasal flaring as the infant works harder to exch ange air. Reference: Olds. NJ: Pe arson Education. Reference: Olds. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation . retractions and apnea. S. A nurse is caring for a premature newborn and suspects the development o f respiratory distress syndrome (hyaline membrane disease).B.).A. breathing and circulation. Characteristics include increasing cyanosis. 12. Nasal flaring. Upper Saddle River. & Davidson.. In respiratory distress. 938-939.. Artificial surfactant may be administered within the first several days of life to decrease the risk of respiratory distress synd rome (RDS).Rationale: The highest priority after delivery is to maintain and support respir atory function. intercostal or subcostal r etractions. M. Follow the ABC's of resuscitation: airway. more common in the premature infant. Mate rnal-Newborn Nursing & Women's Health Care (7th ed.

An infant of a diabetic mother (IDM) is admitted to the nursery. (2004). M.B.). S. The pri ority intervention of the nurse is to: You answered correctly: Assess the infant's blood glucose. and 3 because these interventio ns are important.. M.. Eliminate option 3 because oxygen s hould be weaned and not withdrawn suddenly. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Analysis Content Area: Maternal-Newborn Strategy: Eliminate options 1.). M. Eliminate option 1 because at this t ime no data is given to support this action. Which sign in the newborn should be evaluated further? You answered correctly: Enlarged liver Rationale: Hepatosplenomegaly may be an early sign of HIV infection in an infant .). & Davidson. pp.L. Inc. NJ: Pe arson Education. M. Ladewig... The nurse's best reply is: You answered correctly: "The high intensity lights help convert the bilirubin to a form the baby can get rid of. The other answers do not describe this process. Eliminate option 4 because artificia l surfactant may be administered to decrease the risk of respiratory distress sy ndrome (RDS). Ladewig. Reference: Olds.. London. Inc. Upper Saddle River. P. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning . Mate rnal-Newborn Nursing & Women's Health Care (7th ed. NJ: Pe arson Education. M. 14.. & Davidson. (2004). London..L. but not the highest priority." Rationale: Phototherapy assists the body in converting unconjugated bilirubin to conjugated bilirubin. 910. Mate rnal-Newborn Nursing & Women's Health Care (7th ed.A. All other interventions are important. pp. which is water soluble and easier for the body to elimina te. Reference: Olds. A father asks how the phototherapy lights make the bilirubin level go do wn.B. 15. P. Planning Content Area: Maternal-Newborn Strategy: Knowledge of the care of the premature infant with the potential for R OP will aid in choosing the correct answer. Eliminate options 1. Ladewig. 924-929.R. and 4 because they present assessment data tha t are within normal limits. 16. S. 2. (2004). You are caring for an infant born to an HIV positive mother. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recognize that hypoglycemia is the greatest risk for this infant and c an be life-threatening. M.Integrated Process: Nursing Process. P. Inc. Mate rnal-Newborn Nursing & Women's Health Care (7th ed.L. 2. Rationale: An infant of a diabetic mother is at risk for hypoglycemia and should be monitored closely after delivery. 896-899. Upper Saddle River. NJ: Pe arson Education. London.R.R.A.. p.A. All other assessment data are within normal limits. S.B. but not the highest priority.. & Davidson. Reference: Olds. Upper Saddle River.

