Exam 3 - Practice Questions (High Risk Newborn)

Question 1

1. A 1-day-old neonate, 32 weeks’ gestation, is in an overhead warmer. The nurse assesses
   the morning axillary temperature as 96.9ºF. Which of the following could explain
   this assessment finding?
2. This is a normal temperature for a preterm neonate.
3. Axillary temperatures are not valid for preterm babies.
4. The supply of brown adipose tissue is incomplete.
5. Conduction heat loss is pronounced in the baby.

Answer 1

3. Preterm babies are born with an insufficient
   supply of brown adipose tissue
   that is needed for thermogenesis,
   or heat generation.

TEST-TAKING TIP: It is important for the
test taker not to read into questions.
Even though conduction can be a means
of heat loss in the neonate and, more
particularly, in the premature, there are
three other means by which neonates
lose heat—radiation, convection, and
evaporation. Conduction could only be
singled out as a cause of the hypothermia
if it were clear from the question that
that were the cause of the problem.

Question 2

2. Which of the following neonates is at highest risk for cold stress syndrome?
3. Infant of diabetic mother.
4. Infant with Rh incompatibility.
5. Postdates neonate.
6. Down syndrome neonate.

Answer 2

3. Postdates babies are at high risk for
   cold stress syndrome because while
   still in utero they often metabolize
   the brown adipose tissue for nourishment
   when the placental function deteriorates.

TEST-TAKING TIP: The test taker must
know that cold stress syndrome results
from a neonate’s inability to create heat
through metabolic means. Brown adipose
tissue (BAT) and glycogen stores in the
liver are the primary substances used for
thermogenesis. The test taker must then
deduce that the infant most likely to have
poor supplies of BAT and glycogen is the
postdates infant

Question 3

3. Which of the following would lead the nurse to suspect cold stress syndrome in a
   newborn with a temperature of 96.5ºF?
4. Blood glucose of 50 mg/dL.
5. Acrocyanosis.
6. Tachypnea.
7. Oxygen saturation of 96%.

Answer 3

3. Babies who have cold stress syndrome
   will develop respiratory distress. One
   symptom of the distress is tachypnea.

TEST-TAKING TIP: It is important for the
test taker to know the normal variations
seen in the neonate—for example, normal
blood glucoses are lower in neonates
than in the older child and adult and
acrocyanosis is normal for a neonate’s
first day or two.

Question 4

4. Four babies are in the newborn nursery. The nurse pages the neonatalogist to see
   the baby who exhibits which of the following?
5. Intracostal retractions.
6. Erythema toxicum.
7. Pseudostrabismus.
8. Vernix caseosa.

Answer 4

1. Intracostal retractions are symptomatic
   of respiratory distress syndrome.

TEST-TAKING TIP: It is important for the
test taker to be familiar with the signs of
respiratory distress in the neonate. Babies
who are stressed by, for example,
cold, sepsis, or prematurity will often exhibit
signs of respiratory distress. The
neonatologist should be called promptly.

Question 5

5. A baby is grunting in the neonatal nursery. Which of the following actions by the
   nurse is appropriate?
6. Place a pacifier in the baby’s mouth.
7. Check the baby’s diaper.
8. Have the mother feed the baby.
9. Assess the respiratory rate.

Answer 5

4. Grunting is often accompanied by
   tachypnea, another sign of respiratory
   distress.
   TEST-TAKING TIP: If the test taker were to
   attempt to grunt, he or she would feel
   the respiratory effort that the baby is creating.
   Essentially, the baby is producing
   his or her own positive end-expiratory
   pressure (PEEP) in order to maximize his
   or her respiratory function.

Question 6

6. A 6-month-old child developed kernicterus immediately after birth. Which of the
   following tests should be done to determine whether or not this child has developed
   any sequelae to the illness?
7. Blood urea nitrogen and serum creatinine.
8. Alkaline phosphotase and bilirubin.
9. Hearing and vision assessments.
10. Peak expiratory flow and blood gas assessments.

Answer 6

3. Because the central nervous system
   (CNS) may have been damaged by the
   high bilirubin levels, testing of the
   senses as well as motor and cognitive
   assessments are appropriate.

TEST-TAKING TIP: The test taker must be
aware that kernicterus is the syndrome
that develops when a neonate is exposed
to high levels of bilirubin over time. The
bilirubin crosses the blood-brain barrier,
often leading to toxic changes in the CNS.

Question 7

7. A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To
   provide safe newborn care, which of the following actions should the nurse perform?
8. Cover the baby’s eyes with eye pads.
9. Turn the lights on for ten minutes every hour.
10. Clothe the baby in a shirt and diaper only.
11. Tightly swaddle the baby in a baby blanket.

Answer 7

1. When phototherapy is administered,
   the baby’s eyes must be protected
   from the light source.

TEST-TAKING TIP: There is a difference
between phototherapy administered by
fluorescent light and phototherapy administered
via fiber optic tubing to a biliblanket.
When a bili-blanket is used, the
baby can be clothed and the baby’s eyes
do not need to be protected.

Question 8

8. A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms
   would the nurse expect to see?
9. Ruddy complexion.
10. Anasarca.
11. Alopecia.
12. Erythema toxicum.

Answer 8

2. Babies born with erythroblastosis
   fetalis often are in severe congestive
   heart failure and, therefore, exhibit
   anasarca.

TEST-TAKING TIP: A baby with erythroblastosis
fetalis has marked red blood cell
destruction in utero secondary to the
presence of maternal antibodies against
the baby’s blood. The severe anemia that
results often leads to congestive heart
failure of the fetus in utero.

Question 9

9. Which of the following laboratory findings would the nurse expect to see in a baby
   diagnosed with erythroblastosis fetalis?
10. Hematocrit 24%.
11. Leukocyte count 45,000 cells/mm3.
12. Sodium 125 mEq/L.
13. Potassium 5.5 mEq/L.

Answer 9

1. The baby with erythroblastosis fetalis
   would exhibit signs of severe anemia,
   which a hematocrit of 24% reflects.

TEST-TAKING TIP: The test taker must be
familiar with the pathophysiology of Rh
incompatibility. If a mother who is Rh
negative has been sensitized to Rh positive
blood, she will produce antibodies
against the Rh positive blood. If she then
becomes pregnant with an Rh positive
baby, her anti-Rh antibodies will pass directly
through the placenta into the fetal
system. Hemolysis of fetal red blood cells
results, leading to severe fetal anemia.

Question 10

10. A baby’s blood type is B negative. The baby is at risk for hemolytic jaundice if the
    mother has which of the following blood types?
11. Type O negative.
12. Type A negative.
13. Type B positive.
14. Type AB positive.

Answer 10

1. ABO incompatibility can arise when
   the mother is type O and the baby is
   either type A or type B.

TEST-TAKING TIP: A mother whose blood
type is O, the blood type that is antigen
negative, will produce anti-A and/or anti-
B antibodies against blood types A and/or
B, respectively. The anti-A (and/or anti-B)
that passes into the baby’s bloodstream
via the placenta can attack the baby’s red
blood cells if he or she is type A or B. As a
result of the blood cell destruction, the
baby becomes jaundiced.

Question 11

11. A newborn admitted to the nursery has a positive direct Coombs’ test. Which of
    the following is an appropriate action by the nurse?
12. Monitor the baby for jitters.
13. Assess the blood glucose level.
14. Assess the rectal temperature.
15. Monitor the baby for jaundice.

Answer 11

4. When the neonatal bloodstream
   contains antibodies, hemolysis of the
   red blood cells occurs and jaundice
   develops.
   TEST-TAKING TIP: The indirect Coombs’
   test is performed on the pregnant
   woman to detect whether or not she carries
   antibodies against her fetus’ red
   blood cells. The direct Coombs’ test is
   performed on the newborn to detect
   whether or not he or she carries maternal
   antibodies in his or her blood.

Question 12

12. An 18-hour-old baby is placed under the bili-lights with an elevated bilirubin level.
    Which of the following is an expected nursing action in these circumstances?
13. Give the baby oral rehydration therapy after all feedings.
14. Rotate the baby from side to back to side to front every two hours.
15. Tightly swaddle in baby blankets to maintain normal temperature.
16. Administer intravenous fluids via pump per doctor orders.

Answer 12

2. Rotating the baby’s position maximizes
   the therapeutic response because the
   more skin surface that is exposed to
   the light source, the better the results.

TEST-TAKING TIP: Bilirubin levels decrease
with exposure to a light source.
The more skin surface that is exposed,
the more efficient the therapy. Although
fluids are needed to maintain hydration
and to foster stooling, oral rehydration
therapy is nutritionally insufficient.

Question 13

13. A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the
    following actions should the nurse make during the procedure?
14. Cover the foot with an iced wrap for one minute prior to the procedure.
15. Avoid puncturing the lateral heel to prevent damaging sensitive structures.
16. Blot the site with a dry gauze after rubbing it with an alcohol swab.
17. Grasp the calf of the baby during the procedure to prevent injury.

Answer 13

3. Alcohol can irritate the punctured
   skin and can cause hemolysis.

TEST-TAKING TIP: The test taker must be
aware of the physiological structures in
the body. In the case of a heel stick, if the
posterior surface of the heel is punctured,
the posterior tibial nerve and artery
could be injured.

Question 14

14. A newborn nursery nurse notes that a baby’s body is jaundiced at 36 hours of life.
    Which of the following nursing interventions will be most therapeutic?
15. Maintain a warm ambient environment.
16. Have the mother feed the baby frequently.
17. Have the mother hold the baby skin to skin.
18. Place the baby naked by a closed sunlit window.

Answer 14

2. Bilirubin is excreted through the
   bowel. The more the baby consumes,
   the more stools, and therefore the
   more bilirubin the baby will expel.

TEST-TAKING TIP: This is one example of
a change in practice that has occurred
because of updated knowledge. In the
past, babies have been placed in sunlight
in order to reduce their bilirubin levels,
but that practice is no longer considered
to be safe. It is important, therefore, for
the test taker to have as current knowledge
as possible.

Question 15

15. A neonate is under phototherapy for elevated bilirubin levels. The baby’s stools are
    now loose and green. Which of the following actions should the nurse take at this
    time?
16. Discontinue the phototherapy.
17. Notify the health care practitioner.
18. Take the baby’s temperature.
19. Assess the baby’s skin integrity.

