Chapter 31 The Newborn at Risk: Conditions Present at Birth

Olds' Maternal-Newborn Nursing & Women's Health, 10e (Davidson et al.
)
Chapter 31 The Newborn at Risk: Conditions Present at Birth
1) The nurse is caring for the newborn of a diabetic mother whose blood glucose level is 39
mg/dL. What should the nurse include in the plan of care for this newborn?
1. Offer early feedings with formula or breast milk.
2. Provide glucose water exclusively.
3. Evaluate blood glucose levels at 12 hours after birth.
4. Assess for hypothermia.
Answer: 1
Explanation: 1. IDMs whose serum glucose falls below 40 mg/dL should have early feedings
with formula or breast milk (colostrum).
2. If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion
of glucose will be necessary.
3. Blood glucose determinations should be performed on blood by heel stick hourly during the
first 4 hours after birth and at 4-hour intervals until the risk period (about 48 hours) has passed.
4. Impaired gluconeogenesis predisposes SGA infants to profound hypoglycemia within first few
hours of life.
Page Ref: 766
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and
standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8.
Implement evidence-based nursing interventions as appropriate for managing the acute and
chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality
and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing
Process: Planning
Learning Outcome: 3 Describe the impact of maternal diabetes mellitus on the newborn.
MNL LO: 4.5.3 Correlate high-risk conditions present at birth to their associated nursing care.
1
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2) The nurse is caring for several pregnant clients. Which client should the nurse anticipate is
most likely to have a newborn at risk for mortality or morbidity?
1. 37-year-old, with a history of multiple births and preterm deliveries who works in a chemical
factory
2. 23-year-old of low socioeconomic status, unmarried
3. 16-year-old who began prenatal care at 30 weeks
4. 28-year-old with a history of gestational diabetes
Answer: 1
Explanation: 1. This client is at greatest risk because she has multiple risk factors: age over 35,
high parity, history of preterm birth, and exposure to chemicals that might be toxic.
2. The main risk factor for this client is her low socioeconomic status.
3. This client has two risk factors: young age and late onset of prenatal care.
4. This client's only risk factor is the history of gestational diabetes.
Page Ref: 758, 759
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care
Conduct comprehensive and focused physical, behavioral, psychological, spiritual,
socioeconomic, and environmental assessments of health and illness parameters in patients,
using developmentally and culturally appropriate approaches. | NLN Competencies: Quality and
Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts:
Nursing Process: Assessment
Learning Outcome: 1 Identify the factors present at birth that indicate an at-risk newborn.
MNL LO: 4.5.1 Examine characteristics of the high-risk newborn.
2
3) The nurse is caring for an infant born at 37 weeks that weighs 1750 g (3 pounds 10 ounces).
The head circumference and length are in the 25th percentile. What statement would the nurse
expect to find in the chart?
1. Preterm appropriate for gestational age, symmetrical IUGR
2. Term small for gestational age, symmetrical IUGR
3. Preterm small for gestational age, asymmetrical IUGR
4. Preterm appropriate for gestational age, asymmetrical IUGR
Answer: 3
Explanation: 1. Head circumference and length between the 10th and 90th percentiles indicate
asymmetrical IUGR.
2. Head circumference and length between the 10th and 90th percentiles indicate asymmetrical
IUGR.
3. The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is small for gestational age. Head circumference and length between the 10th and 90th
percentiles indicate asymmetrical IUGR.
4. The infant is preterm at 37 weeks. Because the weight is below the 10th percentile, the infant
is considered small for gestational age.
Page Ref: 761
Standards: QSEN Competencies: VI. B. 2. Apply technology and information management tools
to support safe processes of care. | AACN Essentials Competencies: IV. 6. Evaluate data from all
relevant sources, including technology, to inform the delivery of care. | NLN Competencies:
Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts:
Nursing Process: Assessment
Learning Outcome: 2 Differentiate the underlying etiologies of the physiologic complications of
small-for-gestational-age (SGA) newborns and preterm appropriate-for-gestational-age (Pr
AGA) newborns and the nursing care management for each.
MNL LO: 4.5.2 Determine nursing care for the high-risk newborn as it relates to gestational age.
3
4) A 38-week newborn is found to be small for gestational age (SGA). Which nursing
intervention should be included in the care of this newborn?
1. Monitor for feeding difficulties.
2. Assess for facial paralysis.
3. Monitor for signs of hyperglycemia.
4. Maintain a warm environment.
Answer: 4
Explanation: 1. LGA, not SGA, newborns are more difficult to arouse to a quiet alert state, and
can have feeding difficulties.
2. LGA, not SGA, newborns often are prone to birth trauma, such as facial paralysis, due to
cephalopelvic disproportion.
3. SGA newborns are more prone to hypoglycemia.
4. Hypothermia is a common complication in the SGA newborn; therefore, the newborn's
environment must remain warm, to decrease heat loss.
Page Ref: 762
Client Need/Sub: Safe and Effective Care Environment: Management of Care
Process: Implementation
Learning Outcome: 2 Differentiate the underlying etiologies of the physiologic complications of
AGA) newborns and the nursing care management for each.
MNL LO: 4.5.2 Determine nursing care for the high-risk newborn as it relates to gestational age.
4
5) The nurse is caring for a 2-hour-old newborn whose mother is diabetic. The nurse assesses
that the newborn is experiencing tremors. Which nursing action has the highest priority?
1. Obtain a blood calcium level.
2. Take the newborn's temperature.
