High Risk Neonate

Question 1

The nurse is teaching a group of parents who have preterm newborns about the difference between a full-term NB and a preterm NB. Which characteristic would the nurse describe as associated with a preterm NB but not a term NB?

A. Fewer visible blood vessels through the skin
B. More SQ fat in the neck and abdomen
C. Well-developed flexor muscles in the extremities
D. greater body surface area in proportion to weight

Answer 1

D. greater body surface area in proportion to weight

Rationale: preterm NB have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm nbs often have thin transparent skin with numerous visible veins, minimal SQ fat, and poor muscle tone

Question 2

A nurse is assessing a post term NB. Which finding would the nurse correlate with this gestation age variation?

A. Moist, supple, plum skin appearance
B. Abundant lanugo and vernix
C. Thin umbilical cord
D. Absence of sole creases

Answer 2

C. Thin umbilical cord

Rationale: a post term NB typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet

Question 3

The parents of a preterm NB being cared for in the NICU are coming to visit for the first time. The NB is receiving mechanical ventilation, IV fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate?

A. Suggest that the parents stay for just a few mins to reduce their anxiety
B. Reassure them that their NB is progressing well
C. Encourage the parents to touch their preterm NB
D. Discuss the care they will be giving to the NB upon DC

Answer 3

C. Encourage the parents to touch their preterm NB

Rationale: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their NB. Doing so helps to acquaint the parents with their NB, promotes self-confidence, and fosters parent-NB attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the nb’s status improves and plans for DC are initiated

Question 4

Rapid assessment of a NB indicates the need for resuscitation. The NB has copious secretions. The NB is dried and placed under a radiant warmer. Which action would the nurse do next?

A. Intubate with an appropriate sized ET tube
B. Give chest compressions at a rate of 80/min
C. Administer epinephrine IV
D. Clear the airway with a bulb syringe

Answer 4

D. Clear the airway with a bulb syringe

Rationale: After placing the NB’s head in a neutral position, the nurse would clear the airway with a bulb syringe or suction. This is followed by assessment of breathing and bagging if needed, placing a pulse oximeter, ventilating the NB, assessing the HR and giving chest compressions if needed, and then administering epinephrine and/or volume expansion if needed

Question 5

The nurse prepares to assess a NB who is considered to be LGA. Which characteristic would the nurse correlate with this gestational age variation?

A. Strong, brisk motor skills
B. Difficulty in arousing to a quiet alert state
C. Birthweight of 7 lb 14 oz or 3572 g
D. Wasted appearance of extremities

Answer 5

B. Difficulty in arousing to a quiet alert state

Rationale: LGA NBs typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz or 3997 g at term

Question 6

A preterm NB has received large concentrations of oxygen therapy during a three month stay in the NICU. As the NB is prepared to be DC home, the nurse anticipates a referral for which specialist?

A. Ophthalmologist
B. Nephrologist
C. Cardiologist
D. Neurologist

Answer 6

A. Ophthalmologist

Use of large concentrations of oxygen and sustained oxygen saturations higher than 95% while on supplemental oxygen have been associated with the development of retinopathy of prematurity and further respiratory complications in the preterm NB. For these reasons, oxygen should be used judiciously to prevent the development of further complications. A guiding principle for oxygen therapy is it should be targeted to levels appropriate to the condition, gestational age, and postnatal age of the NB. As a result, an ophthalmology consult for F/U after DC is essential for preterm infants who have received extensive oxygen. Although referrals to other specialists may be warranted depending on the nb’s status, there is no information to suggest that any would be needed

Question 7

A nurse is developing the POC for a SGA NB. Which action would the nurse determine as a priority?

A. Preventing hypoglycemia with early feedings
B. Observing for NB reflexes
C. Promoting bonding between the parents and the NB
D. Monitor V/S every two hours

Answer 7

A. Preventing hypoglycemia with early feedings

The nurse must consider the implications of a SGA NB. With the loss of the placenta at birth, the NB must now assume control of glucose homeostasis. This is achieved by early PO intermittent feedings. Observing for NB reflexes, promoting bonding, and monitoring v/s, although important, aren’t the priority

Question 8

The nurse is providing care to a NB who was born at 36 weeks gestation. Based on the nurse’s understanding of gestational age, the nurse identifies this NB as:

A. Preterm
B. Late preterm
C. Term
D. Postterm

Answer 8

B. Late preterm

Rationale: Gestational age is typically measured in weeks: a nb born before completion of 37 weeks is classified as preterm nb, and one born after completion of 42 weeks is classified as postterm nb. An infant born from the first day of the 38th week through 42 weeks is classified as a term nb. The late preterm nb is one who is born between 34 weeks and 36 weeks, 6 days of gestation

Question 9

Which intervention would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm nb?