Answer 15

4. The stools can be very caustic to the
   baby’s delicate skin. The nurse should
   cleanse the area well and inspect the
   skin for any sign that the skin is
   breaking down.
   TEST-TAKING TIP: The test taker must
   know the difference between signs that
   are normal and those that reflect a possible
   illness. Although green stools can be
   seen with diarrheal illnesses, in this situation,
   the green stools are expected. The
   green stools are due to the increased
   bilirubin excreted and not related to an
   infectious state.

Question 16

16. A nursing diagnosis for a 5-day-old newborn under phototherapy is: Risk for fluid
    volume deficit. For which of the following client outcomes should the nurse plan to
    monitor the baby?
17. 6 saturated diapers in 24 hours.
18. Breastfeeds 6 times in 24 hours.
19. 12% weight loss since birth.
20. Apical heart rate of 176 bpm.

Answer 16

1. Healthy, hydrated neonates saturate
   their diapers a minimum of 6 times in
   24 hours

TEST-TAKING TIP: This is an evaluation
question. The test taker is being asked to
identify signs that would indicate a baby that is fully hydrated. It is important for
the test taker to know the expected intake
and output of the neonate and to
understand the evaluation phase of the
nursing process.

Question 17

17. There is a baby in the neonatal intensive care unit (NICU) who is exhibiting
    signs of neonatal abstinence syndrome. Which of the following medications is
    contraindicated for this neonate?
18. Morphine.
19. Opium.
20. Narcan.
21. Phenobarbital.

Answer 17

3. Narcan is an opiate. If it were to be
   given to the neonate with neonatal
   abstinence syndrome, the baby would
   go into a traumatic withdrawal

TEST-TAKING TIP: Neonatal abstinence syndrome
is the term used to describe the
many behaviors exhibited by neonates
who are born drug addicted. The behaviors
range from hyperreflexia to excessive
sneezing and yawning to loose diarrheal
stools. Medications may or may not be
administered to control the many
signs/symptoms of the syndrome.

Question 18

18. A baby is in the NICU whose mother was addicted to heroin during the pregnancy.
    Which of the following nursing actions would be appropriate?
19. Tightly swaddle the baby.
20. Place the baby prone in the crib.
21. Provide needed stimulation to the baby.
22. Feed the baby half-strength formula.

Answer 18

1. Tightly swaddling drug-addicted
   babies often helps to control the hyperreflexia
   that they may exhibit.

TEST-TAKING TIP: Drug-exposed babies
exhibit signs of neonatal abstinence syndrome:
hyperactivity, hyperreflexia, and
the like. The test taker should look for a
nursing intervention that would minimize
those behaviors. Tightly swaddling
the baby would help to reduce the baby’s
behavioral responses.

Question 19

19. A newborn in the nursery is exhibiting signs of neonatal abstinence syndrome.
    Which of the following signs/symptoms is the nurse observing? Select all that
    apply.
20. Hyperphagia.
21. Lethargy.
22. Prolonged periods of sleep.
23. Hyporeflexia.
24. Persistent shrill cry.

Answer 19

1 and 5 are correct.
1. Babies with signs of neonatal abstinence
syndrome repeatedly exhibit
signs of hunger.

5. Babies with signs of neonatal abstinence
   syndrome often have a shrill
   cry that may continue for prolonged
   periods.
   TEST-TAKING TIP: The baby who is exhibiting
   signs of neonatal abstinence syndrome
   is craving an addicted drug. The
   baby’s body is agitated because the illicit
   narcotics he or she has been exposed to
   are central nervous system depressants
   and their removal has agitated him or
   her. The test taker, therefore, should
   consider symptoms that reflect central
   nervous stimulation as correct responses.

Question 20

20. Based on maternal history of alcohol addiction, a baby in the neonatal nursery is
    being monitored for signs of fetal alcohol syndrome (FAS). The nurse should assess
    this baby for which of the following?
21. Poor suck reflex.
22. Ambiguous genitalia.
23. Webbed neck.
24. Absent Moro reflex.

Answer 20

1. FAS babies usually have a very weak
   suck.

TEST-TAKING TIP: The characteristic
facial signs of fetal alcohol syndrome—
shortened palpebral (eyelid) fissures, thin
upper lip, and hypoplastic philtrum
(median groove on the external surface
of the upper lip)—are rarely evident in
the neonatal period. They typically appear
later in the child’s life. Rather the
behavioral characteristics of the FAS
baby, such as weak suck, irritability,
tremulousness, and seizures, are present
at birth.

Question 21

21. A baby born addicted to cocaine is being given paregoric. The nurse knows that
    which of the following is a rationale for its use?
22. Paregoric is nonaddictive.
23. Paregoric corrects diarrhea.
24. Paregoric is nonsedating.
25. Paregoric suppresses the cough reflex.
    324 MATERNAL AND NEWBORN SUCCESS
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Answer 21

2. Paregoric does help to control the diarrhea
   seen in drug-addicted neonates

TEST-TAKING TIP: Paregoric, a liquid
form of morphine, is an especially effective
therapy for a baby who is experiencing
severe neonatal abstinence syndrome.
The narcotic relieves the cravings that
the baby has for the addicted drug, while,
in addition, paregoric is effective against the diarrhea that many addicted baby’s
experience

Question 22

22. A baby was born 24 hours ago to a mother who received no prenatal care. The
    infant has tremors, sneezes excessively, constantly mouths for food, and has a shrill,
    high-pitched cry. The baby’s serum glucose levels are normal. For which of the
    following should the nurse request an order from the pediatrician?
23. Urine drug toxicology test.
24. Biophysical profile test.
25. Chest and abdominal ultrasound evaluations.
26. Oxygen saturation and blood gas assessments.

Answer 22

1. The symptoms are characteristic
   of neonatal abstinence syndrome.
   A urine toxicology would provide
   evidence of drug exposure

TEST-TAKING TIP: It is important for the
test taker to attend to the fact that this
child has normal serum glucose levels.
When babies exhibit tremors, the first
thing the nurse should consider is hypoglycemia.
Once that has been ruled out,
and since the baby is exhibiting other
signs of drug withdrawal, the nurse
should consider drug exposure.

Question 23

23. A nurse makes the following observations when admitting a full-term, breastfeeding
    baby into the neonatal nursery: 9 lbs 2 oz, 21 inches long, TPR: 96.6ºF, 158, 62,
    jittery, pink body with bluish hands and feet, crying. Which of the following actions
    should the nurse perform first?
24. Swaddle the baby to provide warmth.
25. Assess the glucose level of the baby.
26. Take the baby to the mother for feeding.
27. Administer the neonatal medications.

Answer 23

2. The glucose level should be assessed
   to determine whether or not this baby
   is hypoglycemic

TEST-TAKING TIP: The test taker should
note that this baby is macrosomic and
hypothermic, both of which make the
baby at high risk for hypoglycemia. Plus,
jitters are a classic symptom in hypoglycemic
babies. In order to make an accurate
assessment of the problem, the
baby’s glucose level must be assessed.

Question 24

24. An infant admitted to the newborn nursery has a blood glucose level of 35 mg/dL.
    The nurse should monitor this baby carefully for which of the following?
25. Jaundice.
26. Jitters.
27. Erythema toxicum.
28. Subconjunctival hemorrhages

Answer 24

2. Babies who are hypoglycemic will often
develop jitters (tremors).

TEST-TAKING TIP: The test taker should
remember that the normal glucose level
for neonates in the immediate postdelivery
period—approximately 45 to
90 mg/dL—is less than that seen in older
babies and children

Question 25

25. A full-term infant admitted to the newborn nursery has a blood glucose level of
    35 mg/dL. Which of the following actions should the nurse perform at this time?
26. Feed the baby formula or breast milk.
27. Assess the baby’s blood pressure.
28. Tightly swaddle the baby.
29. Monitor the baby’s urinary output.

Answer 25

1. A baby with a blood glucose of
   35 mg/dL is hypoglycemic. The action
   of choice is to feed the baby either
   formula or breast milk.

TEST-TAKING TIP: Although the test taker
may believe that glucose water should be
fed to the baby at this time, the substance
of choice is either formula or
breast milk. The sugars in the milk will
elevate the baby’s blood values in the
short term and the proteins and fats in
the milk will help to maintain the glucose
values in the normal range.

Question 26

26. A nurse is inserting a gavage tube into a preterm baby who is unable to suck and
    swallow. Which of the following actions must the nurse take during the procedure?
27. Measure the distance from the tip of the ear to the nose.
28. Lubricate the tube with an oil-based solution.
29. Insert the tube quickly if the baby becomes cyanotic.
30. Inject a small amount of sterile water to check placement.

Answer 26

1. The gavage tubing must be measured
   to approximate the length of the
   insertion

TEST-TAKING TIP: The placement of
gavage tubing is potentially dangerous.
Not only must the distance between the
nose and the ear be measured, but also
the length from the ear to the point
midway between the ear and the xiphoid
process. This entire distance is the
tubing insertion length. To assess placement,
air should be injected into the
tubing rather than water because the
tubing may mistakenly have been inserted
into the trachea.

Question 27

27. A neonate is in the warming crib for poor thermoregulation. Which of the following
    sites is appropriate for the placement of the skin thermal sensor?
28. Xiphoid process.
29. Forehead.
30. Abdominal wall.
31. Great toe.

Answer 27

3. The abdominal wall is the appropriate
   placement for the skin thermal sensor

TEST-TAKING TIP: It is essential that the
test taker be prepared safely to perform
relatively simple procedures for the premature
infant. To monitor the temperature
of the premature, the probes
should be placed on a nonbony and wellperfused
tissue site. The abdominal wall
is the site of choice.

Question 28

28. The nurse must perform nasopharyngeal suctioning of a newborn with profuse
    secretions. Place the following nursing actions for nasopharyngeal suctioning in
    chronological order.
29. Slowly rotate and remove the suction catheter.
30. Place thumb over the suction control on the catheter.
31. Assess type and amount of secretions.
32. Insert free end of the tubing through the nose.

Answer 28

4, 2, 1, and 3 is the correct order.

4. Inserting the free end of the tubing
   through the nose is the first step in nasopharyngeal
   suctioning process
5. Rotation and removal of the suction
   catheter should be done after the tubing
   has been inserted through the nose and a
   thumb placed over the suction control on
   the catheter.
6. The nurse should place a thumb over the
   suction control on the catheter after inserting
   the free end of the tubing
   through the nose—and before the other
   two steps are taken.
7. Assessing the type and amount of secretions
   in the last step in the process.

TEST-TAKING TIP: It is important for the
test taker to remember that once the
suction control is covered, the baby is
unable to take in air. It is important,
therefore, not to cover the suction control
until the catheter is being removed.