3. Obtain a bilirubin level.
4. Place a pulse oximeter on the newborn.
Answer: 1
Explanation: 1. Tremors are a sign of hypocalcemia. Diabetic mothers tend to have decreased
serum magnesium levels at term. This could cause secondary hypoparathyroidism in the infant.
2. Body temperature might be necessary to monitor, but obtaining a blood calcium level takes
priority for this newborn.
3. Bilirubin level might be necessary to monitor, but obtaining a blood calcium level takes
4. Oxygen saturation might be necessary to monitor, but obtaining a blood calcium level takes
Page Ref: 766
5
6) A 7 pound 14 ounce girl was born to an insulin-dependent type II diabetic mother 2 hours ago.
The infant's blood sugar is 47 mg/dL. What is the best nursing action?
1. To recheck the blood sugar in 6 hours
2. To begin an IV of 10% dextrose
3. To feed the baby 1 ounce of formula
4. To document the findings in the chart
Answer: 4
Explanation: 1. Blood glucose determinations should be performed on blood by heel stick
hourly during the first 4 hours after birth and at 4-hour intervals.
2. A blood sugar reading of 47 mg/dL is considered normal for a neonate. No IV is needed.
3. Feeding would be appropriate if the infant's blood sugar was below 45 mg/dL, but this infant's
reading is 47.
4. A blood sugar level of 47 mg/dL is a normal finding; documentation is an appropriate action.
Page Ref: 763
6
7) The nurse is caring for the newborn of a diabetic mother. Which of the following should be
included in the nurse's plan of care for this newborn?
1. Offer early feedings.
2. Administer an intravenous infusion of glucose.
3. Assess for hypercalcemia.
4. Assess for hyperbilirubinemia immediately after birth.
Answer: 1
Explanation: 1. Newborns of diabetic mothers may benefit from early feeding as they are
extremely valuable in maintaining normal metabolism and lowering the possibility of such
complications as hypoglycemia and hyperbilirubinemia.
2. If normal glucose levels cannot be maintained with oral feeding, an intravenous (IV) infusion
of glucose will be necessary.
3. The newborn should be assessed for hypocalcemia.
4. Hyperbilirubinemia can occur 48 to 72 hours after birth.
Page Ref: 772
Cognitive Level: Understanding
Process: Planning
7
8) The nurse caring for a postterm newborn would not perform what intervention?
1. Providing warmth
2. Frequently monitoring blood glucose
3. Observing respiratory status
4. Restricting breastfeeding
Answer: 4
Explanation: 1. Provision of warmth is an important intervention for postterm newborns.
2. Frequent monitoring of blood glucose is an important intervention for postterm newborns.
3. Observation of respiratory status is an important intervention for postterm newborns.
4. Breastfeeding is an appropriate means of feeding for the postterm newborn.
Page Ref: 773
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Learning Outcome: 4 Compare the characteristics and potential complications that influence
nursing management of the postterm newborn and the newborn with postmaturity syndrome.
8
9) The pregnant client at 41 weeks is scheduled for labor induction. She asks the nurse whether
induction is really necessary. What response by the nurse is best?
1. "Babies can develop postmaturity syndrome, which increases their chances of having
complications after birth."
2. "When infants are born 2 or more weeks after their due date, they have meconium in the
amniotic fluid."
3. "Sometimes the placenta ages excessively, and we want to take care of that problem before it
happens."
4. "The doctor wants to be proactive in preventing any problems with your baby if he gets any
bigger."
Answer: 1
Explanation: 1. The term postmaturity applies to the infant who is born after 42 completed
weeks of gestation and demonstrates characteristics of postmaturity syndrome.
2. Although this statement is partially true, meconium-stained amniotic fluid is not always
present or the only complication of postmaturity syndrome.
3. Although this statement is true, it is too vague. It is better to be specific and call postmaturity
syndrome by its name.
4. Although this is true, the answer is incomplete. The risk of postmaturity syndrome is also an
issue.
Page Ref: 767
Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active
partnerships that promote health, safety and well-being, and self-care management. | AACN
Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental
stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-Centered Care:
Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 4 Compare the characteristics and potential complications that influence
nursing management of the postterm newborn and the newborn with postmaturity syndrome.
9
10) The mother of a premature newborn questions why a gavage feeding catheter is placed in the
mouth of the newborn and not in the nose. What is the nurse's best response?
1. "Most newborns are nose breathers."
2. "The tube will elicit the sucking reflex."
3. "A smaller catheter is preferred for feedings."
4. "Most newborns are mouth breathers."
Answer: 1
Explanation: 1. Orogastric insertion is preferable to nasogastric because most infants are
obligatory nose breathers.
2. The tube or gavage feeding method is used with preterm infants who lack or have a poorly
coordinated suck-swallow-breathing pattern.
3. A small catheter is used for a nasogastric tube to minimize airway obstruction.
4. Orogastric insertion is preferable to nasogastric because most infants are obligatory nose
breathers.
Page Ref: 776
Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality,
patient preferences, and health literacy considerations to foster patient engagement in their care. |
NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen
openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5 Examine the physiologic characteristics of the preterm newborn that
predispose each body system to various complications and are used in development of a plan of
care that includes nutritional management.
10
11) A 3-month-old baby who was born at 25 weeks has been exposed to prolonged oxygen