A. Avoid using the terms “death” or “dying”
B. Provide opportunities for them to hold the nb
C. Refrain from initiating conversations with the parents
D. Quickly refocus the parents to a more pleasant topic

Answer 9

B. Provide opportunities for them to hold the nb

Rationale: When dealing with grieving parents, nurses should provide them with opportunities to hold the NB if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the nb. These interventions help to validate the parents’ sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as “dying” “died” and “death” to help the parents accept the reality of death. Nurses need to demonstrate empathy and to respect the parents’ feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents’ feelings and facilitate the grieving process

Question 10

A nurse is reviewing the maternal history of a LGA nb. Which factor, if noted in the maternal history, would the nurse ID as possibly contributing to the birth of this nb?

A. Substance use disorder
B. DM
C. Pre-eclampsia
D. Infection

Answer 10

B. DM

Rationale: Maternal factors that increase the chance of having an LGA nb include maternal Dm or glucose intolerance, multiparity, prior history of macroscopic infant, post date gestation, maternal obesity, male fetus, and genetics. Substance use disorder is associated with SGA nb and preterm nb. A maternal history of preeclampsia and infection would be associated with preterm birth

Question 11

A nurse is assessing a preterm nb. Which finding would alert the nurse to suspect that a preterm nb is in pain?

A. Bradycardia
B. Oxygen saturation level of 94%
C. Decreased muscle tone
D. Sudden high-pitched cry

Answer 11

D. Sudden high-pitched cry

Rationale: the nurse should suspect pain if the nb exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone

Question 12

A 22-year-old woman experiencing homelessness arrives at a walk-in clinic seeking pregnancy confirmation. The nurse notes on assessment her uterus suggests 12 weeks’ gestation, a BP of 110/70 mm Hg, and a BMI of 17.5. The client admits to using cocaine a few times. The client has been pregnant before and indicates she “loses them early.” What characteristic(s) place the client in the high-risk pregnancy category? SATA.

A. BMI 17.5
B. BP 110/70 mm Hg
C. Prenatal history
D. Homelessness
E. Age
F. Prenatal care

Answer 12

A. BMI 17.5
C. Prenatal history
D. Homelessness
F. Prenatal care

Rationale: The key to identifying a nb with special needs related to birthweight or gestational age variation is an awareness of the factors that could place a nb at risk. These factors are similar to those that would suggest a high-risk pregnancy and include maternal nutrition, substandard living conditions or low SES, maternal age of <20 or >35 years, lack of prenatal care, and history of previous preterm birth

Question 13

A neonate born at 40 weeks’ gestation weighing 2300 g or 5 lb 1 oz is admitted to the nb nursery for observation only. What is the nurse’s first observation about the infant?

A. The neonate is average for its gestational age
B. The neonate is small for its gestational age
C. The neonate is large for its gestational age
D. The neonate is fetal growth restricted

Answer 13

B. The neonate is small for its gestational age

Rationale: SGA describes nbs that typically weight <2500 g or 5 lb 8 oz at term due to less growth than expected in utero. A nb is also classified as SGA if his or her birthweight is at or below the 10th percentile as correlated with the number of weeks of gestation. In some SGA nbs, the rate of growth doesn’t meet the expected growth pattern. These infants are considered to have fetal growth restriction resulting in pathology

Question 14

A thin nb has a RR of 80 breaths/min, nasal flaring with sternal retractions, a HR of 120 beats/min, temp of 36 C or 96.8 F and persisting oxygen saturation of <87%. The nurse interprets these findings as:

A. Cardiac distress
B. Respiratory alkalosis
C. Bronchial PNA
D. Respiratory distress

Answer 14

D. Respiratory distress

Rationale: Ineffective breathing pattern r/t immature respiratory system and respiratory distress as evidenced by tachypnea, nasal flaring, sternal retractions, and/or oxygen saturation <87%. These assessment findings don’t indicate bronchial PNA respiratory alkalosis or cardiac distress at this time

Question 15

A one-day-old neonate born at 32 weeks’ gestation is in the NICU under a radiant overhead warmer. The nurse assesses the morning axilla temperature as 95 F or 35 C. What could explain the assessment finding?