Question 29

29. A neonate is being given intravenous fluids through the dorsal vein of the wrist.
    Which of the following actions by the nurse is essential?
30. Tape the arm to an arm board.
31. Change the tubing every 24 hours.
32. Monitor the site every 5 minutes.
33. Infuse the fluid intermittently.

Answer 29

1. Neonates are incapable of controlling
   their movements. In order to maintain
   a safe IV site, it is essential to
   tape the baby’s arm to an arm board

TEST-TAKING TIP: Although restraints
and arm boards are often unnecessary
when caring for older children and
adults, to be assured that the intravenous
remains intact, the use of restraints
and/or arm boards is often necessary
when caring for infants, toddlers, and
other young children

Question 30

30. A Roman Catholic couple has just delivered a baby with an Apgar of 1 at 1 minute,
    2 at 5 minutes, and 2 at 10 minutes. Which of the following interventions is appropriate
    at this time?
31. Advise the parents that they should pray very hard so that everything turns out
    well.
32. Ask the parents whether they would like the nurse to baptize the baby.
33. Leave the parents alone to work through their thoughts and feelings.
34. Inform the parents that a priest will listen to their confessions whenever they
    are ready.

Answer 30

2. This baby’s Apgar is very low. There
   is a chance that the baby will not
   survive. It is appropriate to ask the
   parents, since they are known to be
   Roman Catholic, if they would like
   their baby baptized

TEST-TAKING TIP: When a baby is doing
very poorly during the first minutes after
delivery, there is a possibility that
the baby may not survive. Couples who
are Roman Catholic often wish to have
their babies baptized in such situations.
Because a priest is not present, it is appropriate
for a nurse, of any religious
faith, to perform the baptism at that
time.

Question 31

31. The nurse assesses a newborn as follows:
    heart rate: 70
    respirations: weak and irregular
    tone: flaccid
    color: pale
    baby grimaces when a pediatrician attempts to insert an endotracheal tube
    What should the nurse calculate the baby’s Apgar score to be?

Answer 31

The baby’s Apgar score is 3.
TEST-TAKING TIP: Assessing the Apgar
score is often a nursing function. The
test taker, therefore, should know the
criteria for the Apgar score.
The score is traditionally performed
at 1 and 5 minutes after birth. A total
score of 7 to 10 means that the baby is
having little to no difficulty transitioning
to extrauterine life. With a total score of
4 to 6, the baby is having moderate difficulty
transitioning to extrauterine life.
Resuscitative measures may need to be
instituted. With a total score of 0 to 3,
the baby is in severe distress. Resuscitative
measures must be instituted.

Question 32

32. A neonate is in the neonatal intensive care nursery with a diagnosis of large-forgestational
    age. The baby was born at 38 weeks’ gestation and weighed 3
33. The diagnosis is inaccurate because the baby’s weight is too high for a diagnosis
    of appropriate-for-gestational age.
34. The diagnosis is inaccurate because the baby’s weight needs to be higher than
    3500 grams.
35. The diagnosis is inaccurate because the baby’s weight needs to be lower than
    3500 grams.
36. The diagnosis is inaccurate because full-term babies are never large-forgestational
    age.

Answer 32

2. A baby who is large-for-gestational
   age is defined as a baby whose
   weight is above the 90th percentile.
   According to the graph, at 38 weeks’
   gestation, a 3500-gram baby is
   below the 90th percentile for
   weight. Therefore, the diagnosis
   is inaccurate.

TEST-TAKING TIP: It is important for the
test taker to become comfortable with
reading and interpreting graphs. The
gestational age graph—weight in grams
on the y-axis and weeks of gestation on
the x-axis—is cut by 2 curves. The upper
curve shows the weight at the 90th percentile
for babies at differing gestational
ages, while the lower curve shows the
weight at the 10th percentile for babies
of differing gestational ages. Those babies
who fall above the upper curve—that
is, whose weights are above the 90th
percentile—are defined as large-forgestational
age (LGA). Those babies
who fall below the lower curve—those
with weights that are below the 10th
percentile—are defined as small-forgestational
age (SGA). Those babies who
fall between the upper and lower curves
are defined as appropriate-for-gestational
age (AGA).

Question 33

33. A neonate has been admitted to the neonatal intensive care unit with the following
    findings:
    completely flaccid posturing
    square window sign of 60º
    arm recoil of 180º
    popliteal angle of 160º
    full scarf sign
    heel that touches the ear
    skin that is red and translucent
    sparse lanugo
    faint red marks on the plantar surface
    barely perceptible breast tissue
    eye lids that are open but flat ear pinnae
    prominent clitoris and small labia minora

Using the Ballard scale, what is the gestational age of this neonate estimated to be?
_____________ weeks

Answer 33

24 weeks
TEST-TAKING TIP: There are six characteristics
on the neuromuscular maturity chart
and six characteristics on the physical maturity
chart (see charts on next page). The
baby is given a score for each characteristic
and the scores are added together to get a
total score. The total score is compared to
the maturity rating chart. The baby in the
question had a total score of 0, which relates
to a gestational age score of 24 weeks.

Question 34

34. A neonate is in the neonatal intensive care unit. The baby is 28 weeks’ gestation
    and weighs 1000 grams. Which of the following is correct in relation to this baby’s
    growth?
35. Weight is appropriate-for-gestational age.
36. Weight is below average for gestational age.
37. Baby experienced intrauterine growth restriction.
38. Baby experienced congenital growth hypertrophy

Answer 34

1. The baby’s weight is appropriatefor-
   gestational age. The baby’s
   weight of 1000 grams falls between
   the upper and lower curves for
   28 weeks’ gestation.

TEST-TAKING TIP: Even if the test
taker did not know the definitions of
intrauterine growth restriction and congenital
growth hypertrophy, if the individual
words are understood, the test
taker would be able to deduce the meanings
of the terms by defining each word
in the terms and then putting the definitions
together. Intrauterine means in the
uterus and restriction is a limitation.
Intrauterine growth restriction, therefore,
means limited growth in the uterus.
The term congenital refers to conditions
that are present at or before birth and
hypertrophy means enlargement or overgrowth.
Congenital growth hypertrophy, therefore, refers to a baby that is larger
than expected.

Question 35

35. A neonate, 40 weeks by dates, has been admitted to the nursery. Place an “X” on
    the graph where the baby would be labeled large-for-gestational age.

Answer 35

TEST-TAKING TIP: The test taker should
locate the 40-week-gestation line on the
x-axis and follow it up to the second
curve. Babies whose weights are above
the second curve are labeled large-forgestational
age (see figure below).

Question 36

36. A 42-week-gestation baby, 2400 grams, whose mother had no prenatal care, is admitted
    into the NICU. The neonatalogist orders blood work. Which of the following
    laboratory findings would the nurse expect to see?
37. Blood glucose 30 mg/dL.
38. Leukocyte count 1000 cells/mm3.
39. Hematocrit 30%.
40. Serum pH 7.8.

Answer 36

1. This baby is small-for-gestational age.
   Full-term babies (40 weeks’ gestation)
   should weigh between 2500 and 4000
   grams. It is very likely that this baby
   used up his glycogen stores in utero
   because of an aging placenta. An aging
   placenta is unable to deliver sufficient
   nutrients to the fetus. As a result
   the fetus must use its glycogen
   stores to sustain life and, therefore, is
   high risk for hypoglycemia after birth.

TEST-TAKING TIP: The test taker must attend
carefully to the gestational age in
any question relating to neonates. Postterm
and preterm babies are at high risk
for certain problems. Postterm babies
are especially at high risk for hypoglycemia
and chronic hypoxia because
the aging placenta has not supplied sufficient
quantities of oxygen and nutrients.

Question 37

37. A woman who received an intravenous analgesic 4 hours ago has had prolonged late
    decelerations in labor. She will deliver her baby shortly. Which of the following is
    the priority action for the delivery room nurse to take?
38. Preheat the overhead warmer.
39. Page the neonatalogist on call.
40. Draw up Narcan (naloxone) for injection.
41. Assemble the neonatal eye prophylaxis.

Answer 37

2. The neonatalogist must be called to
   the delivery room so that he or she
   arrives before the baby is delivered

TEST-TAKING TIP: This is a prioritizing
question. Although all of these actions
may be performed by the nurse, only one
is a priority. This baby is showing signs
of fetal distress—prolonged late decelerations.
The baby may need to be resuscitated.
The nurse must, therefore, page
the neonatalogist so that he or she is
present for the birth of the baby.

Question 38

38. A baby has been admitted to the neonatal intensive care unit with a diagnosis of
    postmaturity. The nurse expects to find which of the following during the initial
    newborn assessment?
39. Abundant lanugo.
40. Flat breast tissue.
41. Prominent clitoris.
42. Wrinkled skin.

Answer 38

4. The postterm baby does have dry,
   wrinkled, and often desquamating
   skin. The baby’s dehydration is secondary
   to a placenta that progressively
   deteriorates after 40 weeks’
   gestation.
   TEST-TAKING TIP: The test taker should
   be familiar with the characteristic presentations
   of preterm and postmature
   neonates. Studying the items on the New
   Ballard Scale and the corresponding gestational
   ages when the items are seen are
   excellent ways to associate certain characteristics
   with dysmature babies.

Question 39

39. A 42-week-gestation baby has been admitted to the neonatal intensive care unit. At
    delivery, thick green amniotic fluid was noted. Which of the following actions by
    the nurse is critical at this time?
40. Bath to remove meconium-contaminated fluid from the skin.
41. Ophthalmic assessment to check for conjunctival irritation.
42. Rectal temperature to assess for septic hyperthermia.
43. Respiratory evaluation to monitor for respiratory distress.

Answer 39

4. Meconium aspiration syndrome
   (MAS) is a serious complication seen
   in postterm neonates who are exposed
   to meconium-stained fluid. Respiratory
   distress would indicate that the
   baby has likely developed MAS.
   TEST-TAKING TIP: Although meconium
   appears black in a newborn’s diaper, it is
   actually a very dark green color. When
   diluted in the amniotic fluid, therefore,
   the fluid takes on a greenish tinge. Because
   meconium is a foreign substance,
   when aspirated by the baby, a chemical
   and, secondarily, a bacterial pneumonia
   often develop

Question 40

40. A 42-week gravida is delivering her baby. A nurse and pediatrician are present at
    the bith. The amniotic fluid is green and thick. The baby fails to breathe spontaneously.
    Which of the following actions should the nurse take next?
41. Stimulate the baby to breathe.
42. Assess neonatal heart rate.
43. Assist with intubation.
44. Place the baby in the prone position.

