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 97.5F. 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.

3. While observing the parents interact with their high risk newborn, 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. Parents should wash their hands when they enter the unit but do not need to wear gloves when in contact with their infant. 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. 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. 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. 913-916, 983. 4. In formulating a plan of care for an infant born at 28 weeks' gestation, the nurse writes a goal that within one week the infant will: You answered incorrectly: Maintain body temperature in a bassinet. The correct answer was: Maintain respiratory rate between 30-60 breaths/minute. Rationale: A normal respiratory rate for all newborns is 30-60 breaths/min. A 28 -week gestation infant cannot maintain body temperature, drink from a bottle or recognize parents at one week of age. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: Eliminate options 1, 2, and 4 because they are not appropriate for a 2 8-week gestation infant at one week of age. 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., p. 822, 889-895. 5. The nurse is making client assignments. 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, administer blood, or m ake nursing decisions based on changes in a client's assessment. An LPN/LVN is q ualified to perform certain procedures and care for stable clients (option 3). 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. 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. 7-13. 6. A newborn is receiving phototherapy for the treatment of hyperbilirubine mia. The nurse concludes that client teaching has been effective when the parent s are observed doing which of the following? Select all that apply. 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; 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. 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. Breastfeeding is not contraindicated with hyperbilirubinemia. Loose g reen stools are a side effect of bilirubin excretion through the intestines. 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. The light sources affect the surfaces of the body. Wh en thinking about sources of light, use eye protection as a key guiding principl e. Think also about other measures that protect the skin. 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. 965-970. 7. 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. The other three answers may warrant furt her investigation, but the priority at delivery is to establish and maintain an airway. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Remember airway, breathing and circulation. Eliminate options 1, 2, a nd 4 because these findings may warrant further investigation, but the priority at delivery is to establish and maintain an airway. 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. 667-668, 889. 8. The parents of a preterm neonate ask why their baby gets cold so easily. The nurse explains that preterm neonates: You answered correctly: Have minimal body fat to retain body heat. Rationale: Preterm infants have minimal adipose tissue so they tend to lose heat faster through their skin. Their skin is thin with blood vessels near the surfa ce which increases the amount of heat lost through their skin. Because they are weak and neurologically immature, 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

e more heat. In general, infants are not able to shiver to produce body heat whe n they are cold. 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. Use this information to eliminate each incorrect option systemat ically. 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., p. 901. 9. While feeding an infant the nurse notices white adherent patches on the infant's gums and buccal cavity. 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, or thrush, is white patc hes in the mouth that tend to bleed if they are touched. The other answers are b ased on incorrect conclusions about the significance of the symptom. 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. Eliminate option 1 because this is not a normal findi ng. Eliminate option 3 because vitamin K is not related to this finding. Elimina te option 4 because this finding would not be indicative of herpes infection. 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., p. 974. 10. 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, sunken fontanelle, and dry skin turgor. The other assessment data are expected finding s in an infant. 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. Eliminate options 1, 2, and 3 because th ese assessment findings are expected in an infant. 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. 806-807, 825. 11. A newborn is admitted to the nursery 15 minutes after delivery. His skin is mottled, mucus membranes are blue, he is active, and is wrapped in a blanket . The highest priority of the nurse is to assess: You answered correctly: Patent airway.