A. Conduction heat loss is a problem in the baby
B. The supply of brown adipose tissue isn’t developed
C. Axillary temperatures aren’t accurate
D. This is a normal temperature

Answer 15

B. The supply of brown adipose tissue isn’t developed

Rationale: typically nbs use non-shivering thermogenesis for heat production by metabolizing their own brown adipose tissue. However, this preterm nb has an inadequate supply of brown fat because he or she left the uterus early before the supply was adequate. Conduction heat loss allows an increased transfer of heat from their bodies to the environment but there is nothing to substantiate conduction heat loss. Axillary temperatures are accurate and the mode of taking temperatures for neonates

Question 16

A 42-year-old woman is 26 weeks’ pregnant. She lives at a shelter for female victims of intimate partner violence. Her BP is 170/90 mm Hg, the FHR is 140 bpm, TORCH studies are positive, and she is bleeding vaginally. What findings put her at risk of giving birth to a SGA infant? SATA.

A. The age of the client
B. Living in a shelter for victims of IPV
C. Vaginal bleeding
D. FHR
E. BP
F. Positive test for TORCH

Answer 16

A. The age of the client
B. Living in a shelter for victims of IPV
C. Vaginal bleeding
E. BP
F. Positive test for TORCH

Rationale: Some factors contributing to the birth of SGA nbs include maternal age of 20 or 35 years old, low SES, and preeclampsia with increased BP. The vaginal bleeding indicates placental problems, and she tests positive for STD by TORCH group infections

Question 17

A term neonate has been admitted to the observational nb nursery with the Dx of being SGA. Which factors would predispose the neonate to this Dx? SATA.

A. The mother had chronic placental abruption
B. At birth the placenta was noted to be decreased in weight
C. On assessment the placenta had areas of infarction
D. At birth the placenta was a shiny Schultz presentation
E. Placental talipes was present at birth

Answer 17

A. The mother had chronic placental abruption
B. At birth the placenta was noted to be decreased in weight
C. On assessment the placenta had areas of infarction
D. At birth the placenta was a shiny Schultz presentation

Rationale: Placental factors that can contribute o a SGA infant include chronic placental abruption, infarction on surface of placenta, and decreased placental weight. A shiny Schultz placenta is a normal description because the fetal side of the placenta comes out first, which is shiny. Placenta talipes doesn’t exist

Question 18

A SGA infant is admitted to the observational care unit with the nursing Dx of ineffective thermoregulation r/t lack of fat stores as evidenced by persistent low temperatures. Which are inappropriate nursing interventions? SATA.

A. Assess the axillary temperature every hour
B. Review maternal history
C. Assess environment for sources of heat loss
D. Bathe the neonate with warmer water
E. Minimize kangaroo care
F. Encourage skin-to-skin contact

Answer 18

A. Assess the axillary temperature every hour
B. Review maternal history
C. Assess environment for sources of heat loss
F. Encourage skin-to-skin contact

Rationale: Proper care to promote thermoregulation include assessing the axillary temperature every hour, reviewing the maternal history to ID RFs contributing to problem, assessing the environments for sources of heat loss, avoiding bathing and exposing nb to prevent cold stress, and encouraging kangaroo care to provide warmth

Question 19

A couple has just given birth to a baby who has low Apgar scores due to asphyxia from prolonged cord compression. The neonatologist has given a poor prognosis to the nb, who isn’t expected to live. Which interventions are appropriate at this time? SATA

A. Advise the parents that the hospital can make the arrangements
B. Offer to pray with the family if appropriate
C. Leave the parents to talk through their next steps
D. Initiate spiritual comfort by calling the hospital clergy, if appropriate
E. Respect variations in the family’s spiritual needs and readiness

Answer 19

B. Offer to pray with the family if appropriate
D. Initiate spiritual comfort by calling the hospital clergy, if appropriate
E. Respect variations in the family’s spiritual needs and readiness

Rationale: When assisting the parents to cope with a perinatal loss, the nurse must respect variations in the family’s spiritual needs and readiness. The nurse will also initiate spiritual comfort by calling the hospital clergy, if appropriate, and can offer to pray with the family, if appropriate

Question 20

A neonate is born at 42 weeks gestation weighing 4.4 kg (9lb 7oz) with satisfactory Apgar scores. Two hours later birth the neonate’s blood sugar indicates hypoglycemia. Which symptoms would the baby demonstrate? SATA.