Answer 40

3. Before breathing, the baby must be
   intubated so that the meconiumcontaminated
   fluid can be aspirated
   from the baby’s airway.

TEST-TAKING TIP: It is actually a positive
fact that the baby has not breathed
immediately after delivery because the
airway can then be aspirated to remove
the meconium. The nurse, once the fluid
was seen, should have paged the appropriate
health care professional who
would perform the intubation. The nurse
would then assist with the procedure.

Question 41

41. At 1 minute of life a baby, who appears preterm, has exhibited no effort to breathe
    even after being stimulated. Which of the following actions should the nurse perform
    first?
42. Perform a gestational age assessment.
43. Inflate the lungs with positive pressure.
44. Provide external chest compressions.
45. Palpate the base of the umbilical cord.

Answer 41

2. The baby’s airway should be established
   by inflating the lungs with an
   ambu bag.

TEST-TAKING TIP: Although the steps of a
neonatal resuscitation are slightly different
than those for an older baby, child, or
adult, the basic principles of resuscitation
still apply: ABC. A, the airway must first
be established; B, artificial breathing is
then begun, and after that, C, chest compressions
are performed to establish an
artificial circulation

Question 42

42. A neonatalogist requests Narcan (naloxone) during a neonatal resuscitation effort.
    Which of the following dosages would the nurse expect to prepare?
43. 1 microgram/kg.
44. 10 microgram/kg.
45. 0.1 milligrams/kg.
46. 1 milligram/kg.

Answer 42

3. 0.1 milligram/kg is the correct
   dosage. This dosage can also be expressed
   as 100 microgram/kg

TEST-TAKING TIP: The test taker must
not confuse micrograms and milligrams.
There are 1000 micrograms in
1 milligram. The correct answer,
therefore, could have been stated as
0.1 milligram/kg or 100 microgram/kg.

Question 43

43. During neonatal cardiopulmonary resuscitation, which of the following actions
    should be performed?
44. Provide assisted ventilation at 40 to 60 breaths per minute.
45. Begin chest compressions when heart rate is 0 to 20 beats per minute.
46. Compress the chest using the three-finger technique.
47. Administer compressions and breaths in a 5 to 1 ratio.

Answer 43

1. Assisted ventilations should be administered
   at a rate of 40 to 60 per minute.

TEST-TAKING TIP: The correct answer
could be deduced by the test taker by
remembering the normal respiratory rate
of the neonate (30 to 60 breaths per
minute). During a resuscitation, the
nurses and other health care practitioners
would be attempting to simulate
normal functioning

Question 44

44. The staff on the maternity unit is developing a protocol for nurses to follow after a
    baby is delivered who fails to breathe spontaneously. Which of the following should
    be included in the protocol as the first action for the nurse to take?
45. Prepare epinephrine for administration.
46. Provide positive pressure oxygen.
47. Administer chest compressions.
48. Rub the back and feet of the baby.

Answer 44

4. The first interventions when a
   neonate fails to breathe include providing
   tactile stimulation.
   TEST-TAKING TIP: When a neonate fails
   to breathe, the nurse should: dry the
   baby and provide tactile stimulation,
   place the child in the “sniff ” position under
   a radiant warmer, and suction the
   mouth and nose of any mucus. Only after
   these initial actions fail—since the vast
   majority of the time the baby will respond—
   should further intervention be
   begun.

Question 45

45. A nurse in the newborn nursery suspects that a new admission, 42 weeks’ gestation,
    was exposed to meconium in utero. What would lead the nurse to suspect this?
46. The baby is bradycardic.
47. The baby’s umbilical cord is green.
48. The baby’s anterior fontanel is sunken.
49. The baby is desquamating

Answer 45

2. Because meconium is a dark green
   color, when it is expelled in utero, the
   baby can be stained green.

TEST-TAKING TIP: The test taker may
choose “4” because he or she remembers
that there is a relationship between babies
who expel meconium and those who
desquamate. That is true, but it is not a
direct relationship. The fact that the baby
is postdates is the common denominator between the two. The test taker should
choose the response that is clearly correct:
because meconium is green it can
stain the baby’s tissues green. Desquamation
is merely a fancy term for skin
peeling.

Question 46

46. The birth of a baby, weight 4500 grams, was complicated by shoulder dystocia.
    Which of the following neonatal complications should the nursery nurse observe for?
47. Leg deformities.
48. Brachial palsy.
49. Fractured radius.
50. Buccal abrasions

Answer 46

2. During a difficult delivery with shoulder
   dystocia, the brachial nerve can
   become stretched and may even be
   severed. The nurse should, therefore,
   observe the baby for signs of palsy

TEST-TAKING TIP: The key to answering
this question is understanding the terminology.
A shoulder dystocia is a difficult
delivery when the shoulder fails to pass
easily through the pelvis. Deformities
are disfigurements or malformations.
Although the arm and shoulder may be
injured, the baby is not disfigured.
A buccal abrasion would occur on the
inside of the cheek.

Question 47

47. During a health maintenance visit at the pediatrician’s office, the nurse notes that a
    breastfeeding baby has thrush. Which of the following actions should the nurse
    take?
48. Nothing because thrush is a benign problem.
49. Advise the mother to bottlefeed until the thrush is cured.
50. Obtain an order for antifungals for both mother and baby.
51. Assess for other evidence of immunosuppression.

Answer 47

3. Candida is a fungal infection, and it
   is important to treat both the
   mother’s breasts and the baby’s mouth
   to prevent the infection from being
   transmitted back and forth between
   the two.

TEST-TAKING TIP: It is important to keep
from confusing pathology with the normal
processes of birth and growth and
development. Thrush, which is often
seen in the mouth of immunosuppressed
patients, is also a normal flora in the
vagina of women. The baby may have
contracted the fungus in his or her
mouth during delivery or from his or her
mother’s poorly washed hands.

Question 48

48. A neonate, whose mother is HIV positive, is admitted to the NICU. A nursing
    diagnosis: Risk for infection related to perinatal exposure to HIV/AIDS is made.
    Which of the following interventions should the nurse make in relation to the
    diagnosis?
49. Monitor daily viral load laboratory reports.
50. Check the baby’s viral antibody status.
51. Obtain an order for antiviral medication.
52. Place the baby on strict precautions.

Answer 48

3. The standard of care for neonates
   born to mothers with HIV/AIDS is to
   begin them on anti-AIDS medication
   in the nursery. The mother will be
   advised to continue to give the baby
   the medication after discharge.

TEST-TAKING TIP: The test taker should
be aware that neonates must be followed
after delivery because of the viral exposure
in utero. The best way to prevent
vertical transmission from the mother to
the newborn is to administer antiviral
medications to the mother during pregnancy
and delivery and for 6 weeks to the
newborn following delivery.

Question 49

49. A baby was just born to a mother who had positive vaginal cultures for group B
    streptococcus. The mother was admitted to the labor room 2 hours before the birth.
    For which of the following should the nursery nurse closely observe this baby?
50. Hypothermia.
51. Mottling.
52. Omphalocele.
53. Stomatitis.

Answer 49

1. Hypothermia in a neonate may be indicative
   of sepsis.

TEST-TAKING TIP: Group B streptococci
can seriously adversely affect neonates.
In fact, group B strep has been called
“the baby killer.” To prevent a severe infection
from the bacteria, mothers are
given intravenous antibiotics every
4 hours from admission, or from rupture
of membranes, until delivery. A minimum
of 2 doses is considered essential
to protect the baby. Since this woman
arrived only 2 hours prior to the delivery,
there was not enough time for 2 doses to
be administered.

Question 50

50. A baby in the newborn nursery was born to a mother with spontaneous rupture of
    membranes for 14 hours. The woman has Candida vaginitis. For which of the following
    should the baby be assessed?
51. Papular facial rash.
52. Thrush.
53. Fungal conjunctivitis.
54. Dehydration.

Answer 50

2. Thrush is commonly seen in babies
   whose mothers have Candida vaginitis.

TEST-TAKING TIP: The test taker should
be familiar with the various presentations
of common fungi and bacteria.
Candida is a fungus that is a normal
vaginal flora. During pregnancy, it is
not uncommon for the vaginal flora to
shift and the woman to develop Candida
vaginitis.

Question 51

51. A baby has been admitted to the neonatal nursery whose mother is hepatitis
    B–surface antigen positive. Which of the following actions by the nurse should
    be taken at this time?
52. Monitor the baby for signs of hepatitis B.
53. Place the baby on contact isolation.
54. Obtain an order for the hepatitis B vaccine and the immune globulin.
55. Advise the mother that breastfeeding is absolutely contraindicated.

Answer 51

3. Babies exposed to hepatitis B in utero
   should receive the first dose of hepatitis
   B vaccine as well as hepatitis B
   immune globulin (HBIG) within
   12 hours of delivery to reduce
   transmission of the virus

TEST-TAKING TIP: Although breastfeeding
is contraindicated when a mother is HIV
positive, hepatitis B transmission rates
do not change significantly when a
mother breastfeeds. The mother should,
however, take care to prevent any cracking
and bleeding from her breasts since
the virus is bloodborne

Question 52

52. Four full-term babies were admitted to the neonatal nursery. The mothers of each
    of the babies had labors of 4 hours or less. The nursery nurse should carefully
    monitor which of the babies for hypothermia?
53. The baby whose mother cultured positive for group B strep during her third
    trimester.
54. The baby whose mother had gestational diabetes.
55. The baby whose mother was hospitalized for 3 months with complete placenta
    previa.
56. The baby whose mother previously had a stillbirth.

Answer 52

1. Group B streptococcus causes severe
   infections in the newborn. A sign of
   neonatal sepsis is hypothermia.

TEST-TAKING TIP: It is important for the
test taker not to confuse terms. Babies
with neonatal sepsis often become hypothermic,
while babies born to mothers
with GDM become hypoglycemic. The
two conditions are very different, although
the prefix—hypo—is the same.

Question 53

53. Four 38-week-gestation gravidas have just delivered. Which of the babies should be
    monitored closely by the nurse for respiratory distress?
54. The baby whose mother has diabetes mellitus.
55. The baby whose mother has lung cancer.
56. The baby whose mother has hypothyroidism.
57. The baby whose mother has asthma.

Answer 53

1. The lung maturation of infants of diabetic
   mothers is often delayed. These
   babies must be monitored at birth for
   respiratory distress.