Rationale: The highest priority after delivery is to maintain and support respir atory function. This infant is demonstrating initial signs of respiratory defici ency. Follow the ABC's of resuscitation: airway, breathing and circulation. 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. Follow the ABC's of resuscitation: airway, breathing and circulation. 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. 938-939, 942-946. 12. A nurse is caring for a premature newborn and suspects the development o f respiratory distress syndrome (hyaline membrane disease). Which of the followi ng assessment findings would support the nurse's judgment? Select all that appl y. You answered correctly: Expiratory grunting sounds; Nasal flaring; Substernal re traction with inspiration Rationale: The physiologic changes that occur with respiratory distress syndrome , more common in the premature infant, include hypoxia with respiratory and meta bolic acidosis. Characteristics include increasing cyanosis, tachypnea, grunting respirations, nasal flaring, retractions and apnea. In respiratory distress, re spirations are labored with suprasternal, substernal, intercostal or subcostal r etractions, grunting sounds and nasal flaring as the infant works harder to exch ange air. 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. Eliminate option 1 because the respiratory rate would increase rather than decrease. Eliminate option 3 because the skin c olor would change from pink to pale, mottled or bluish (cyanotic). Eliminate opt ion 6 because symmetrical and diaphragmatic respiratory movement characterizes n ormal breathing. 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. 945-946. 13. 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. 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). All preterm infants who r eceived oxygen should have a thorough eye exam done by an ophthalmologist prior to discharge. It is important to administer the minimum amount of oxygen to infa nts to decrease the risk that this condition will develop. Oxygen should be wean ed and not withdrawn suddenly. Artificial surfactant may be administered within the first several days of life to decrease the risk of respiratory distress synd rome (RDS). Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process, 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 option 1 because at this t ime no data is given to support this action. Eliminate option 3 because oxygen s hould be weaned and not withdrawn suddenly. Eliminate option 4 because artificia l surfactant may be administered to decrease the risk of respiratory distress sy ndrome (RDS). 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., p. 910. 14. You are caring for an infant born to an HIV positive mother. 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 . All other assessment data are within normal limits. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process: Analysis Content Area: Maternal-Newborn Strategy: Eliminate options 1, 2, and 4 because they present assessment data tha t are within normal limits. 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. 924-929. 15. An infant of a diabetic mother (IDM) is admitted to the nursery. The pri ority intervention of the nurse is to: You answered correctly: Assess the infant's blood glucose. Rationale: An infant of a diabetic mother is at risk for hypoglycemia and should be monitored closely after delivery. All other interventions are important, but not the highest priority. 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. Eliminate options 1, 2, and 3 because these interventio ns are important, but not the highest priority. 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. 896-899. 16. A father asks how the phototherapy lights make the bilirubin level go do wn. 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." Rationale: Phototherapy assists the body in converting unconjugated bilirubin to conjugated bilirubin, which is water soluble and easier for the body to elimina te. The other answers do not describe this process. Cognitive Level: Application Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

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. 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., p. 965. 17. The nurse assesses a arm limp and extended, left terally, no response on left ursing intervention for this newborn and obtains the following information: left hand internally rotated, positive grasp reflex bila side to Moro reflex. 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. It is important to p rovide passive range of motion on the affected side to prevent muscle wasting. T he infant should not be positioned on the affected side. Occasionally a splint m ay be applied, but a cast is not indicated. 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. Eliminate option 2 because the infant should not be p ositioned on the affected side. Eliminate option 4 because occasionally a splint may be applied, but a cast is not indicated. 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. 816-817. 18. A neonatal nurse is attending a high risk delivery and is told that the mother received morphine sulfate IV 30 minutes ago. 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. Naloxone (Narcan) is the drug of c hoice to reverse respiratory depression caused by narcotics. The other answers a re incorrect and do not reverse respiratory depression. Cognitive Level: Application Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process, Planning Content Area: Maternal-Newborn Strategy: Eliminate options 2, 3, and 4 because these drugs will not reverse the action of a narcotic drug. 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., p. 940-942. 19. The nurse is preparing to discharge an infant with fetal alcohol syndrom e home with foster parents. The nurse should place priority on teaching regardin g: You answered correctly: Feeding methods. Rationale: Infants with fetal alcohol syndrome have an increased risk of feeding difficulties related to hyperactivity. The other teaching topics are important,

but not the highest priority at this time. 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. Eliminate options 1, 2, and 4 because these teaching topics are i mportant, but not the highest priority at this time. 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. 920-921. 20. Which of the following infants is at greatest risk for the nursing diagn osis, high risk for infection? You answered correctly: 38-week gestation, 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. The other infants are not at any greater r isk for infection. 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. Eliminate options 2, 3, and 4 because this information is important bu t would not place the infant at increased risk for infection. 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., p. 889-895, 973. 21. A nurse is admitting a baby to the nursery 30 minutes after delivery. Wh ich information from the mother's history should be of greatest concern? You answered incorrectly: Marginal placenta previa. The correct answer was: Preexisting insulin-dependent diabetes mellitus. Rationale: A maternal history of diabetes increases the risk of hypoglycemia in the newborn and this infant should be monitored closely. 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 marginal p lacenta previa increases the mother's risk of bleeding during pregnancy, but sho uld not cause significant complications in the newborn after delivery. Membranes ruptured greater than 24 hours prior to delivery increase the mother's and infa nt's risk of infection. 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. Remember the information o f greatest concern is related to the greatest risk for the infant's safety. Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mat ernal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: P earson Education, Inc., pp. 896-899. 22. A baby's mother is Hepatitis B positive. Which of the following interven tions is most important when planning care for this newborn?