Inc.L. Naloxone (Narcan) is the drug of c hoice to reverse respiratory depression caused by narcotics.B.R.. 19. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. M.). & Davidson. A neonatal nurse is attending a high risk delivery and is told that the mother received morphine sulfate IV 30 minutes ago. Inc. The other answers a re incorrect and do not reverse respiratory depression. and 4 because these drugs will not reverse the action of a narcotic drug. London. The nurse is preparing to discharge an infant with fetal alcohol syndrom e home with foster parents. & Davidson. London. but a cast is not indicated. T he infant should not be positioned on the affected side. It is important to p rovide passive range of motion on the affected side to prevent muscle wasting. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Eliminate option 1 because the assessment findings involve the arm not the infant's hip or leg. left terally. 17. London. p. Eliminate option 2 because the infant should not be p ositioned on the affected side. P.Content Area: Maternal-Newborn Strategy: Knowledge of the underlying rationale for the use of phototherapy and how it works will aid in choosing the correct answer. Inc. M. 816-817. S. S. 18. Reference: Olds.. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. (2004). Ladewig. The nurse should place priority on teaching regardin g: You answered correctly: Feeding methods.A.. Cognitive Level: Application Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process. The nurse assesses a arm limp and extended.R. no response on left ursing intervention for this newborn and obtains the following information: left hand internally rotated.B.). Reference: Olds.A.. 3.. Rationale: Infants with fetal alcohol syndrome have an increased risk of feeding difficulties related to hyperactivity.R. What is the most appropriate n infant? You answered incorrectly: Assess for congenital hip dysplasia The correct answer was: Perform passive range-of-motion Rationale: This infant has signs of Erb-Duchenne paralysis. Upper Saddle River. Upper Saddle River. S. NJ: Pe arson Education.. Eliminate option 4 because occasionally a splint may be applied.. Ladewig.). The nurse should be prepared to give which of the following medications immediately after delivery? You answered incorrectly: Double dose of vitamin K (AquaMEPHYTON) The correct answer was: Naloxone (Narcan) Rationale: Narcotics cross the placenta and can cause respiratory depression in a neonate when given shortly before delivery. Ladewig. . 965.. pp. p. 940-942.. but a cast is not indicated. M.L. Planning Content Area: Maternal-Newborn Strategy: Eliminate options 2. Occasionally a splint m ay be applied.L. NJ: Pe arson Education. (2004).A. M. P. NJ: Pe arson Education. & Davidson. M. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. Reference: Olds. (2004). Upper Saddle River. P. M. The other teaching topics are important. positive grasp reflex bila side to Moro reflex.B.

Wh ich information from the mother's history should be of greatest concern? You answered incorrectly: Marginal placenta previa. A baby's mother is Hepatitis B positive. S. Ladewig. NJ: P earson Education. London.). and 4 because this information is important bu t would not place the infant at increased risk for infection. & Davidson.. 896-899. 973. M. 3. NJ: Pe arson Education. Upper Saddle River.. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Analysis Content Area: Maternal-Newborn Strategy: Knowledge of SGA and the risks imposed will aid in choosing the correc t answer. M. P.B. Ladewig. M. M. M.. (2004)..L. 920-921. Mate rnal-Newborn Nursing & Women's Health Care (7th ed. Upper Saddle River. but sho uld not cause significant complications in the newborn after delivery. 2. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Knowledge of the infant born to the diabetic mother as at risk for hyp oglycemia will aid in determining the correct answer.B. Reference: Olds. Eliminate options 2. Inc.A.L. S. & Davidson. S.B.. If the woman received m eperidine (Demerol) most of the drug would be metabolized within three hours and should not cause respiratory depression in the infant at delivery..A. Which of the following infants is at greatest risk for the nursing diagn osis. Which of the following interven tions is most important when planning care for this newborn? . Remember the information o f greatest concern is related to the greatest risk for the infant's safety. P. Rationale: A maternal history of diabetes increases the risk of hypoglycemia in the newborn and this infant should be monitored closely. 889-895. pp. p. 20.R. The correct answer was: Preexisting insulin-dependent diabetes mellitus.. small for gestational age (SGA) Rationale: Infants who are small for gestational age (SGA) often experience intr auterine growth restriction related to decreased blood flow to the placenta whic h increases their risk for infection. P. 22.. pp. and 4 because these teaching topics are i mportant.). high risk for infection? You answered correctly: 38-week gestation.). (2004). & Davidson. Eliminate options 1. Reference: Olds. London. A marginal p lacenta previa increases the mother's risk of bleeding during pregnancy. Reference: Olds. but not the highest priority at this time. Ladewig. Mate rnal-Newborn Nursing & Women's Health Care (7th ed.L. Inc. NJ: Pe arson Education.R. Upper Saddle River. London. Mat ernal-Newborn Nursing & Women's Health Care (7th ed. Membranes ruptured greater than 24 hours prior to delivery increase the mother's and infa nt's risk of infection.R. 21. The other infants are not at any greater r isk for infection.but not the highest priority at this time. M. (2004). Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Content Area: Maternal-Newborn Strategy: Knowledge of the complications from fetal alcohol syndrome and what th e parents will need to know to care for the infant will aid in determining the c orrect answer. A nurse is admitting a baby to the nursery 30 minutes after delivery.A.. Inc.