TEST-TAKING TIP: Two answers to this
question relate to maternal pulmonary
diagnoses, i.e., lung cancer and asthma.
Simply because a mother has a pulmonary
problem does not mean, however,
that her neonate will have a similar
problem. Even if the neonate has respiratory
distress, it may not be related to the
mother’s problem. The test taker should
not be swayed by this association. Babies
born to diabetic mothers, however, are at
risk for delayed lung maturation and
should be monitored for respiratory
distress.

Question 54

54. A client is seeking preconception counseling. She has type 1 diabetes mellitus and is
    found to have an elevated glycosylated hemoglobin (HgbA1c) level. Before actively
    trying to become pregnant, she is strongly encouraged to stabilize her blood glucose
    to reduce the possibility of her baby developing which of the following?
55. Port wine stain.
56. Cardiac defect.
57. Hip dysplasia.
58. Intussusception.

Answer 54

2. The incidence of cardiac defects and
   neural tube defects is high in infants
   born to diabetic mothers.

TEST-TAKING TIP: The test taker should
be familiar with maternal diseases that
can seriously impact pregnancy. One of
the most significant of the chronic diseases
is diabetes. When a woman is in
poor diabetic control during the first
trimester, the incidence of birth defects
is quite high.

Question 55

55. A baby is born with caudal agenesis. Which of the following maternal complications
    is associated with this defect?
56. Poorly controlled myasthenia gravis.
57. Poorly controlled diabetes mellitus.
58. Poorly controlled splenic syndrome.
59. Poorly controlled hypothyroidism

Answer 55

2. Poorly controlled maternal diabetes
   mellitus is one of the most important
   predisposing factors for caudal agenesis
   in the fetus.

TEST-TAKING TIP: Women with diabetes
must be in excellent glucose control
before becoming pregnant. Because
fetal deformities develop during the
organogenic period in the first trimester,
it is too late to educate diabetic women
to control their disease when they are
already pregnant.

Question 56

56. A macrosomic infant of a non–insulin dependent diabetic mother has been admitted
    to the neonatal nursery. The baby’s glucose level on admission to the nursery is
    25 mg/dL and after a feeding of mother’s expressed breast milk is 35 mg/dL.
    Which of the following actions should the nurse take at this time?
57. Nothing because the glucose level is normal for an infant of a diabetic mother.
58. Administer intravenous glucagon slowly over five minutes.
59. Feed the baby a bottle of dextrose and water and reassess the glucose level.
60. Notify the neonatalogist of the abnormal glucose levels.

Answer 56

4. If the glucose level has not risen to
   normal as a result of the feeding, the
   nurse should notify the physician and
   anticipate that the doctor will order
   an intravenous of dextrose and water.
   TEST-TAKING TIP: The test taker should
   be aware that the normal glucose level
   of a neonate after delivery—40 mg/dL to
   90 mg/L—is much lower than the adult
   normal of 60 to 110 mg/dL. Hypoglycemia
   is a common problem seen in
   infants, especially macrosomic infants
   and infants of diabetic mothers. Protocols
   to monitor for hypoglycemia in
   infants of diabetic mothers exist in all
   well-baby nurseries and NICUs

Question 57

57. A baby has just been born to a type 1 diabetic mother with retinopathy and
    nephropathy. Which of the following neonatal findings would the nurse expect
    to see?
58. Hyperalbuminemia.
59. Polycythemia.
60. Hypercalcemia.
61. Hypoinsulinemia

Answer 57

2. Because the placenta is likely to be
   functioning less than optimally, it is
   highly likely that the baby will be
   polycythemic. The increase in red
   blood cells would improve the baby’s
   oxygenation in utero.

TEST-TAKING TIP: The test taker must be
familiar with the pathology of diabetes
and its effect on pregnancy. Although infants
of diabetic mothers (IDMs) are
usually macrosomic as a result of increased
plasma glucose levels, when
mothers have vascular damage, the placenta
functions poorly. The IDM consequently
may be small-for-gestational age
with intrauterine growth restriction and
polycythemia from the poor nourishment
and oxygenation.

Question 58

58. A baby is born to a type 1 diabetic mother. Which of the following lab values would
    the nurse expect the neonate to exhibit?
59. Plasma glucose 30 mg/dL.
60. Red blood cell count 1 million/mm3.
61. White blood cell count 2000/mm3.
62. Hemoglobin 8 g/dL.

Answer 58

1. The nurse should anticipate that the
   plasma glucose levels would be low

TEST-TAKING TIP: The fetus, responding
to elevated glucose levels from the
mother, produces large quantities of insulin.
After the birth, however, the placenta
no longer is providing the baby
with the mother’s glucose. It takes the
baby some time to adjust his or her extrauterine
insulin production to be in
synchrony with the sugars provided by
the breast milk or formula feedings.
Until the baby makes the adjustment,
he or she will exhibit hypoglycemia
(40 mg/dL).

Question 59

59. A baby has just been admitted into the neonatal intensive care unit with a diagnosis
    of intrauterine growth restriction (IUGR). Which of the following maternal factors
    would predispose the baby to this diagnosis? Select all that apply.
60. Hyperopia.
61. Gestational diabetes.
62. Substance abuse.
63. Chronic hypertension.
64. Advanced maternal age.

Answer 59

3, 4, and 5 are correct.

3. Placental function is affected by the
   vasoconstrictive properties of many
   illicit drugs, as well as by cigarette
   smoke.
4. Placental function is diminished in
   women who have chronic hypertension.
5. Placental function has been found to
   be diminished in women of advanced
   maternal age.
   TEST-TAKING TIP: The test taker should
   be reminded that any condition that inhibits
   the flow of blood, including illicit
   drug use, hypertension, cigarette smoking,
   and the like, can lead to fetal IUGR—that is, a fetus smaller than expected
   for the gestational period.

Question 60

60. A baby has been admitted to the neonatal intensive care unit with a diagnosis of
    symmetrical intrauterine growth restriction. Which of the following pregnancy
    complications would be consistent with this diagnosis?
61. Severe preeclampsia.
62. Chromosomal defect.
63. Infarcts in an aging placenta.
64. Premature rupture of the membranes.

Answer 60

2. Chromosomal abnormalities are associated
   with symmetrical IUGR.

TEST-TAKING TIP: There is a distinct difference
between symmetrical and asymmetrical
IUGR. Babies with chromosomal
defects often grow poorly from the
time of conception. Their entire bodies,
therefore, will grow poorly and will be
small. Babies that are exposed to complications
like preeclampsia or an aging placenta
during the pregnancy will grow
normally during the beginning of the
pregnancy but start to grow poorly at the
time of the insult. Their growth, therefore,
will be disproportionally affected

Question 61

61. A neonate has intrauterine growth restriction secondary to placental insufficiency.
    Which of the following signs/symptoms should the nurse expect to observe at
    delivery?
62. Thrombocytopenia.
63. Neutropenia.
64. Polycythemia.
65. Hyperglycemia.

Answer 61

3. Babies who have lived in utero with
   an aging placenta usually are born
   with polycythemia.

TEST-TAKING TIP: Even if the test taker
were unfamiliar with the expected lab
findings of a neonate that had been born
after living with an aging placenta, deductive
reasoning could assist the test
taker to choose the correct response. Aging
placentas function poorly, and therefore
the fetuses receive less nutrition and
oxygenation. The baby’s body, therefore,
must compensate for the losses by metabolizing
glycogen stores in the liver
and producing increased numbers of red
blood cells. The neonate, therefore, is
often polycythemic and hypoglycemic.

Question 62

62. A woman is visiting the NICU to see her 26-week-gestation baby for the first time.
    Which of the following methods would the nurse expect the mother to use when
    first making physical contact with her baby?
63. Fingertip touch.
64. Palmar touch.
65. Kangaroo hold.
66. Cradle hold.

Answer 62

1. Most mothers, even those of full-term
   babies, usually use finger-tip touch
   during their first physical contact with
   their babies.

TEST-TAKING TIP: The delivery of a
preterm infant is very stressful and
frightening. In fact, the appearance of
the premature can be overwhelming to
new parents. In order to become familiar
with their baby, all parents proceed
through a pattern of touch behaviors.
When the baby is preterm, the procession
through touch responses is often
slowed.

Question 63

63. A 6-month-old child is being seen in the pediatrician’s office. The child was born
    preterm and remained in the neonatal intensive care unit 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 the prematurity? Select all that apply.
64. Bronchopulmonary dysplasia.
65. Cerebral palsy.
66. Retinopathy.
67. Hypothyroidism.
68. Seizure disorders.

Answer 63

1, 2, 3, and 5 are correct.
1. Bronchopulmonary dysplasia often is
a consequence of the respiratory therapy
that preemies receive in the
NICU.
2. Cerebral palsy results from a hypoxic
insult that likely occurred as a result
of the baby’s prematurity.
3. Retinopathy of the premature is a disease
resulting from the immaturity of
the vascular system of the eye. 5. Seizure disorders can result either
from a hypoxic insult to the brain or
from a ventricular bleed. Both of
these conditions likely occurred as a
result of the prematurity.
TEST-TAKING TIP: Many parents are of
the opinion that babies, even when born
many weeks prematurely, will be healthy
as they mature because there are so
many machines and medications that can
be given to the babies. Unfortunately,
many babies suffer chronic problems as a
result of their prematurity even when
they receive excellent medical and nursing
care

Question 64

64. A neonatalogist prescribes Garamycin (gentamicin) for a 2-day-old, septic preterm
    infant who weighs 1653 grams and is 38 centimeters long. The drug reference
    states: Neonatal dosage of Garamycin for babies less than 1 week of age is
    2.5 mg/kg q 12–24 hours. Calculate the safe daily dosage of this medication.
    _____________ mg q 24 hours.

Answer 64

4.13 mg q 24 hours
The formula for calculating the safe dosage
(per weight) is:
Known dosage

Needed dosage
1 kg Weight of the child in kg
2.5 mg

x mg
1 kg 1.653 kg
x 4.13 mg q 24 hours

TEST-TAKING TIP: When calculating the
safe dosage of a medication for a child,
the test taker must first note whether the
recommended dosage for the medication
is written per kg or per meters squared.
If the dosage is written per kg, then the
denominator of the ratio and proportion
equation is in kg. If the dosage is written
per m2, the denominator of the ratio and
proportion equation is in m2.

Question 65

65. The neonatalogist has ordered 12.5 micrograms of digoxin po for a neonate in
    congestive heart failure. The medication is available in the following elixir—
    0.05 mg/mL. How many milliliters (mL) should the nurse administer?
    _____________ mL.

