NCM 109 FINALLSSS Flashcards
The most common cause of jaundice in newborns
Physiologic jaundice
A major risk factor for jaundice in a newborn is
prematurity (35-36 week’s gestation)
A correct statement about physiologic jaundice in a newborn is that the jaundice:
May develop 2-3 days after birth
The primary goal of treatment for RDS:
Dilate the bronchioles
part of the respiratory system primarily affected by RDS
Nasopharynx
Condition is not associated with respiratory distress in children
Respiratory syncytial virus (RSV)
The nurse is caring for a newborn on phototherapy.
What nursing intervention(s) is appropriate to include
in the plan of care to prevent the side effects of
phototherapy in a newborn with hyperbilirubinemia:
*Assess temperature frequently.
*Monitor intake and output.
A neonatal nurse admits a preterm infant with the
diagnosis of respiratory distress syndrome and
reviews the maternal labor and birth record. Which
factors in the record would the nurse correlate with
this diagnosis
32 weeks’ gestation
cesarean birth
male gender
maternal diabetes
The nurse frequently assesses the respiratory status
of a preterm newborn based on the understanding that
the newborn is at increased risk for respiratory
distress syndrome because of
deficiency of surfactant.
The nurse assessing a 15-hour-old term neonate
notes the skin color in the face is yellow. The nurse
obtains a transcutaneous bilirubin reading per a
standing order and the result is 9. What is the priority
action the nurse needs to take:
Notify the health care
provider of the finding.
A preterm neonate is transferred to a NICU. When the
parents visit, which action would be most important for
the nurse to urge them to do:
do:.Touch firmly and, if
possible, hold the baby
The cause of conjugated hyperbilirubinemia is
Impairment in
hepatic excretion or an extrahepatic
obstruction
Jaundice in a newborn with hyperbilirubinemia initially
appears on the face and progresses in which pattern:
Cephalocaudal
The average bilirubin production in newborns is
2 to 3
times more than adults
Elevation of serum bilirubin is also affected by the rate
of excretion. In a newborn, excretion of bilirubin is
complicated by
Decreased transit time in the intestines
and decreased enterohepatic circulation time
Jaundice is considered pathological if it occurs In the
first
24 hours after birth
Phototherapy is a treatment for jaundice. The
mechanism of phototherapy is T
Transforming
unconjugated bilirubin into photoproducts that can be
excreted
Potential complications for a newborn being treated
with phototherapy include all of the following except
Decreased stooling
When providing discharge education to the family of a
newborn treated for hyperbilirubinemia, they should be
instructed to contact the provider if they notice
Decreased voiding or stooling
Newborns are least likely to develop jaundice if they
are
Breastfed with less than 38 weeks’ gestation
An accurate level assessment of hyperbilirubinemia
can be performed by
Measuring serum bilirubin
An early sign of bilirubin toxicity in newborns is
Hypotonia
A condition characterized by staining of the brainstem
nuclei and cerebellum is known as
Kernicterus
Pulmonary stenosis in Tetralogy of Fallot is dangerous
because
it can lead to inadequate passage of blood to
the Lungs
What finding would you expect when measuring blood
pressure on all four extremities of a child with a
coarctation of the aorta is blood pressure that is:
Lower in the legs than the arms
Why does a child who is diagnosed with tetralogy of
fallot favor the squatting position:
It increases the
return of venous blood back to the heart
What does a chest x-ray of a patient with tetralogy of
fallot typically reveal:
Boot-shaped heart
What is often the first sign(s) of tetralogy of fallot:
Heart murmur
Cyanosis
You’re providing an in-service to a group of new
nurses who will be caring for patients who have
Tetralogy of Fallot. Which statement below is
INCORRECT concerning how the blood normally
flows through the heart:
Unoxygenated blood enters
through the superior and inferior vena cava and
travels to the left atrium.
As the nurse you know which statements are TRUE
about Tetralogy of Fallot:
“Tetralogy of Fallot is a
cyanotic heart defect.”
While feeding a 3-month-old infant, who has Tetralogy
of Fallot, you notice the infant’s skin begins to have a
bluish tint and the breathing rate has increased. Your
immediate nursing action is to?
Stop feeding the infant
and place the infant in the knee-to-chest position and
administer oxygen.