Reference: Olds. 23. J. Reference: Olds. not just those at risk for Hepatitis B. (2004) Maternal-New born Nursing & Women's Health Care (7th ed. Tachypnea. London. Ladewig.). & Davidson. . Abdominal distention. Eliminate options 1. which would be evidenced by signs of respiratory distress including s ternal retractions and tachypnea. Ladewig. Knowledge of how to administer a gavage feeding is necessary to choose the correct answer. The nurse realizes that a neonate born at 34 weeks gestation may not hav e enough surfactant. N.You answered correctly: Administer Hepatitis B vaccine within 12 hours after del ivery. The nurse must intervene if which of the following is observed? You answered incorrectly: The stomach contents are aspirated prior to administer ing the feeding. M. Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is assessment findings in a premature infant with the potential for developing respiratory distress. This can lead to the development of respiratory distress syndr ome (RDS). Rationale: Infants born to mothers who are Hepatitis B positive should receive a Hepatitis B vaccine within 12 hours of birth to decrease their risk of acquirin g the infection from maternal exposure. 2. & Davidson. so the nurse should observe closely for: (Select all that a pply.. The nurse is observing a graduate nurse administering a gavage feeding t o a newborn. 24. Upper Saddle River. Tachypnea Rationale: Preterm infants lack adequate surfactant to keep their alveoli open d uring expiration. p. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Implementation Content Area: Maternal-Newborn Strategy: The key focus of the question is the risk of transmission of Hepatitis B from mother to infant. It is appropriate to assess for HIV risk factors in all infants.. 905-907. P.: Pearson Education. you are l ooking for an incorrect method.. P.). M. Therefore. (2004) Maternal-New born Nursing & Women's Health Care (7th ed. S. 862. Inc. Inc. The correct answer would be the option that contains a nursing action to reduce the risk of disease transmission for this infant. Cognitive Level: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process. An exchange tra nsfusion and isolating the infant are not appropriate in this situation. p. M. London. and jitterines s are not directly related to RDS.. J. Upper Saddle River. The correct answer was: The feeding is administered within 15 seconds. M.: Pearson Education. jaundice. All of the other options are correct when administering a gavage feeding.) You answered incorrectly: Sternal retractions. Rationale: Gavage feedings should be administered over 5-10 minutes to decrease the risk of GI distress. Evaluation Content Area: Maternal-Newborn Strategy: Critical words are "the nurse must intervene" which means that the gra duate nurse is performing an incorrect step in the process.. S. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process. Abdominal distention The correct answers were: Sternal retractions. N..

Reference: Olds.. Upper Saddle River. S. S. (2004) Maternal-New born Nursing & Women's Health Care (7th ed. Ladewig. bu t seeing the baby is more effective. Rationale: Parents should be given a Polaroid picture of the infant before the b aby is transported.: Pearson Education. Metabolic acido sis and electrolyte imbalance would be determined by serum not urine analysis. Rationale: Adequate hydration is evidenced by urine output of 1-3 mL/kg/hr and s pecific gravity <1. J. jaundice and jitteriness are not directly r elated to RDS. P. This newborn shows signs of dehydration. M. It is important to be honest with parents. M. p. The nurse can best promote parental bonding with a high risk newborn by doing which of the following? You answered incorrectly: Allowing parents to see the newborn for 15 minutes thr ee times each day.: Pearson Education. London.. ev en if the prognosis is poor. (2004) Maternal-New born Nursing & Women's Health Care (7th ed. p. London. M. A nurse observes that a preterm infant's urine output is less than 1 mL/ kg/hr with a specific gravity >1. Cognitive Level: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process: Analysis Content Area: Maternal-Newborn Strategy: Knowledge of specific gravity and adequate urinary output will aid in determining the correct answer. p. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process. Ladewig. & Davidson. N. All of the other assessments are normal for an infant. The nurse determines that this indicates: You answered incorrectly: Electrolyte imbalance. Cognitive Level: Application Client Need: Psychosocial Integrity . The correct answer was: Giving the parents a Polaroid picture of baby prior to t ransport to the NICU. Which neonate requires the closest observation by the nurse? You answered correctly: The neonate whose color became cyanotic during the first feeding. & Davidson.. Inc. Inc.and 3 because abdominal distention. and 4 because these assessmen t findings are normal for an infant.020. Upper Saddle River. M. 26. 27. M. 929-930. 3. Inc. Rationale: Central cyanosis is always considered abnormal and warrants further e valuation. N. Upper Saddle River. The correct answer was: Dehydration. P. London. Calling the unit to check on their baby may help bonding.)..). (2004) Maternal-New born Nursing & Women's Health Care (7th ed.: Pearson Education.)... Reference: Olds. P. Eliminate options 1. Parents are typically allowed to visit as o ften and for as long as they want. 946. Knowledge of the ominous sign of central cy anosis and the need for close observation will also help to determine the correc t answer. Reference: Olds. J. J. & Davidson. Ladewig. N. M.013. 786-787. 25. Assessment Content Area: Maternal-Newborn Strategy: The key focus of the question is abnormal assessment findings in need of further investigation.. S...