A. Poor sucking
B. Respiratory distress
C. Weak cry
D. Jitteriness
E. Blood glucose >40 mg/dL

Answer 20

A. Poor sucking
B. Respiratory distress
C. Weak cry
D. Jitteriness

Rationale: Some of the common problems associated with newborns experiencing a variation in gestation age, such as a post term newborn, are respiratory distress, jitteriness, feeble sucking, weak cry, and a blood glucose of 40 mg/dL

Question 21

A premature, 36-week-gestation neonate is admitted to the observational nursery and placed under bililights with evidence of hyperbilirubinemia. Which assessment findings would the neonate demonstrate? SATA.

A. Increased serum bilirubin levels
B. Clay-colored stools
C. Tea-colored urine
D. Cyanosis
E. Mongolian spots

Answer 21

A. Increased serum bilirubin levels
B. Clay-colored stools
C. Tea-colored urine

Rationale: Hyperbilirubinemia is indicated when the newborn presents with elevated serum bilirubin levels, tea-colored urine, and clay-colored stools. Cyanosis wouldn’t be seen in infants in this scenario. Mongolian spots are not associated with newborn jaundice.

Question 22

A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? SATA.

A. There is flaccid muscle tone of the affected limb
B. Respiration rate is 52 breaths per minute
C. Heart rate is 180 beats per minutes
D. Oxygen saturation level is 88%
E. The infant has facial grimacing and quivering chin

Answer 22

C. Heart rate is 180 beats per minutes
D. Oxygen saturation level is 88%
E. The infant has facial grimacing and quivering chin

Rationale: Suspect pain if the newborn exhibits a sudden high-pitched cry; facial grimace is noted with furrowing of the brow and quivering of the chin with an increase in muscle tone when disturbed. Oxygen desaturation will be noted with an increase in heart rate. Increase in the normal BP, pulse, and RR are noted

Question 23

During a neonate resuscitation attempt, the neonatologist has ordered 0.1 mL/kg IV epinephrine in a 1:10000 concentration to be given stat. The neonate weighs 3000 grams and is 38 cm long. How many mL should the nurse administer? Record your answer using one decimal place.

Answer 23

0.3

Question 24

A macrosomic infant in the NB nursery is being observed for a possible fractured clavicle. For which would the nurse assess? SATA.

A. Facial grimacing with movement
B. Bruising over area
C. Asymmetrical movement
D. Edema present
E. Positive Babinski reflex

Answer 24

A. Facial grimacing with movement
B. Bruising over area
C. Asymmetrical movement
D. Edema present

Rationale: Birth trauma for LGA NBs would be demonstrated by an obvious deformity, with bruising at the site and edema noted. There would be asymmetrical movement when he newborn moves the limb. Babinski reflex is a neurological test and would be normal to be positive

Question 25

A set of NB twins has been admitted to the NICU with the Dx of FGR. Which maternal factors would predispose the NB to this Dx? SATA.

A. Hemoglobin 15 g/dL (150 g/L)
B. A1C levels of 8% (0.08)
C. Heroin use disorder
D. BP baseline of 170/90 mm Hg
E. Age 39 years
F. Multiple gestation

Answer 25

B. A1C levels of 8% (0.08)
C. Heroin use disorder
D. BP baseline of 170/90 mm Hg
E. Age 39 years
F. Multiple gestation

Rationale: Assessment of the SGA or FGR infant begins by reviewing the maternal history to ID RFs such as maternal age over 30 years, a substance use disorder, HTN, multiple gestation. Gestational DM or DM is also a factor. Normal A1C level is 5.7% (0.57) for a person without DM. Hgb is normal for pregnant woman in third trimester

Question 26

A neonate is admitted to the newborn observation nursery with the possible Dx of polycythemia. The nurse would be observing for which findings? SATA.

A. Ruddy skin color
B. Respiratory distress
C. Cyanosis
D. Pink gums and tongue
E. Jitteriness

Answer 26

A. Ruddy skin color
B. Respiratory distress
C. Cyanosis
E. Jitteriness

Rationale: Observe for clinical signs of polycythemia - respiratory distress, cyanosis, jitteriness, jaundice, ruddy skin color, and lethargy - and monitor blood results

Question 27

A 20-hour-old neonate is suspected of having polycythemia. Which nursing intervention(s) will the nurse utilize to provide care for this neonate? SATA.