therapy. Due to oxygen therapy, the nurse explains to the parents, their infant is at a greater risk
for which of the following?
1. Visual impairment
2. Hyperthermia
3. Central cyanosis
4. Sensitive gag reflex
Answer: 1
Explanation: 1. Extremely premature newborns are particularly susceptible to injury of the
delicate capillaries of the retina causing characteristic retinal changes known as retinopathy of
prematurity (ROP). Judicious use of supplemental oxygen therapy in the premature infant has
become the norm.
2. Hypothermia is more common in premature infants.
3. Central cyanosis can be caused by decreased oxygen.
4. An absent or decreased gag reflex is more common in premature infants.
Page Ref: 779
11
12) A NICU nurse plans care for a preterm newborn that will provide opportunities for
development. Which interventions support development in a preterm newborn in a NICU?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.
1. Schedule care throughout the day.
2. Silence alarms quickly.
3. Place a blanket over the top portion of the incubator.
4. Do not offer a pacifier.
5. Dim the lights.
Answer: 2, 3, 5
Explanation: 1. Nursing care should be planned to decrease the number of times the baby is
disturbed.
2. Noise levels can be lowered by replacing alarms with lights or silencing alarms quickly.
3. Dimmer switches should be used to shield the baby's eyes from bright lights with blankets
over the top portion of the incubator.
4. Pacifiers can be offered because they provide opportunities for nonnutritive sucking.
5. Dimming the lights may encourage infants to open their eyes and be more responsive to their
parents.
Page Ref: 785
Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and
respect for the diversity of human experience. | AACN Essentials Competencies: IX. 8.
chronic care of patients and promoting health across the lifespan. | NLN Competencies:
Relationship-Centered Care: Appreciate the patient as a whole person, with his or her own life
story and ideas about the meaning of health or illness. | Nursing/Integrated Concepts: Nursing
12
13) The nurse assesses the gestational age of a newborn and informs the parents that the newborn
is premature. Which of the following assessment findings is not congruent with prematurity?
1. Cry is weak and feeble
2. Clitoris and labia minora are prominent
3. Strong sucking reflex
4. Lanugo is plentiful
Answer: 3
Explanation: 1. Findings that indicate prematurity include a weak cry.
2. Findings that indicate prematurity include a prominent clitoris and labia minora.
3. Poor suck, gag, and swallow reflexes are characteristic of a preterm newborn.
4. Findings that indicate prematurity include lanugo that is plentiful and widely distributed.
Page Ref: 781
Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 4. Communicate observations or concerns related to
hazards and errors to patients, families, and the health care team. | AACN Essentials
Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age,
culture, spirituality, patient preferences, and health literacy considerations to foster patient
engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate
information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing
Process: Assessment
13
14) The nurse is working with parents who have just experienced the birth of their first child at
34 weeks. Which statements by the parents indicate that additional teaching is needed?
1. "Our baby will be in an incubator to keep him warm."
2. "Breathing might be harder for our baby because he is early."
3. "The growth of our baby will be faster than if he were term."
4. "Tube feedings will be required because his stomach is small."
5. "Because he came early, he will not produce urine for 2 days."
Answer: 3, 4, 5
Explanation: 1. Preterm infants have little subcutaneous fat, and have difficulty maintaining
their body temperature. An incubator or warmer is used to keep the baby warm.
2. Surfactant production might not be complete at 34 weeks, which leads to respiratory distress
syndrome. The infant may become hypoxic, pulmonary blood flow may be inefficient, and the
preterm newborn's available energy is depleted.
3. Preterm infants grow more slowly than do term infants because of difficulty in meeting high
caloric and fluid needs for growth due to small gastric capacity.
4. Although tube feedings might be required, it would be because preterm babies have a marked
danger of aspiration and its associated complications due to the infant's poorly developed gag
reflex, incompetent esophageal cardiac sphincter, and inadequate suck/swallow/breathe reflex.
5. Although preterm babies have diminished kidney function due to incomplete development of
the glomeruli, they can produce urine. Preterm infants usually have some urine output during the
first 24 hours of life.
Page Ref: 770
Client Need/Sub: Health Promotion and Maintenance: Reduction of Risk Potential
Standards: QSEN Competencies: I. B. 10. Provide appropriate patient teaching that reflects
developmental stage, age, culture, spirituality, patient preferences, and health literacy
considerations to foster patient engagement in their care. | AACN Essentials Competencies: IX.
7. Provide appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster patient engagement in
their care. | NLN Competencies: Relationship-Centered Care: Communicate information
effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process:
Evaluation
14
15) The neonatal special care unit nurse is overseeing the care provided by a nurse new to the
unit. Which action requires immediate intervention?
1. The new nurse holds the infant after giving a gavage feeding.
2. The new nurse provides skin-to-skin care.
3. The new nurse provides care when the baby is awake.
4. The new nurse gives the feeding with room-temperature formula.
Answer: 4
Explanation: 1. If the infant cannot be held during a feeding, she should be held after feedings
for comfort.
2. Skin-to-skin (kangaroo) care has become the norm in NICUs across the United States and is
defined as the practice of holding infants skin to skin next to their parents.
3. Preterm babies spend more time in sleep cycles; it is best to not interrupt sleep when possible.