Answer 65

0.25 mL
0.05 mg/mL 12.5 microgram/x mL
(0.05 mg 50 microgram)
50/1 12.5/x
50 x 12.5
x 0.25 mL
TEST-TAKING TIP: Digoxin is administered
in very small dosages to infants and
neonates. If the nurse calculates a quantity
that is larger than 1 mL, it is very
likely that the calculation is incorrect.
The nurse should recalculate the quantity
and, for safety safe, ask another
nurse to check the arithmetic.

Question 66

66. A neonatalogist prescribes Platinol-AQ (cisplatin) for a neonate born with a neuroblastoma.
    The baby’s current weight is 3476 grams and the baby is 57 centimeters
    long. The drug reference states: Children: IV 30 mg/m2 q week. Calculate the safe
    dosage of this medication.
    ____________ mg q week.

Answer 66

6.9 mg q week
The formula for calculating the safe dosage
per body surface area in meters squared is:
Known dosage

Needed dosage
1 m2 Body surface area of the child
To calculate the body surface area for this
baby the test taker must take the square root
of the product of the baby’s weight times its
length.
3.476 57
0.23 m2
3600
Then, to calculate the safe dosage, a ratio
and proportion equation must be solved.
30 mg

x mg
1 m2 0.23 m2
x 6.9 mg q week
TEST-TAKING TIP: When calculating a
safe dosage for a child using the body
surface area formula, it is important for
the test taker to note whether the child’s
statistics are written in the metric system
or the English system. If in the metric
system, the divisor for the formula is
3600. If the statistics are in the English
system, however, the divisor is 3131.
And it is important for the test taker to
remember to take the square root of the calculation. It is very easy to forget that
step.

Question 67

67. A preterm baby is to receive 4 mg Garamycin (gentamicin) IV every 24 hours. The
    medication is being injected into an IV soluset. A total of 5 cc is to be administered
    via IV pump over 90 minutes. The pump should be set at what rate?
    _____________ mL/hr.

Answer 67

3.33 mL/hr
5 mL/90 min 5 mL/1.5 hours 3.33 mL/hr
TEST-TAKING TIP: Whenever a pump is
used to deliver intravenous fluids, the
rate should be set in mL/hr units. Pumps
should always be used to deliver IV fluids
to preterm neonates since, because of
their small size, they can so easily become
fluid overloaded.

Question 68

68. A mother of a preterm baby is performing kangaroo care in the neonatal nursery.
    Which of the following responses would the nurse evaluate as a positive neonatal
    outcome?
69. Respiratory rate of 70.
70. Temperature of 97.0ºF.
71. Licking the mother’s nipples.
72. Flaring of the baby’s nares.

Answer 68

3. The baby is showing signs of interest
   in breastfeeding. This is a positive
   sign.

TEST-TAKING TIP: Kangaroo care, when
mothers hold their babies skin-to-skin, is
a technique that has been shown to benefit
preterm infants. The vital signs of
babies who kangaroo with their mothers
have been shown to stabilize more
quickly. The babies also have been
shown to nipple feed earlier and to have
shorter lengths of stay in the NICUs.

Question 69

69. A neonate is being assessed for necrotizing enterocolitis (NEC). Which of the following
    actions by the nurse is appropriate? Select all that apply.
70. Perform hemoccult test on stools.
71. Monitor for an increase in abdominal girth.
72. Measure gastric contents before each feed.
73. Assess bowel sounds before each feed.
74. Assess for anal fissures daily.

Answer 69

1, 2, 3, and 4 are correct.
1. Babies with necrotizing enterocolitis
(NEC) have blood in their stools.
2. The abdominal girth measurements
of babies with NEC increase.
3. When babies have NEC, they have increasingly
larger undigested gastric
contents after feeds.
4. The neonates’ bowel sounds are
diminished with NEC.

TEST-TAKING TIP: NEC is an acute inflammatory
disorder seen in preterm babies.
It appears to be related to the
shunting of blood from the gastrointestinal
tract, which is not a vital organ system,
to the vital organs. The baby’s
bowel necroses with the shunting and
the baby’s once normal flora become
pathological. Resection of the bowel is
often necessary.

Question 70

70. A woman whose 32-week-gestation neonate is to begin oral feedings is expressing
    breast milk (EBM) for the baby. The neonatalogist is recommending that fortifier
    be added to the milk because which of the following needs of the baby are not met
    by EBM?
71. Need for iron and zinc.
72. Need for calcium and phosphorus.
73. Need for protein and fat.
74. Need for sodium and potassium.

Answer 70

2. Calcium and phosphorus in EBM are
   in quantities that are less than body
   requirements for the very low birth
   weight baby. Therefore, a fortifier
   may need to be added to the EBM.

TEST-TAKING TIP: Premature babies who
are breastfed have fewer complications
than bottlefed babies, especially necrotizing
enterocolitis. Unfortunately, very
low birth weight babies do not receive
sufficient quantities of calcium and phosphorus
from the EBM. The breast milk,
then, is enriched with a milk fortifier
that contains the needed elements

Question 71

71. A 1000-gram neonate is being admitted to the neonatal intensive care unit. The
surfactant Survanta (beractant) has just been prescribed to prevent respiratory distress
syndrome. Which of the following actions should the nurse take while administering
this medication?
1. Flush the intravenous line with normal saline solution.
2. Assist the neonatalogist during the intubation procedure.
3. Inject the medication deep into the vastus lateralis muscle.
4. Administer the reconstituted liquid via an oral syringe.

Answer 71

2. Surfactant is administered intratracheally.
   The baby must first be intubated.
   The nurse would assist the
   doctor with the procedure.

TEST-TAKING TIP: Surfactant is a slippery
substance that is needed to prevent the
alveoli from collapsing during expiration.
It is prescribed for preterm babies who
are so immature that they do not produce
sufficient quantities of the substance
in their lung fields. The medication
is used to prevent and/or to treat
respiratory distress syndrome (RDS).

Question 72

72. A 30-week-gestation neonate, 2 hours old, has received Survanta (beractant).
    Which of the following would indicate a positive response to the medication?
73. Axillary temperature 98.0ºF.
74. Oxygen saturation 96%.
75. Apical heart rate 154 bpm.
76. Serum potassium 4.0 mEq/L.

Answer 72

2. A normal oxygen saturation level
   would be considered a positive result
   of the medication

TEST-TAKING TIP: The medication is
given to provide the baby with lung surfactant.
The drug is given to treat RDS.
When preterm babies have RDS, they
are having respiratory difficulty that
leads to poor gas exchange. When there
is poor gas exchange, the oxygen saturation
drops. A normal O2 saturation level,which is 96%, therefore, indicates a
positive outcome.

Question 73

73. For which of the following reasons would a nurse in the well baby nursery report to
    the neonatalogist that a newborn appears to be preterm?
74. Baby has a square window angle of 90º.
75. Baby has leathery and cracked skin.
76. Baby has popliteal angle of 90º.
77. Baby has pronounced plantar creases.

Answer 73

1. A baby whose square window sign is
   90° is preterm

TEST-TAKING TIP: A number of neonatal
characteristics are assessed to determine
the gestational age of a neonate. Four of
those characteristics are square window
sign, appearance of the skin, popliteal
angle, and presence of plantar creases.
The test taker should be familiar with
the Ballard Scale and the many characteristics
on which gestational age is
measured.

Question 74

74. A full-term neonate in the NICU has been diagnosed with congestive heart failure
    secondary to a cyanotic heart defect. Which of the following activities is most likely
    to result in a cyanotic episode?
75. Feeding.
76. Sleeping in the supine position.
77. Rocking in an infant swing.
78. Swaddling.

Answer 74

1. Babies who have cardiac defects
   frequently feed poorly. And when
   they do feed, they frequently become
   cyanotic.

TEST-TAKING TIP: Any activity that requires
an increased oxygen demand can
trigger a cyanotic spell in a neonate with
a heart defect. The two activities that require
the greatest amount of oxygen and
energy are feeding and crying. In fact,
because feeding demands that the baby
be able to suck, swallow, and breathe
rhythmically and without difficulty, many
sick babies refuse to eat because it is
such a demanding activity.

Question 75

75. The nurse is providing discharge teaching to the parents of a baby born with a cleft
    lip and palate. Which of the following should be included in the teaching?
76. Correct technique for the administration of a gastrostomy feeding.
77. Need to watch for the appearance of blood-stained mucus from the nose.
78. Optimal position for burping after nasogastric feedings.
79. Need to give the baby sufficient time to rest during each feeding.

Answer 75

4. Cleft lip and palate babies require additional
   time to rest as well as to suck
   and swallow when being fed.
   TEST-TAKING TIP: Although cleft lips and
   palates do impact feeding, virtually all of
   the affected babies are able to feed orally and some are even able to breastfeed.
   But, feeding from a standard bottle
   and/or breastfeeding may prove to be
   impossible for some babies with clefts
   and/or palates. In those cases, there are a
   number of bottles that have been designed
   to facilitate their feeding so that
   neither gastrostomy tubes nor nasogastric
   tubes are needed. The Haberman
   feeder is one example. Either expressed
   breast milk or formula can be put in the
   feeder

Question 76

76. A baby is suspected of having esophageal atresia. The nurse would expect to see
    which of the following signs/symptoms?
77. Frequent vomiting.
78. Excessive mucus.
79. Ruddy complexion.
80. Abdominal distention

Answer 76

2. Babies with esophageal atresia would
   be expected to expel large amounts of
   mucus from the mouth

TEST-TAKING TIP: With esophageal atresia,
the esophagus ends in a blind pouch.
In addition, there is usually a fistula connecting
the stomach to the trachea.
These babies are at high risk for respiratory
compromise because they can aspirate
the large quantity of oral mucus.
The neonatalogist should be notified
whenever esophageal atresia is suspected.

Question 77

77. The nurse is teaching a couple about the special health care needs of their newborn
    child with Down syndrome. The nurse knows that the teaching was successful
    when the parents state that the child will need which of the following?
78. Yearly three-hour glucose tolerance testing.
79. Immediate intervention during bleeding episodes.
80. A formula that is low in lactose and phenylalanine.
81. Prompt treatment of upper respiratory infections.

Answer 77

4. Because of the hypotonia of the respiratory
   accessory muscles, Down babies
   often need medical intervention
   when they have respiratory infections.
   TEST-TAKING TIP: Down syndrome babies
   not only have a characteristic appearance
   but also have physiological characteristics
   that the nurse must be familiar with.
   One of those characteristics is hypotonia.
   Because of this problem, Down babies
   are often difficult to feed during the
   neonatal period, have delayed growth
   and development, and have difficulty
   fighting upper respiratory illnesses.