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

and 3 because abdominal distention, jaundice and jitteriness are not directly r elated to RDS. Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004) Maternal-New born Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 946. 25. A nurse observes that a preterm infant's urine output is less than 1 mL/ kg/hr with a specific gravity >1.020. The nurse determines that this indicates: You answered incorrectly: Electrolyte imbalance. The correct answer was: Dehydration. Rationale: Adequate hydration is evidenced by urine output of 1-3 mL/kg/hr and s pecific gravity <1.013. This newborn shows signs of dehydration. Metabolic acido sis and electrolyte imbalance would be determined by serum not urine analysis. 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. Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004) Maternal-New born Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 786-787. 26. Which neonate requires the closest observation by the nurse?

You answered correctly: The neonate whose color became cyanotic during the first feeding. Rationale: Central cyanosis is always considered abnormal and warrants further e valuation. All of the other assessments are normal for an infant. Cognitive Level: Analysis Client Need: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process, Assessment Content Area: Maternal-Newborn Strategy: The key focus of the question is abnormal assessment findings in need of further investigation. Eliminate options 1, 3, and 4 because these assessmen t findings are normal for an infant. 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, S., London, M., Ladewig, P., & Davidson, M. (2004) Maternal-New born Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 929-930. 27. 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. The correct answer was: Giving the parents a Polaroid picture of baby prior to t ransport to the NICU. Rationale: Parents should be given a Polaroid picture of the infant before the b aby is transported. Calling the unit to check on their baby may help bonding, bu t seeing the baby is more effective. Parents are typically allowed to visit as o ften and for as long as they want. It is important to be honest with parents, ev en if the prognosis is poor. Cognitive Level: Application Client Need: Psychosocial Integrity

Integrated Process: Nursing Process, 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. Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004) Maternal-New born Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 913-914. 28. The nurse is observing a student practicing how to maintain a patent air way on a newborn doll. The nurse must intervene if which of the following is obs erved? You answered correctly: Inserting a nasogastic tube. Rationale: Infants are obligate nose breathers. A gastric tube may be inserted t o keep the stomach decompressed and allow for easier lung expansion. But if it i s inserted nasally, it occludes one nare and may make respiratory effort more di fficult. All other options are correct interventions for maintaining a patent ai rway. 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." This means that you are looking for an incorrect action on the pa rt of the student. Knowledge of the correct procedure to maintain a patent airwa y will be necessary to determine which of the answers gives an incorrect action. Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004) Maternal-New born Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 942-951. 29. s: A priority nursing intervention for a newborn experiencing hypothermia i

You answered incorrectly: Starting phototherapy. The correct answer was: Monitoring for hypoglycemia. Rationale: The newborn reacts to hypothermia by burning brown fat to produce bod y heat. This process requires oxygen and glucose. When an infant experiences hyp othermia, glucose and oxygen needs increase and hypoglycemia may result. The inf ant may require oxygen administration, but the need should always be assessed fi rst. Infants should be re-warmed slowly to prevent hypotension. Phototherapy is not indicated. 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; a risk related to hypothermia is hypoglycemia. Elimi nate option 2 because infants should be re-warmed slowly to prevent hypotension. Eliminate option 3 because no data has been given to support this action at thi s time. Eliminate option 4 because phototherapy is not indicated in this situati on. Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mat ernal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: P earson Education, Inc., p. 959. 30. The nurse is caring for a 30-week gestation infant at risk for necrotizi ng enterocolitis (NEC). The nurse should observe for which of the following:

You answered incorrectly: A bulging fontanelle. The correct answer was: Abdominal distention. Rationale: Changes in the gastrointestinal assessment, including abdominal diste ntion, occur with NEC. The other choices should be reported to the health care p rovider, but are not related to NEC. 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, a digestiv e disorder. Eliminate options 1, 3, and 4 because these assessment findings shou ld be reported to the health care provider, but are not related to NEC. Reference: Ball, J. & Binder, R. (2006). Child health nursing: Partnering with c hildren and families. Upper Saddle River, N.J.: Pearson Education, Inc., p 11371139.