4. Preterm babies have little subcutaneous fat, and do not maintain their body temperature well.
Formula should be warmed prior to feedings to help the baby maintain its temperature.
Page Ref: 769, 782
15
16) Benefits of skin-to-skin care as a developmental intervention include which of the following?
1. Routine discharge
2. Stabilization of vital signs
3. Increased periods of awake-alert state
4. Decline in the episodes of apnea and bradycardia
5. Increased growth parameters
Answer: 2, 4, 5
Explanation: 1. Early discharge is a benefit of skin-to-skin care as a developmental intervention.
2. Stabilization of vital signs is a benefit of skin-to-skin care as a developmental intervention.
3. Increased periods of quiet sleep is a benefit of skin-to-skin care as a developmental
intervention.
4. Decline in the episodes of apnea and bradycardia is a benefit of skin-to-skin care as a
developmental intervention.
5. Increased growth parameters are a benefit of skin-to-skin care as a developmental
intervention.
Page Ref: 784, 785
Cognitive Level: Understanding
Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and
respect for the diversity of human experience. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient and family
preferences. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or
threaten health. | Nursing/Integrated Concepts: Nursing Process: Planning
16
17) In caring for the premature newborn, the nurse must assess hydration status continually.
Assessment parameters should include which of the following?
1. Volume of urine output
2. Weight
3. Blood pH
4. Head circumference
5. Bowel sounds
Answer: 1, 2
Explanation: 1. In order to assess hydration status, volume of urine output must be evaluated.
2. In order to assess hydration status, the infant's weight must be evaluated.
3. Blood pH is not an indicator of hydration.
4. Head circumference is not an indicator of hydration.
5. Bowel sounds are not an indicator of hydration.
Page Ref: 782
Process: Assessment
17
18) The nurse is planning care for a preterm newborn. Which nursing diagnosis has the highest
priority?
1. Tissue Integrity, Impaired
2. Infection, Risk for
3. Gas Exchange, Impaired
4. Family Processes, Dysfunctional
Answer: 3
Explanation: 1. Tissue Integrity, Impaired is related to fragile capillary network in the germinal
matrix, but is not the highest priority.
2. Infection, Risk for is related to lack of passive immunity and immature immune defenses due
to preterm birth, but is not the highest priority.
3. Gas Exchange, Impaired is related to immature pulmonary vasculature and inadequate
surfactant production and has the highest priority.
4. Family Processes, Dysfunctional is related to anger or guilt at having given birth to a
premature baby and is a psychosocial need, and is therefore a lower priority than are physiologic
needs.
Page Ref: 781
Client Need/Sub: Health Promotion and Maintenance: Physiological Adaptation
Deliver compassionate, patient-centered, evidence-based care that respects patient and family
preferences. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety.
| Nursing/Integrated Concepts: Nursing Process: Diagnosis
18
19) The nurse is teaching the parents of an infant with an inborn error of metabolism how to care
for the infant at home. What information does teaching include?
1. Specially prepared formulas
2. Cataract problems
3. Low glucose concentrations
4. Administration of thyroid medication
Answer: 1
Explanation: 1. An afflicted PKU infant can be treated by a special diet that limits ingestion of
phenylalanine. Special formulas low in phenylalanine, such as Lofenalac, Minafen, and
Albumaid XP, are available.
2. Cataracts are associated with infants who have galactosemia.
3. Low glucose concentrations are not an indication an inborn error of metabolism.
4. Thyroid medication is given to infants with congenital hypothyroidism.
Page Ref: 808
Learning Outcome: 10 Summarize the special care needed by a newborn diagnosed with an
inborn error of metabolism.
19
20) The nurse is caring for a newborn in the special care nursery. The infant has hydrocephalus,
and is positioned in a prone position. The nurse is especially careful to cleanse all stool after
bowel movements. This care is most appropriate for an infant born with which of the following?
1. Omphalocele
2. Gastroschisis
3. Diaphragmatic hernia
4. Myelomeningocele
Answer: 4
Explanation: 1. Omphalocele is a herniation of abdominal contents into the base of the umbilical
cord. Hydrocephalus is not associated with an omphalocele.
2. Gastroschisis is a full-thickness defect of the abdominal wall, resulting in the abdominal
organs being located on the outside of the body. Hydrocephalus is not associated with a
gastroschisis.
3. Diaphragmatic hernia is a portion of intestines in the thoracic cavity through abnormal
opening in diaphragm, occurring commonly on the left side. Hydrocephalus is not associated
with a diaphragmatic hernia.
4. Myelomeningocele is a saclike cyst containing meninges, spinal cord, and nerve roots in
thoracic and/or lumbar area. Meticulous cleaning of the buttocks and genitals helps prevent
infection. The infant is positioned on abdomen or on side and restrain (to prevent pressure and
trauma to sac). Hydrocephalus often is present.
Page Ref: 791
Client Need/Sub: Safe and Effective Care Environment: Safety and Infection Control
Learning Outcome: 6 Explain the nursing assessments of and initial interventions for a newborn
born with selected congenital anomalies.
MNL LO: 4.5.4 Correlate congenital anomalies to their associated nursing care.
20
21) During discharge planning for a drug-dependent newborn, the nurse explains to the mother
how to do which of the following?
1. Place the newborn in a prone position.
2. Limit feedings to three a day to decrease diarrhea.
3. Place the infant supine and operate a home apnea-monitoring system.
4. Wean the newborn off the pacifier.
Answer: 3
Explanation: 1. Infants with neonatal abstinence syndrome are at a significantly higher risk for
sudden infant death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The