A. Obtain Hgb and Hct laboratory tests
B. Provide early feedings to prevent hypoglycemia
C. Maintain oxygen saturation parameters
D. Monitor urinary output
E. Insert peripheral IV

Answer 27

A. Obtain Hgb and Hct laboratory tests
B. Provide early feedings to prevent hypoglycemia
C. Maintain oxygen saturation parameters
D. Monitor urinary output

Rationale: Polycythemia in a neonate is defined as a hematocrit above 65% and a hemoglobin level above 20 g/dL. The hematocrit and hemoglobin peak between 6 and 12 hours of life and then start to decrease. If these values do not decrease as expected, then hypoperfusion will occur and polycythemia will develop. In the beginning, the nurse may assess feeding difficulties, hypoglycemia, jitteriness and respiratory distress. As the condition worsens, a ruddy skin color could be seen, cyanosis could develop, the neonate could become lethargic and seizures could develop. Nursing care for this neonate requires obtaining hematocrit and hemoglobin laboratory tests at 2 hours, 12 hours and 24 hours. Feeding should be started to provide fluid, nutrition and prevent hypoglycemia. The oxygen saturation should be monitored. If the levels are below the established parameters from the health care provider, oxygen therapy will be needed. The urine output should be monitored continuously because polycythemia can cause renal failure. A peripheral IV may or may not be needed. This would depend on on the neonate’s condition and if IV fluids would be required

Question 28

A client has given birth to a full-term infant weighing 10 pounds 5 ounces. What priority assessment should be completed by the nurse?

A. Blood glucose
B. Temperature control
C. Feeding difficulty
D. Perfusion

Answer 28

A. Blood glucose

Rationale: Hypoglycemia is a common concern with a LGA infant. This infant will deplete the glucose stores very rapidly. Therefore, it is important to assess the glucose level within 30 minutes of birth and to repeat every hour until stable. Hypoglycemia is defined as glucose level <35-45 mg/dL in the first 4 hours of life, and intervention should occur when the glucose is <40 mg/dL. Intervention should also occur if the blood glucose is <45 mg/dL at 4 and 24 hours of life respectively. Generally the nurse assesses symptoms of jitteriness, irritability and tachypnea first. These symptoms can progress to temperature instability, lethargy, bradycardia, hypoxia and seizures

Question 29

A client expresses concerns that her grandmothers had complicated pregnancies. What principle(s) should the nurse discuss to allay the fears of the client? SATA.

A. “We work to ensure that birth of high-risk infants happens in settings where we are able to care for them”
B. “We will work with you to identify prenatal risk factors early and take actions to reduce their impact”
C. “We support those at risk of having a preterm births with the goal of delaying early births”
D. “We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death
E. “We allow families to grieve the loss of a newborn, should it occur”

Answer 29

A. “We work to ensure that birth of high-risk infants happens in settings where we are able to care for them”
B. “We will work with you to identify prenatal risk factors early and take actions to reduce their impact”
C. “We support those at risk of having a preterm births with the goal of delaying early births”
D. “We work to ensure care for mothers and infants to reduce infant illnesses, disabilities, and death

Rationale: The nurse will attempt to allay the client’s fears by discussing the actions the facility enacts to promote a healthy birth and infant. This includes ensuring the birth of high-risk infants takes place in settings that have the technological capacity to care for them, identifying risk factors early and taking action to reduce their impact, working to delay the birth of those pregnancies identified at risk of preterm birth, and promoting an overall reduction in infant illness, disability, and death to proper care of the mother and infant. Although allowing a family to grieve in instances of infant death, discussing this factor with the client is likely to create more fear

Question 30

A late preterm newborn is being prepared for discharge to home after being in the NICU for 4 days. The nurse instructs the parents about the care of their NB and emphasizes warning signs that should be reported to the pediatrician immediately. The nurse determines that additional teaching is needed based on which parental statement?
A. “We will call 911 if we start to see that our newborn’s lips or skin are looking bluish”
B. “If our newborn’s skin turns yellow, it is from the treatments and our newborn is okay”
C. “If our newborn doesn’t have a wet diaper in 12 hours, we will call our pediatrician”
D. “We will let the pediatrician know if our newborn’s temperature goes above 100.4 F

Answer 30

B. “If our newborn’s skin turns yellow, it is from the treatments and our newborn is okay”

Rationale: The parents of a preterm newborn need teaching about when to notify their pediatrician or nurse practitioner. These include: displaying a yellow color to the skin; having difficulty breathing or turning blue (call for emergency services in this case); having a temperature below 97 F or above 100.4 F; and failing to void for 12 hours

Question 31

The nurse is assigned to care for an infant of a diabetic mother that was just delivered. What assessment would the nurse consider to be a priority for this neonate?