Question 78

78. An infant in the neonatal nursery has low set ears, Simian creases, and slanted eyes.
    The nurse should monitor this infant carefully for which of the following
    signs/symptoms?
79. Blood-tinged urine.
80. Hemispheric paralysis.
81. Cardiac murmur.
82. Hemolytic jaundice.

Answer 78

3. Cardiac anomalies occur much more
   frequently in Down babies than in
   other babies.

TEST-TAKING TIP: Babies with Down syndrome
have the following characteristic
anomalies: low set ears, simian creases,
and slanted eyes. Because they are at
high risk for internal anomalies as well,
in particular cardiac defects, the nurse
should carefully evaluate the baby for a
heart murmur.

Question 79

79. Which of the following actions would the NICU nurse expect to perform when
    caring for a neonate with esophageal atresia and tracheoesophageal fistula (TEF)?
80. Position the baby flat on the left side.
81. Maintain low nasogastric suction.
82. Give small frequent feedings.
83. Place on hypothermia blanket.

Answer 79

2. Low nasogastric suction is usually
   maintained to minimize the amount
   of the baby’s oral secretions.

TEST-TAKING TIP: Because TEF babies’
esophagi end in a blind pouch, they
excrete large quantities of mucus from
their mouths, placing them at high
risk for aspiration. To decrease the potential
for respiratory insult until surgery
can take place, nasogastric suctioning
is started and the babies’ heads are
elevated

Question 80

80. A nurse is assisting a mother to feed a baby born with cleft lip and palate. Which of
    the following should the nurse teach the mother?
81. The baby is likely to cry from pain during the feeding.
82. The baby is likely to expel milk through the nose.
83. The baby will feed more quickly than other babies.
84. The baby will need milk with added calories.

Answer 80

2. It is likely that milk will be expelled
   from the baby’s nose during feedings

TEST-TAKING TIP: This question asks
about the feeding of a baby with a cleft
palate. Although the lip is intact, a cleft
in the palate means that there is direct
communication between the mouth and
the sinuses. Because of the opening, milk
is often expelled from the nose. Plus, the
milk frequently enters the eustachian
tubes. These babies, therefore, are at
high risk for ear infections.

Question 81

81. A neonate that is admitted to the neonatal nursery is noted to have a 2-vessel cord.
    The nurse notifies the neonatalogist to get an order for which of the following
    assessments?
82. Renal function tests.
83. Echocardiogram.
84. Glucose tolerance test.
85. Electroencephalogram

Answer 81

1. Babies with 2-vessel cords are at high
   risk for renal defects.

TEST-TAKING TIP: The umbilical cord is
developed in fetal life at approximately
the same time as the renal system. Because
of this fact, when a defect is seen
in the umbilical cord, there may also be a
defect in the renal system.

Question 82

82. In the delivery room, which of the following infant care interventions must a nurse
    perform when a neonate with a meningomyelocele is born?
83. Perform nasogastric suctioning.
84. Place baby in the prone position.
85. Administer oxygen via face mask.
86. Swaddle the baby in warm blankets.

Answer 82

2. The baby should be lain prone to prevent
   injury to the sac.

TEST-TAKING TIP: The baby with
meningomyelocele is born with an opening
at the base of the spine through
which a sac protrudes. The sac contains
cerebral spinal fluid and nerve endings
from the spinal cord. It is essential that
the nurse not injure the sac; therefore,
the baby should be placed in a prone
position immediately after birth.

Question 83

83. A baby in the NICU, who is exhibiting signs of congestive heart failure from an atrioventricular
    canal defect, is receiving a diuretic. In the plan of care, the nurse should
    include that the desired outcome for the child will be which of the following?
84. Loss of body weight.
85. Drop in serum sodium level.
86. Rise in urine specific gravity.
87. Increase in blood pressure.

Answer 83

1. A diuretic will increase urinary output
   which in turn will lead to weight loss

TEST-TAKING TIP: The heart is pumping
inefficiently when a baby has congestive
heart failure. Because of this pathology,
the kidneys are poorly perfused leading
to fluid retention and weight gain. Diuretics
are administered to improve the
excretion of the fluid. When the urinary
output is increased, the weight will drop
and the urine will be less concentrated.

Question 84

84. The nurse caring for a neonate with congestive heart failure identifies which of the
    following nursing diagnoses as highest priority?
85. Fatigue.
86. Activity intolerance.
87. Sleep pattern disturbance.
88. Altered tissue perfusion.

Answer 84

4. Altered tissue perfusion is the priority
   diagnosis.
   TEST-TAKING TIP: Whenever the test
   taker is asked to identify the priority
   response, it is important to remember
   the hierarchy of needs. Respiratory issues
   almost always take precedence.
   Although the answer to this question
   does not refer to the respiratory system,
   it does relate to the oxygenation of the
   tissues. None of the other responses relates
   to critical physiological processes.

Question 85

85. The nurse administers Lanoxin (digoxin) to a baby in the NICU that has a cardiac
    defect. The baby vomits shortly after receiving the medication. Which of the following
    actions should the nurse perform next?
86. Give a repeat dose.
87. Notify the physician.
88. Assess the apical and brachial pulses concurrently.
89. Check the vomitus for streaks of blood.

Answer 85

2. The nurse should notify the physician
   that the baby has vomited the digoxin

TEST-TAKING TIP: Vomiting is a sign of
digoxin toxicity. This baby needs to have
a digoxin level drawn. Because the nurse
needs an order for the test, the nurse
must notify the doctor of the problem.

Question 86

86. A baby is born with a meningomyelocele at L2. In assessing the baby, which of the
    following would the nurse expect to see?
87. Sensory loss in all four extremities.
88. Tuft of hair over the lumbosacral region.
89. Flaccid paralysis of the legs.
90. Positive Moro reflex.

Answer 86

3. With a defect at L2, the nurse would
   expect to see paralysis of the legs.

TEST-TAKING TIP: If the test taker remembers
that a sac with cerebral spinal
fluid and nerves is seen at the base of the
spine in a baby with myelomeningocele
and that L2 innervates the motor nerves
of the legs, the answer becomes obvious.
This is an example of the importance of carefully studying normal anatomy and
physiology and the pathophysiology of
important diseases

Question 87

87. When examining a nenonate in the well-baby nursery, the nurse notes that the sclerae
    of both of the baby’s eyes is visible above the iris of the eyes. Which of the following
    assessments is highest priority for the nurse to make next?
88. Babinski and tonic neck reflexes.
89. Evaluation of bilateral eye coordination.
90. Blood type and Coombs’ test results.
91. Circumferences of the head and chest

Answer 87

4. The baby should be assessed for signs
   of hydrocephalus, especially a disparity
   between the circumferences of the
   neonatal head and the neonatal chest.
   TEST-TAKING TIP: Setting sun sign—
   when the sclera of the eye is visible
   above the iris of the eye—is one sign of
   hydrocephalus. An additional indication
   of hydrocephalus would be if the head
   circumference of the baby were found to
   be greater than 2 cm larger than the
   baby’s chest circumference.

Question 88

88. A baby is born with a suspected coarctation of the aorta. Which of the following assessments
    should be done by the nurse?
89. Check blood pressures in all four limbs.
90. Palpate the anterior fontanel for bulging.
91. Assess hematocrit and hemoglobin values.
92. Monitor for harlequin color changes.

Answer 88

1. The blood pressures in all four quadrants
   should be assessed

TEST-TAKING TIP: The pathophysiology
of coarctation of the aorta provides the
rationale for the assessment of the blood
pressures. Since the narrowing of the
aorta is usually distal to the ascending
aorta, blood is able to pass unimpeded
into the upper body but is unable to pass
through the descending aorta toward the
lower body. The blood pressures of the
upper body, therefore, are much higher
than the blood pressures in the lower
extremities.

Question 89

89. The nurse is developing a teaching plan for parents of an infant with a tetralogy of
    Fallot. Which of the following positions should parents be taught to place the infant
    during a “blue,” or “tet,” spell?
90. Supine.
91. Prone.
92. Knee-chest.
93. Semi-Fowler’s

Answer 89

3. Parents should place an infant during a
   “tet” spell into the knee-chest position.

TEST-TAKING TIP: The four defects that
are present in tetralogy of Fallot—
ventricular septal defect, overriding
aorta, pulmonary stenosis, and hypertrophied
right ventricle—create a circulatory
system in which much of the blood
bypasses the lungs. As a result, a baby
with tetralogy is predisposed to cyanotic,
or “tet,” spells. When a baby is placed in
a squatting or knee-chest position, the
femoral arteries are constricted, decreasing
the amount of blood perfusing the
lower body. This leads to improved
perfusion to the upper body and the vital
organs. With this action, the cyanotic
spell will likely resolve.

Question 90

90. A child has been diagnosed with a small ventricular septal defect (VSD). Which of
    the following symptoms would the nurse expect to see?
91. Cyanosis and clubbing of the fingers.
92. Respiratory distress and extreme fatigue.
93. Systolic murmur with no other obvious symptoms.
94. Feeding difficulties with marked polycythemia.

Answer 90

3. This response is correct

TEST-TAKING TIP: The VSD—an opening
between the ventricles of the heart—is
the most common acyanotic heart defect
seen. The defect leads to a left-to-right
shunt since the left side of the heart is
more powerful than the right side of the
heart, causing a murmur. Small VSDs
rarely result in severe symptoms and, in
fact, often close over time without any
treatment.

Question 91

91. A newborn in the NICU has just had a ventriculoperitoneal shunt inserted. Which
    of the following signs indicates that the shunt is functioning properly?
92. Decrease of the baby’s head circumference.
93. Absence of cardiac arrhythmias.
94. Rise of the baby’s blood pressure.
95. Appearance of setting sun sign.

Answer 91

1. Ventriculoperitoneal (VP) shunts
   are inserted for the treatment of
   hydrocephalus. A positive finding,
   therefore, would be decreasing head
   circumferences.

TEST-TAKING TIP: One of the first signs
of hydrocephalus in the neonate is increasing
head circumferences because,
since the fetal head is unfused, excess
fluid in the brain forces the skull to expand. Once the diagnosis of
hydrocephalus has been made, a ventriculoperitoneal
(VP) shunt is usually
inserted. The shunt is designed to remove
excess cerebral spinal fluid from
the ventricles of the brain. With the reduction
in fluid, the size of the baby’s
head decreases.