infant should sleep in a supine position, and home apnea monitoring should be implemented.
2. Small, frequent feedings are recommended.
3. Infants with neonatal abstinence syndrome are at a significantly higher risk for sudden infant
death syndrome (SIDS) when the mother used heroin, cocaine, or opiates. The infant should
sleep in a supine position, and home apnea monitoring should be implemented.
4. A pacifier may be offered to provide nonnutritive sucking.
Page Ref: 797
Concepts: Nursing Process: Planning
Learning Outcome: 7 Describe the specialized needs by an in utero alcohol- or drug-exposed
newborn.
21
22) The nurse is assessing a drug-dependent newborn. Which symptom would require further
assessment by the nurse?
1. Occasional watery stools
2. Spitting up after feeding
3. Jitteriness and irritability
4. Nasal stuffiness
Answer: 3
Explanation: 1. An occasional watery stool can be associated with the normal newborn.
2. Spitting up after some feedings can be associated with the normal newborn.
3. Jitteriness and irritability can be an indicator of drug withdrawal.
4. Nasal stuffiness can be associated with the normal newborn.
Page Ref: 797
Process: Assessment
newborn.
22
23) Parents have been told their child has fetal alcohol syndrome (FAS). Which statement by a
parent indicates that additional teaching is required?
1. "Our baby's heart murmur is from this syndrome."
2. "He might be a fussy baby because of this."
3. "His face looks like it does due to this problem."
4. "Cuddling and rocking will help him stay calm."
Answer: 4
Explanation: 1. Valvular and septal defects are common in babies with FAS.
2. FAS babies can be irritable and hyperactive in childhood.
3. Facial characteristics of the FAS child include short palpebral fissures, epicanthal folds, broad
nasal bridge, flattened midface, short upturned or beaklike nose, micrognathia (abnormally small
lower jaw) or hypoplastic maxilla, thin upper lip or vermilion border, and smooth philtrum
(groove on upper lip).
4. The FASD baby is most comfortable in a quiet, minimally stimulating environment.
Page Ref: 793
Concepts: Nursing Process: Evaluation
newborn.
23
24) The nurse is caring for the newborn of a drug-addicted mother. Which assessment findings
would be typical for this newborn?
1. Hyperirritability
2. Decreased muscle tone
3. Exaggerated reflexes
4. Low pitched cry
5. Transient tachypnea
Answer: 1, 3, 5
Explanation: 1. Newborns born to drug-addicted mothers exhibit hyperirritability.
2. Newborns born to drug-addicted mothers show increased, not decreased, muscle tone.
3. Newborns born to drug-addicted mothers exhibit exaggerated reflexes.
4. Newborns born to drug-addicted mothers exhibit a high-pitched, not a low-pitched, cry.
5. Newborns born to drug-addicted mothers exhibit transient tachypnea.
Page Ref: 794, 795
using developmentally and culturally appropriate approaches. | NLN Competencies:
Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated
Concepts: Nursing Process: Assessment
newborn.
24
25) In planning care for the fetal alcohol syndrome (FAS) newborn, which intervention would
the nurse include?
1. Allow extra time with feedings.
2. Assign different personnel to the newborn each day.
3. Place the newborn in a well-lit room.
4. Monitor for hyperthermia.
Answer: 1
Explanation: 1. Newborns with fetal alcohol syndrome have feeding problems. Because of their
feeding problems, these infants require extra time and patience during feedings.
2. It is important to provide consistency in the staff working with the baby and parents and to
keep personnel and visitors to a minimum at any one time.
3. The FASD baby is most comfortable in a quiet, minimally stimulating environment.
4. Nursing care of the FASD newborn is aimed at avoiding heat loss.
Page Ref: 793
and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts:
Nursing Process: Planning
newborn.
25
26) The nurse is teaching the parents of a newborn who has been exposed to HIV how to care for
the newborn at home. Which instructions should the nurse emphasize?
1. Use proper hand-washing technique.
2. Provide three feedings per day.
3. Place soiled diapers in a sealed plastic bag.
4. Cleanse the diaper changing area with a 1:10 bleach solution after each diaper change.
5. Take the temperature rectally.
Answer: 1, 3, 4
Explanation: 1. The nurse should instruct the parents on proper hand-washing technique.
2. Small, frequent meals are recommended.
3. The nurse should instruct parents to that soiled diapers are to be placed in plastic bags, sealed,
and disposed of daily.
4. The nurse should instruct parents that the diaper-changing areas should be cleaned with a 1:10
dilution of household bleach after each diaper change.
5. Taking rectal temperatures is to be avoided because it could stimulate diarrhea.
Page Ref: 800, 801
Learning Outcome: 8 Relate the consequences of maternal HIV/AIDS to the management of and
issues for caregivers of infants at risk for HIV/AIDS in the neonatal period.
26
27) A mother who is HIV-positive has given birth to a term female. What plan of care is most
appropriate for this infant?
1. Test with a HIV serologic test at 8 months.
2. Begin prophylactic AZT (Zidovudine) administration.
3. Provide 4 to 5 large feedings throughout the day.
4. Encourage the mother to breastfeed the child.
Answer: 2
Explanation: 1. Currently available HIV serologic tests (enzyme-linked immunosorbent assay
[ELISA] and Western blot test) cannot distinguish between maternal and infant antibodies;
therefore, they are inappropriate for infants up to 18 months of age.
2. For infants, AZT is started prophylactically 2 mg/kg/dose PO every 6 hours beginning as soon
after birth as possible and continuing for 6 weeks.
3. Nutrition is essential because failure to thrive and weight loss are common. Small, frequent
feedings and food supplementation are helpful.
4. Breastfeeding should be avoided with an HIV-positive mother as transmission of the HIV
virus to the newborn in breast milk is well documented.
Page Ref: 800
Nursing Process: Planning
27
28) An HIV-positive mother delivered 2 days ago. The infant will be placed in foster care. The