A. Gestational age assessment
B. Reflexes.
C. Weight and measurements
D. Respiratory assessment. (RDS is a common complication)

Answer 31

D. Respiratory assessment. (RDS is a common complication)

Question 32

A nurse in the ED assesses woman who was just diagnosed at 32-weeks’ gestation as having gestational diabetes. The woman has not received any prenatal care. What factor(s) will determine the risks and/or complications the diabetes will have on her and the baby?

A. Level of insulin resistance of this patient’s diabetes.
B. Level of knowledge the woman has about diabetes.
C. Severity and duration of this patient’s diabetes.
D. Significance of organ damage caused by this patient’s diabetes.

Answer 32

C. Severity and duration of this patient’s diabetes

Question 33

A nurse assists a pregnant patient with heart disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant patient to use these resources primarily to:

A. avoid exposure to potential pathogens and resulting infection.
B. help the mother prepare for labor and delivery.
C. reduce excessive maternal stress and fatigue.
D. prepare the 18-month-old child for maternal separation during hospitalization.

Answer 33

C. reduce excessive maternal stress and fatigue

Question 34

The nurse is assessing a pregnant patient with Type 1 diabetes about her understanding regarding changing insulin needs during pregnancy. The nurse determines that teaching is needed if the patient makes which statement?

A. “Episodes of hypoglycemia are more likely to occur during the first three months of pregnancy.”
B. “I will need to increase my insulin dosage during the first 3 months of pregnancy.”
C. “My insulin needs should begin to normalize after delivery.”
D. “My insulin dose will likely need to be increased during the second and third trimesters.”

Answer 34

B. “I will need to increase my insulin dosage during the first 3 months of pregnancy.”

Question 35

Which of the following labs would the nurse assess to provide the best information about ongoing control of pre-existing Type 1 diabetes in a pregnant adolescent?

A. An oral glucose tolerance test (OGTT).
B. Hemoglobin A1C.
C. Post-prandial blood glucose testing.
D. Fasting blood glucose.

Answer 35

B. Hemoglobin A1C

Question 36

The nurse is conducting a support group for women diagnosed with gestational diabetes. All of the participants must rely on insulin to control their blood sugars. During the meeting, the nurse notices that one of the participants has become confused, clammy, nauseated, and feels like she has to vomit. The nurse suspects that the patient may be:

A. hyperglycemic
B. septic
C. hypertensive
D. hypoglycemic

Answer 36

D. hypoglycemic

Question 37

The nurse is reviewing teaching regarding the development of gestational diabetes with a woman who is 8 weeks pregnant. The nurse becomes concerned when the patient states:

A. “so what you are saying is that I am at risk for developing gestational diabetes because my husband is a diabetic.”
B. “gestational diabetes is most likely to develop after the 20th week of pregnancy.”
C. “diabetes during pregnancy may make me and my baby develop diabetes later in life.”
D. “if I develop diabetes during pregnancy, I may have to take insulin for the duration of my
pregnancy.”

Answer 37

A. “so what you are saying is that I am at risk for developing gestational diabetes because my husband is a diabetic.”

Question 38

A nurse is asked to design a teaching project to present to a gestational diabetic support group regarding risk reduction to prevent recurrence of the disease later in life. The nurse would most likely develop a teaching plan on:

A. vitamin supplementation.
B. antidiabetic medication information.
C. frequent hand washing.
D. lifestyle modifications.

Answer 38

D. lifestyle modifications.

Question 39

When a gestational diabetic patient who has become insulin-dependent during the course of the pregnancy gives birth, the nurse would expect the patient’s insulin requirements in the first 24 hour after delivery to:

A. gradually return to normal.
B. stay the same as before.
C. increase slightly.
D. drop significantly.

Answer 39

D. drop significantly.

Question 40

At birth, a neonate’s heart rate is 75; he exhibits no signs of respiratory effort; his muscle tone shows some flexion; his color is pale. Based on this assessment, the nurse:

A. administers oxygen by mask until he is pink.
B. begins resuscitative actions immediately.
C. notifies the physician at once.
D. admits the neonate to the NICU for further observation.

Answer 40

B. begins resuscitative actions immediately.

Question 41

A client who received no prenatal care delivers a 10-pound, 4-ounce baby who now exhibits signs of respiratory distress syndrome. The nurse obtains a blood sample from the infant to assess for which of the following?

A. hyperbilirubinemia
B. hemolysis
C. sepsis
D. hypoglycemia

Answer 41

D. hypoglycemia

Question 42

The following neonates are admitted to the nursery. The nurse should withhold the scheduled initial feeding on which newborn?