You are assessing the heart sounds of a patient with a
severe case of Tetralogy of Fallot. You would expect
to hear a __________ murmur at the _______ of the
sternal border?
systolic; left
As the registered nurse you are developing a plan of
care for a patient with Tetralogy of Fallot. Select all the
appropriate nursing diagnoses below that would be
specific to this patient:
Activity Intolerance
Failure to thrive
A family member, who is caring for a 2-year-old with
Tetralogy of Fallot, asks you why the child will
periodically squat when playing with other children.
Your response is:
“Squatting helps to normalize
systemic vascular resistance, which will increase the
left to right shunt that is occurring in the ventricles and
this helps increase oxygen levels.”
Which of the following represents an effective nursing
intervention to reduce cardiac demands and decrease
cardiac workload
Clustering nursing care to provide for periods of
uninterrupted rest.
Developing and implementing a developmentally
appropriate plan of care as tolerated.
Defects associated with tetralogy of Fallot include
ventricular septal defect, overriding aorta, pulmonic
stenosis, and right ventricular hypertrophy.
the most common early complication of cardiac
catheterization:
Cardiac dysrhythmias
The nurse is assessing an infant who is admitted for
congestive heart failure. Which sign would the nurse
most likely find:
Dyspnea
Deoxygenated blood flows from the right ventricle to
the left ventricle. What defect does this most likely
describe:
Tetralogy of Fallot
A newborn infant is diagnosed as having a patent
ductus arteriosus. The knowledgeable pediatric nurse
understands that this congenital heart defect
involves:
persistence of the fetal opening between the
pulmonary artery and the aorta.
drugs are most often given to children with congenital
heart disease (CHD)to specifically decrease the
workload of the heart:
Diuretics
The nurse is preparing to discuss a congenital heart
defect that increases pulmonary blood flow. Which
condition should the nurse include
Patent ductus
arteriosus
The nurse is helping a mom breastfeed a newborn
who has a defect that decreases pulmonary flow. The
nurse observes that the newborn has difficulty
breathing and becomes cyanotic during the feeding.
Which instruction should the nurse provide:
Periodically stop the newborn from sucking
The nursing assessment of a newborn reveals
cyanosis, a continuous murmur over the pulmonic
area, and a harsh systolic murmur in the tricuspid area.
Which condition should the nurse suspect
Pulmonary atresia
The nurse is teaching women about vaccinations they
should have before becoming pregnant. Which should
the nurse include that will minimize the risk of having a
child with a congenital heart disorder
Rubella
The nurse is assessing a toddler with uncorrected
cyanotic heart disease. Which question to the parent
is most appropriate
Does your child often squat?
The assessment that would lead the nurse to suspect
that a newborn infant has a ventricular septal defect is:
a loud, harsh murmur with a systolic tremor.
Esophageal Atresia can be best described by which of
the following passages
An incomplete passageway
from the mouth to the stomach present at birth
A newborn who presents with which of the following
symptoms could have Esophageal Atresia with a
Tracheoesophageal Fistula?
A baby who is drooling
and has abnormal respiratory sounds at one hour old.
Tracheoesophageal Fistula is best described by which
of the following statements:
A passageway joining the
trachea and esophagus present at birth
The nurse observes a newborn become cyanotic
when feeding. What procedure will the nurse perform
as prescribed to assess for a tracheoesophageal
fistula (TEF)?
Attempt to pass a nasogastric tube (NG
tube)
A newborn had a repair of Type I tracheoesophageal
fistula (TEF). Which statement would be correct in
educating the family of what to expect in the
immediate post-operative period?
“Frequent suctioning with a pre-measured
catheter is required.”
“The head of bed should be elevated 30-45
degrees.”
“If there is no leak 5-7 days after the surgical
repair, oral feedings will be started.”
“The baby will be on acid suppression therapy
using a proton pump inhibitor (PPI), such as
Lansoprazole postoperatively.”
The finding the nurse would expect when measuring
blood pressure on all four extremities of a child with
coarctation of the aorta is blood pressure that is:
lower in the legs than in the arms.
When a father asks why his child with tetralogy of
Fallot seems to favor a squatting position, the nurse
would explain that squatting:
increases the return of
venous blood back to the heart.
A child develops carditis from rheumatic fever. The
nurse knows that the areas of the heart affected by
carditis are the:
heart muscle and the mitral valve.