nurse is planning discharge teaching for the foster parents on how to care for the newborn at
home. Which instructions should the nurse include?
1. Do not add food supplements to the baby's diet.
2. Place soiled diapers in a sealed plastic bag.
3. Wash soiled linens in cool water with bleach.
4. Shield the baby's eyes from bright lights.
Answer: 2
Explanation: 1. Small, frequent feedings are recommended, as well as food supplementation as
necessary to support weight gain.
2. The nurse should instruct the parents about proper hand-washing techniques, about proper
disposal of soiled diapers, and to wear gloves when diapering.
3. Soiled linens should be washed in hot, sudsy water with bleach.
4. Shielding the baby's eyes from bright lights would be recommended for a preterm infant, not
an infant with HIV.
Page Ref: 800, 801
Concepts: Nursing Process: Planning
28
29) Many newborns exposed to HIV/AIDS show signs and symptoms of disease within days of
birth that include which of the following?
1. Swollen glands
2. Hard stools
3. Smaller than average spleen and liver
4. Rhinorrhea
5. Interstitial pneumonia
Answer: 1, 4, 5
Explanation: 1. Signs that may be seen in the early infancy period include swollen glands.
2. Signs that may be seen in the early infancy period include recurrent gastrointestinal (GI)
problems that include diarrhea.
3. Signs that may be seen in the early infancy period include enlarged spleen and liver.
4. Signs that may be seen in the early infancy period include rhinorrhea.
5. Signs that may be seen in the early infancy period include interstitial pneumonia.
Page Ref: 800
Nursing Process: Diagnosis
29
30) The nurse is analyzing assessment findings on four newborns. Which finding might suggest a
congenital heart defect?
1. Apical heart rate of 140 beats per minute
2. Respiratory rate of 40
3. Temperature of 36.5°C
4. Visible, blue discoloration of the skin
Answer: 4
Explanation: 1. An apical heart rate of 140 is a normal assessment finding for newborns.
2. A respiratory rate of 40 is a normal assessment finding for newborns.
3. Temperature of 36.5°C is a normal assessment finding for newborns.
4. Central cyanosis is defined as a visible, blue discoloration of the skin caused by decreased
oxygen saturation levels and is a common manifestation of a cardiac defect.
Page Ref: 802
using developmentally and culturally appropriate approaches. | NLN Competencies:
Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated
Concepts: Nursing Process: Assessment
Learning Outcome: 9 Identify physical examination findings during the early newborn period
that would make the nurse suspect a congenital cardiac defect or congestive heart failure.
30
31) The parents of a newborn have just been told their infant has tetralogy of Fallot. The parents
do not seem to understand the explanation given by the physician. What statement by the nurse is
best?
1. "With this defect, not enough of the blood circulates through the lungs, leading to a lack of
oxygen in the baby's body."
2. "The baby's aorta has a narrowing in a section near the heart that makes the left side of the
heart work harder."
3. "The blood vessels that attach to the ventricles of the heart are positioned on the wrong sides
of the heart."
4. "Your baby's heart doesn't circulate blood well because the left ventricle is smaller and thinner
than normal."
Answer: 1
Explanation: 1. Tetralogy of Fallot is a cyanotic heart defect that comprises four abnormalities:
pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricle hypertrophy.
The severity of symptoms depends on the degree of pulmonary stenosis, the size of the
ventricular septal defect, and the degree to which the aorta overrides the septal defect.
2. This describes coarctation of the aorta and is characterized by a narrowed aortic lumen. The
lesion produces an obstruction to the flow of blood through the aorta, causing an increased left
ventricular pressure and workload, minimizing systemic circulation of blood.
3. This describes complete transposition of great vessels and is an embryologic defect caused by
a straight division of the bulbar trunk without normal spiraling. As a result, the aorta originates
from the right ventricle, and the pulmonary artery from the left ventricle resulting in a parallel
circulatory system. An abnormal communication between the two circulations must be present to
sustain life.
4. This describes hypoplastic left heart syndrome which is the underdevelopment of the left side
of the heart including aortic valve atresia, severe mitral valve stenosis, and small left ventricle.
Page Ref: 805
Learning Outcome: 9 Identify physical examination findings during the early newborn period
that would make the nurse suspect a congenital cardiac defect or congestive heart failure.
31
32) The nurse is preparing an educational session on phenylketonuria for a family whose neonate
has been diagnosed with the condition. Which statement by a parent indicates that teaching was
effective?
1. "This condition occurs more frequently among Japanese people."
2. "We must be very careful to avoid most proteins to prevent brain damage."
3. "Carbohydrates can cause our baby to develop cataracts and liver damage."
4. "Our baby's thyroid gland isn't functioning properly."
Answer: 2
Explanation: 1. Japanese people have a very low rate of PKU disease; it is most common among
northern Europeans.
2. PKU is the inability to metabolize phenylalanine, an amino acid found in most dietary protein
sources. Excessive accumulation of phenylalanine and its abnormal metabolites in the brain
tissue leads to progressive, irreversible intellectual disability.
3. Galactosemia is the disease that is a carbohydrate metabolism problem.
4. Congenital hypothyroidism is the disorder of low thyroid function at birth.
Page Ref: 803
Concepts: Nursing Process: Evaluation
Learning Outcome: 10 Summarize the special care needed by a newborn diagnosed with an
inborn error of metabolism.
33) The nurse is observed conducting the following measurement. For what reason will this
measurement be used?
1. Determine fetal length