A. A neonate with an axillary temperature of 97.5 F.
B. A neonate with a sustained heart rate of 118 beats/min.
C. A neonate with a sustained respiratory rate of 68 breaths/min.
D. A neonate who is small for gestational age.

Answer 42

C. A neonate with a sustained respiratory rate of 68 breaths/min.

Question 43

The parents of a preterm neonate ask why their baby gets cold so easily. The nurse explains that preterm neonates:

A. are able to shiver to produce body heat.
B. have blood vessels that are deep under the skin surface.
C. have minimal body fat to retain body heat.
D. lose heat faster because they lay in a fetal position

Answer 43

C. have minimal body fat to retain body heat.

Question 44

A 26-week gestation neonate has received 80% to 100% oxygen via mechanical ventilation for 2 weeks and has received several blood transfusions for anemia. The nurse should plan for which of the following interventions?

A. Schedule eye exam by ophthalmologist prior to discharge.
B. Begin phototherapy.
C. Discontinue oxygen immediately.
D. Administer surfactant via the endotracheal tube.

Answer 44

A. Schedule eye exam by ophthalmologist prior to discharge.

Question 45

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 to the infant immediately after delivery?

A. Magnesium sulfate.
B. Naloxone (Narcan)
C. Regular insulin
D. Double dose of vitamin K (Aqua-Mephyton)

Answer 45

B. Naloxone (Narcan)

Question 46

Baby M was born to a mother addicted to heroin. Baby M is jittery, fussy, and constantly moving her legs in a crawling motion. Her knees are abraded and her cheeks are red. Which of the following would be the best intervention for Baby M?

A. Feed her by gavage only and administer medication to decrease her constant activity.
B. Have her mother cuddle and play with her so mother-infant attachment is encouraged.
C. Clean the excoriated areas with an antiseptic soap to prevent secondary infection, position her off her excoriated areas, and loosely wrap her to allow air circulation.
D. Position her to avoid pressure on her excoriated areas, make sure her skin is clean and dry, and swaddle her. (only cause the other one says loosely wrap but you wanna swaddle..)

Answer 46

D. Position her to avoid pressure on her excoriated areas, make sure her skin is clean and dry, and swaddle her. (only cause the other one says loosely wrap but you wanna swaddle..)

Question 47

A baby delivered from a drug-addicted mother should be closely monitored for which of the following additional signs and symptoms of drug withdrawal?

A. progressive lethargy
B. seizure activity
C. subconjunctival hemorrhages
D. generalized, flat, macular rash

Answer 47

B. seizure activity

Question 48

A 1500 gm pre-term infant is showing signs of necrotizing enterocolitis (NEC). The nurse knows these signs are:

A. decreased gastric residuals, hypermotility, diarrhea. (increased gastric residual)
B. increased bowel sounds, gastric distention, fever. (bowel sounds will decrease)
C. bloody stools, vomiting, temperature instability.
D. hypothermia, tachypnea, vomiting. (not just hypothermia..i guess)

Answer 48

C. bloody stools, vomiting, temperature instability.

Question 49

When caring for a newborn, the nurse should be alert for signs of cold stress, which would include:

A. decreased activity level.
B. hyperglycemia. (no, hypoglycemia)
C. decreased respirations. (no, increased RR)
D. shivering.

Answer 49

A. decreased activity level.

Question 50

When caring for a newborn, the nurse should be alert for signs of cold stress, which would include:

a. Decreased activity level – google says increased indermuehle says decreased
b. Increased respiratory rate (quizlet)
c. Hyperglycemia – nope hypoglycemic
d. Shivering – can’t shiver

Answer 50

b. Increased respiratory rate (quizlet)

Question 51

Which action best explains the main role of surfactant in the neonate?

Answer 51

Lower surface tension in the alveoli & stabilizes them to prevent collapse. Keeps alveoli open to prevent atelectasis, same as us i guess? Found this in the book

Question 52

A 6-month-old child is being seen in the pediatrician’s office. The child was born preterm and remained in NICU for the first 5 months of life. The child is being monitored for 5 chronic problems. Which of the following problems are directly related to prematurity? SATA

A. Hypothroidism.
B. Seizure Disorder.
C. Bronchopulmonary Dysplasia (BPD).
D. Cerebral Palsy.
E. Retinopathy.

Answer 52

B. Seizure Disorder.
C. Bronchopulmonary Dysplasia (BPD).
D. Cerebral Palsy.
E. Retinopathy.

Question 53

A NICU nurse knows a strategy that may be supportive to grieving parents after neonatal loss is:

A. providing the mother’s care so that the father is free to grieve.
B. delaying discussion of autopsy and medical findings.
C. waiting for the parents to bring up the loss.
D. offering therapeutic touch when parents cry.