This process requires oxygen and glucose... London.Integrated Process: Nursing Process.. 942-951. M. Phototherapy is not indicated. Infants should be re-warmed slowly to prevent hypotension. S. S. 913-914. Upper Saddle River. Ladewig.R. (2004) Maternal-New born Nursing & Women's Health Care (7th ed. P. p. & Davidson. The nurse must intervene if which of the following is obs erved? You answered correctly: Inserting a nasogastic tube. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The key focus of the question is nursing care to reduce the risk to th e newborn from hypothermia. S. London. glucose and oxygen needs increase and hypoglycemia may result. The inf ant may require oxygen administration. Knowledge of the correct procedure to maintain a patent airwa y will be necessary to determine which of the answers gives an incorrect action.: Pearson Education.: Pearson Education. Reference: Olds. The correct answer was: Monitoring for hypoglycemia.B. M...L. Rationale: Infants are obligate nose breathers. Ladewig. Eliminate option 4 because phototherapy is not indicated in this situati on. London. The nurse is observing a student practicing how to maintain a patent air way on a newborn doll. A gastric tube may be inserted t o keep the stomach decompressed and allow for easier lung expansion. P. Inc. Mat ernal-Newborn Nursing & Women's Health Care (7th ed. NJ: P earson Education.A. N. it occludes one nare and may make respiratory effort more di fficult. (2004).. Elimi nate option 2 because infants should be re-warmed slowly to prevent hypotension.). s: A priority nursing intervention for a newborn experiencing hypothermia i You answered incorrectly: Starting phototherapy.. But if it i s inserted nasally. M. The nurse is caring for a 30-week gestation infant at risk for necrotizi ng enterocolitis (NEC). J." This means that you are looking for an incorrect action on the pa rt of the student. Inc. P. Inc.). Upper Saddle River. M. Upper Saddle River. Rationale: The newborn reacts to hypothermia by burning brown fat to produce bod y heat. Reference: Olds. Ladewig. (2004) Maternal-New born Nursing & Women's Health Care (7th ed. & Davidson. Eliminate option 3 because no data has been given to support this action at thi s time. p. J. 959. Reference: Olds. N. 28. The nurse should observe for which of the following: . & Davidson.. p. M. but the need should always be assessed fi rst. When an infant experiences hyp othermia. Implementation Content Area: Maternal-Newborn Strategy: Knowledge of the care of the family and promoting attachment with the high-risk infant will aid in choosing the correct answer.). Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Evaluation Content Area: Maternal-Newborn Strategy: Critical words are "the nurse must intervene if which of the following is observed. M. a risk related to hypothermia is hypoglycemia. All other options are correct interventions for maintaining a patent ai rway. 29. 30..

You answered incorrectly: A bulging fontanelle. R.J.: Pearson Education. a digestiv e disorder. occur with NEC. The correct answer was: Abdominal distention. Upper Saddle River. The other choices should be reported to the health care p rovider. (2006). but are not related to NEC. p 11371139.. Inc. & Binder. Reference: Ball. and 4 because these assessment findings shou ld be reported to the health care provider. N. Eliminate options 1. including abdominal diste ntion. Child health nursing: Partnering with c hildren and families. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The key focus of the question is necrotizing enterocolitis. 3. . J. Rationale: Changes in the gastrointestinal assessment. but are not related to NEC.

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