2. Gauge stomach contents
3. Placement of gavage tube
32
4. Estimate chest circumference
Answer: 3
Rationale: When measuring gavage tube length measure the distance from the tip of the ear to
the nose to the midpoint between the xiphoid process and the umbilicus, and mark the point with
a small piece of paper tape to ensure there is enough tubing to enter the stomach.

Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered
care
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as
appropriate for managing the acute and chronic care of patients and promoting health across the
lifespan
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural
health assessments and interventions
Nursing/Integrated Concepts: Assessment; Nursing Process
Learning Outcome: 2. Differentiate the underlying etiologies of the physiologic complications of
AGA) newborns and the nursing care management for each
MNL Learning Outcome: 4.5.3. Correlate high-risk conditions present at birth to their associated
nursing care.
Page Number: 776
34) The nurse is caring for a newborn with the following anomaly. What actions should the nurse
take when caring for this infant? (Select all that apply.)
1. Burp frequently
2. Assess patency of nares
3. Assist with parental coping
4. Clean the area with sterile water
5. Feed with a special nipple and bottle
Answer: 1, 3, 4, 5
Rationale: The infant has a cleft lip. The nurse should feed with a special nipple and bottle, burp
33
frequently, clean the cleft with sterile water to prevent crusting on cleft before repair, and
support parental coping. Assessing patency of nares would be appropriate for choanal atresia.