Answer 53

D. offering therapeutic touch when parents cry.

Question 54

An infant girl was born at 29 weeks gestation and has been in the NICU for 4 weeks. She has survived many potential complications, and until now has been fed via orogastric tube. The physician has written orders to start nipple feeding the infant with 70 ml of 22 cal/oz. formula every 3 hours. After 20 minutes, the infant has taken 40 ml of formula via nipple. The nurse should:

A. insert an orogastric tube and administer the remaining prescribed formula. (want to prevent infant from tiring out)
B. burp the infant well and attempt to feed her more formula.
C. wait 30 minutes and try to feed the baby more.
D. discontinue the feeding until the next prescribed hour due.

Answer 54

A. insert an orogastric tube and administer the remaining prescribed formula. (want to prevent infant from tiring out)

Question 55

A 36-hour-old neonate was delivered at term with no complications. The mother had an uneventful pregnancy and delivery. The baby is exhibiting an unstable temperature, requiring strenuous measures to raise his temperature to 98.0 degrees F. The baby nursed well in the first 24 hours, but now appears lethargic and will not nurse. The nurse notifies the pediatrician, as she is concerned that the baby is exhibiting signs of:

A. neonatal sepsis.
B. neonatal abstinence syndrome.
C. necrotizing enterocolitis.
D. neonatal hypoglycemia.

Answer 55

A. neonatal sepsis

Question 56

The reason the nurse keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, he or she requires:

A. less oxygen, and the newborn’s metabolic rate decreases.
B. less oxygen, and the newborn’s metabolic rate increases.
C. more oxygen and the newborn’s metabolic rate increases.
D. more oxygen, and the newborn’s metabolic rate decreases.

Answer 56

C. more oxygen and the newborn’s metabolic rate increases

Question 57

The nurse is assigned to care for an infant of a diabetic mother that was just delivered. What assessment would the nurse consider to be a priority for this neonate?

A. Gestational age assessment.
B. Reflexes.
C. Weight and measurements.
D. Respiratory assessment.

Answer 57

D. Respiratory assessment

Question 58

A hospitalized patient is diagnosed with cardiomyopathy during her pregnancy. The nurse knows that the care for this patient will focus on managing oxygen supply and demand. What interventions can the nurse do to decrease the patient’s oxygen demand? SATA

A. Administer prescribed IV fluids. (nah wanna prevent fluid overload)
B. Administer pain medications as needed.
C. Reposition the patient every hour. (idk about this one)
D. Provide a calm and quiet environment.
E. Assist the patient with her ADLs.

Answer 58

B. Administer pain medications as needed
D. Provide a calm and quiet environment
E. Assist the patient with her ADLs

Question 59

Women with gestational diabetes are at a higher risk for urinary tract infections because they:

A. have higher ketones in the urine.
B. are more likely to lose glucose in their urine. (sugar sugar babyyyy)
C. have a daily fluid restriction.
D. develop insulin resistance.

Answer 59

B. are more likely to lose glucose in their urine. (sugar sugar babyyyy)

Question 60

A Type 1 diabetic patient who is 24 weeks gestation calls to inform the nurse that she has been nauseated and vomiting for the past 4 hours. The nurse should instruct the patient to:

A. closely monitor her blood sugar and urine.
B. discontinue all insulin and increase fluid intake.
C. notify her physician as this condition is a medical emergency. (tas per protocol of sick day rules- DKA possibly)
D. chew a glucose tablet immediately.

Answer 60

C. notify her physician as this condition is a medical emergency. (tas per protocol of sick day rules- DKA possibly)

Question 61

The nurse suspects that a pregnant patient with a past medical history of mitral valve regurgitation may be experiencing left-sided heart failure when the following findings are detected during morning assessment? SATA

A. right upper quadrant pain.
B. dependent edema.
C. coarse crackles bilaterally.
D. decreased oxygen saturation levels.
E. distended jugular veins

Answer 61

C. coarse crackles bilaterally
D. decreased oxygen saturation levels

Question 62

A pregnant client with a past medical history of long-term Type I diabetes has called the high-risk OB clinic reporting flu-like symptoms. The nurse should instruct the client to…

Answer 62

Basically just sick day rules: check BG and ketones q 3-4 hrs, dont skip or dec insulin doses, call MD if constant vomiting, make a sick day kit, eat small freq meals and fluids