care
AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as
appropriate for managing the acute and chronic care of patients and promoting health across the
lifespan
Nursing/Integrated Concepts: Implementation; Nursing Process
Learning Outcome: 6. Explain the nursing assessments of and initial interventions for a newborn
born with selected congenital anomalies
MNL Learning Outcome: 4.5.4. Correlate congenital anomalies to their associated nursing care.
Page Number: 788
35) The nurse is preparing teaching material for the parents of a newborn with
tracheoesophageal fistula. Where on the diagram should the nurse identify the location of this
disorder?
1. A
2. B
3. C
4. D
34
Answer: C
Rationale: In a tracheoesophageal fistula the lower esophageal segment connects to the lower
trachea with upper esophageal segment ending blindly.

care
AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects
considerations to foster patient engagement in their care
Nursing/Integrated Concepts: Implementation; Teaching/Learning
Page Number: 789
36) The nurse is preparing teaching material for the parents of a newborn. For which health
problem should the nurse select the following diagram to be used for teaching?
1. Gastroschisis
2. Omphalocele
3. Diaphragmatic hernia
4. Prune belly syndrome
Answer: 3
Rationale: For a diaphragmatic hernia a portion of intestines enters the thoracic cavity through an
abnormal opening in diaphragm. This common occurs on the left side. An omphalocele is the
herniation of abdominal contents into base of umbilical cord. Gastroschisis is a full-thickness
defect in the abdominal wall allowing viscera outside the body to the right of an intact umbilical
35
cord. Prune belly syndrome is the congenital absence of one or more layers of abdominal
muscles.

care
Page Number: 790
37) An infant is diagnosed with an atrial-septal defect. When teaching the parents of this infant
about the disorder which diagram should the nurse use?
1.
36
2.
3.
4.
Answer: 1
Rationale: Patent ductus arteriosus is a vascular connection that, during fetal life, bypasses the
pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. After birth,
37
blood shunts through the ductus from the aorta to the pulmonary artery (left-to-right shunting).
Coarctation of the aorta is characterized by a narrowed aortic lumen. The lesion produces an
obstruction to the flow of blood through the aorta, causing an increased left ventricular pressure
and workload, minimizing systemic circulation of blood. In tetralogy of Fallot, the severity of
symptoms depends on the degree of pulmonary stenosis, the size of the ventricular septal defect,
and the degree to which the aorta overrides the septal defect. Complete transposition of great
vessels is an embryologic defect caused by a straight division of the bulbar trunk without normal
spiraling. As a result, the aorta originates from the right ventricle, and the pulmonary artery from
the left ventricle resulting in a parallel circulatory system. An abnormal communication between
the two circulations must be present to sustain life.

care
Page Number: 804-806
38) The nurse is preparing to gavage-feed a preterm infant. Put the steps in the order in which the
nurse should provide this feeding.
Standard Text: Click and drag the options below to move them up or down.
1. Check pH of the gastric aspirate

2. Elevate the syringe 6-8 inches above the infant's head
3. Measure from the tip of the nose to the earlobe to the xiphoid process
4. Clear the tubing with 2-3 mL of air
5. Lubricate the tube by dipping it into sterile water
Answer: 3, 5, 1, 2, 4
Rationale: Measurement occurs before inserting the tube into the infant. Lubricating the tube
helps with passage into the infant. After passage the pH of gastric contents is determined. The
syringe is elevated above the infant’s head for the feeding. At the end of the feeding the tube is
cleared with 2-3 mL of air.

38
care
AACN Essentials Competencies: IX. 3. Implement holistic, patient-centered care that reflects an
understanding of human growth and development, pathophysiology, pharmacology, medical
management and nursing management across the health-illness continuum, across lifespan, and
in all healthcare settings
Nursing/Integrated Concepts: Implementation; Nursing Process
Learning Outcome: 5. Examine the physiologic characteristics of the preterm newborn that
care that includes nutritional management
MNL Learning Outcome: 4.5.3. Correlate high-risk conditions present at birth to their associated
nursing care.
Page Number: 776
39

Chapter 31 The Newborn at Risk: Conditions Present at Birth

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Chapter 31 The Newborn at Risk: Conditions Present at Birth

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Olds' Maternal-Newborn Nursing & Women's Health, 10e (Davidson et al.

1. Determine fetal length

Cognitive Level: Applying

Cognitive Level: Applying

Cognitive Level: Applying

Cognitive Level: Applying

Cognitive Level: Applying

1. Check pH of the gastric aspirate

Cognitive Level: Applying

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