Question 92

92. A neonate has just been born with a meningomyelocele. Which of the following
    nursing diagnoses should the nurse identify as related to this medical diagnosis?
93. Deficient fluid volume.
94. High risk for infection.
95. Ineffective breathing pattern.
96. Imbalanced nutrition: less than body requirements.

Answer 92

2. If the fragile sac is injured, the baby is
   very high risk for infection.

TEST-TAKING TIP: Babies with
meningomyelocele, a form of spina bifida,
are at very high risk for infection in
the central nervous system until the defect
is corrected. In addition, the vast
majority of babies with myelomeningocele
also have hydrocephalus for which
they will receive a VP shunt. Plus, the
most common problem associated with
VP shunts is infection. Nurses, therefore,
must care for these affected babies using
strict aseptic technique.

Question 93

93. The neonatalogist assesses a newborn for Hirschsprung’s disease after the baby exhibited
    which of the following signs/symptoms?
94. Passed meconium at 50 hours of age.
95. Apical heart rate of 200 beats per minute.
96. Maculopapular rash.
97. Asymmetrical leg folds.

Answer 93

1. Babies who have delayed meconium
   excretion may have Hirshsprung’s
   disease.

TEST-TAKING TIP: Hirshsprung’s disease
is defined as a congenital lack of
parasympathetic innervation to the distal
colon. Peristalsis, therefore, ceases at the
end of the intestine. Because of the absence
of peristalsis, the passage of meconium
is delayed

Question 94

94. The nurse assessed four newborns admitted to the neonatal nursery and called the
    neonatalogist for a consult on the baby who exhibited which of the following?
95. Excessive amounts of frothy saliva from the mouth.
96. Blood-tinged discharge from the vaginal canal.
97. Secretion of a milk-like substance from both breasts.
98. Heart rate that sped during inhalation and slowed with exhalation

Answer 94

1. Excessive amounts of frothy saliva
   may indicate that the child has
   esophageal atresia.

TEST-TAKING TIP: If the test taker is familiar
with the characteristics of the normal
neonate, the answer to this question
is obvious. A baby whose esophagus ends
in a blind pouch is unable to swallow his
or her saliva. Instead, the mucus bubbles
and drools from the mouth. Healthy babies,
on the other hand, swallow without
difficulty.

Question 95

95. The nurse is caring for a baby diagnosed with developmental dysplasia of the hip
    (DDH). Which of the following therapeutic interventions should the nurse expect
    to perform?
96. Place the baby’s legs in abduction.
97. External rotation of the baby’s hips.
98. Assist with bilateral leg casting.
99. Monitor pedal pulses bilaterally

Answer 95

1. To treat developmental dysplasia of
   the hip, babies’ legs are maintained in
   a state of abduction.

TEST-TAKING TIP: Since the pathology of
DDH is related to the laxity of the hip
joint, the rationale for the therapy is to
maintain physiological positioning of the
hip joint until the ligaments strengthen
and mature. Keeping the legs in a state
of abduction, the hip joint is maintained
with the trochanter centered in the
acetabulum.

Question 96

96. A baby has been diagnosed with developmental dysplasia of the hip. Which of the
    following findings would the nurse expect to see?
97. Pronounced hip abduction.
98. Swelling at the site.
99. Asymmetrical leg folds.
100. Weak femoral pulses.

Answer 96

3. The leg folds of the baby, both anteriorally
   and posteriorly, are frequently
   asymmetrical.

TEST-TAKING TIP: Because of the subluxation
of the hip, the gluteal and thigh
folds of the baby usually appear asymmetrical.
In addition to this finding, the
nurse would expect to see reduced abduction
of the hip and/or asymmetrical
knee heights when the legs are flexed.

Question 97

97. The nurse suspects that a newborn in the nursery has a clubbed right foot because
    the foot is plantar flexed and because the nurse also notices which of the following?
98. Inability to move the foot into proper alignment.
99. Notes positive Ortolani sign on the right.
100. Notes shortened right metatarsal arch.
101. Elicits positive Babinski reflex on the right

Answer 97

1. During the neonatal physical assessment,
   the nurse is unable to move a
   club foot into proper alignment

TEST-TAKING TIP: The most common
form of clubfoot is talipes equinovarus,
when the baby’s foot is in a state of inversion
and plantar flexion. It is important
for the nurse to distinguish between
positional clubfoot that occurs from the
baby’s position in utero and resolves
spontaneously, and pathology that requires
orthopedic therapy.

Question 98

98. The parents of a baby born with bilateral talipes equinovarus ask the nurse what
    medical care the baby will likely need. Which of the following should the nurse tell
    the parents?
99. Need a series of leg casts until the correction is accomplished.
100. Have a Harrington rod inserted when the child is about three years old.
101. Have a Pavlik harness fitted before discharge from the nursery.
102. Need to wear braces on both legs until the child begins to walk.

Answer 98

1. The initial treatment plan for clubfoot
   usually includes a series of casts that
   slowly move the foot into proper
   alignment.

TEST-TAKING TIP: This is an example of a
question that may include a term that the
test taker is unfamiliar with. If the test
taker slowly breaks down the words into
their component parts, the meaning
of the term will become clear. The word
“bilateral,” of course, means that “both
sides” of the body are affected. The word
“talipes” is a word that contains two
roots: talis, meaning “ankle” and pes,
meaning “foot.” The word, therefore,
refers to a deformity of the foot and
ankle—clubfoot. The term “equinovarus”
specifically defines the type of clubfoot
but, since the therapy is the same no
matter which type of clubfoot the child
suffers from, further analysis is not necessary
to answer this question. (Talipes
equinovarus clubfoot refers to a foot that
is plantar flexed and turned inward.)

Question 99

99. The nurse caring for an infant with a congenital cardiac defect is monitoring the
    child for which of the following early signs of congestive heart failure?
100. Hypertension, cyanosis, bradycardia.
101. Irritability, hypotension, palpitations.
102. Tachypnea, tachycardia, diaphoresis.
103. Angina, oliguria, dysrhythmias.

Answer 99

3. No matter whether a baby or an adult
   is developing CHF, the early signs
   that the nurse would note are tachypnea,
   tachycardia, and diaphoresis.

TEST-TAKING TIP: The term that is most
descriptive in the phrase congestive heart
failure is the word failure. If the test taker remembers that, because of poor
functioning, the heart is failing to oxygenate
the body effectively, the test taker
can remember the symptoms of the
disease. When the body is being starved
of oxygen, the body compensates by
increasing respirations to take in more
oxygen and the pulse rate speeds up
to move the oxygenated blood more
quickly through the body. Sweating is
also a component of the early stages of
the disease.

Question 100

100. The nurse assessed four newborns in the neonatal nursery. The nurse called the
     neonatalogist for a cardiology consult on the baby who exhibited which of the following
     signs/symptoms?
101. Setting sun sign.
102. Anasarca.
103. Flaccid extremities.
104. Polydactyly

Answer 100

2. Anasarca refers to overall, systemic
   edema. It is seen is severe cardiovascular
   disease. A cardiac consult would
   be appropriate for this baby as would,
   perhaps, a renal consult.

TEST-TAKING TIP: Although each of the
answer options is abnormal, there is only
one option that describes a symptom of a
cardiac disease. The test taker must carefully
discern what is being asked in each
question in order to choose the one answer
that relates specifically to the stem.

Question 101

101. A preterm infant has a patent ductus arteriosus (PDA). Which of the following explanations
     should the nurse give to the parents about the condition?
102. Hole has developed between the left and right ventricles.
103. Hypoxemia occurs as a result of the poor systemic circulation.
104. Oxygenated blood is reentering the pulmonary system.
105. Blood is shunting from the right side of the heart to the left.

Answer 101

3. There is a left to right shunt of blood
   with a patent ductus arteriosus (PDA)
   resulting in oxygenated blood reentering
   the pulmonary system.

TEST-TAKING TIP: The ductus arteriosus is
a fetal circulatory duct that connects the
pulmonary artery with the aorta. In utero,
the blood is being oxygenated through the
placenta precluding the need for the blood
to enter the lungs. In extrauterine life,
however, the duct should close in order to
create a one-way, intact system. When a ductus arteriosus stays open, a left to right
shunt develops (because the left side of
the heart is stronger than the right side
of the heart) forcing the blood to reenter
the lungs.

Question 102

102. A nurse hears a heart murmur on a full-term neonate in the well baby nursery. The
     baby’s color is pink while at rest and while feeding. The baby most likely has which
     of the following cardiac defects?
103. Transposition of the great vessels.
104. Tetralogy of Fallot.
105. Pulmonic stenosis.
106. Patent ductus arteriosus.

Answer 102

4. Patent ductus arteriosus (PDA) is a
   very common cardiac defect in
   preterm babies. It is an acyanotic defect
   with a left to right shunt. Already
   oxygenated blood reenters the pulmonary
   system.
   TEST-TAKING TIP: The names of cardiac
   defects are very descriptive. Once the
   test taker remembers the pathophysiology
   of each of the defects, it becomes
   clear how the blood flow is affected. Of
   the choices in this question, the only defect
   that is an acyanotic defect, i.e., a defect
   that allows blood to enter the lungs
   to be oxygenated, is the PDA

Question 103

103. Four babies are born with distinctive skin markings. Identify which marking
     matches its description:
104. Café au lait spot A. Raised, blood vessel-filled tumor.
105. Hemangioma B. Flat, sharply demarcated red-to-purple lesion.
106. Mongolian spots C. Multiple grayish blue hyperpigmented skin areas.
107. Port wine stain D. Pale tan- to coffee-colored marking.

Answer 103

The term in column 1 is matched to the
description in column 2.
1. Café au lait spot matches with D.
A café au lait spot is a pale tan to coffee-
colored skin marking.
2. Hemangioma matches with A.
A hemangioma is a raised blood
vessel–filled lesion.
3. Mongolian spot matches with C.
Mongolian spots are multiple grayish
blue hyperpigmented skin areas.
4. Port wine stain matches with B.
A port wine stain is a flat, sharply demarcated
red-to-purple lesion.
TEST-TAKING TIP: This is simply a matching
question. The test taker is asked to
match the lesion that is seen in neonates
with the description of the lesion. In the
NCLEX-RN, this would be a drag and
drop type of question. The test taker will
be asked to drag the corresponding definition
and drop it next to the name of
the lesion.

Question 104

104. A baby, admitted to the nursery, was diagnosed with galactosemia from an amniocentesis.
     Which of the following actions must the nurse take?
105. Feed the baby a specialty formula.
106. Monitor the baby for central cyanosis.
107. Do hemoccult testing on every stool.
108. Monitor baby for signs of abdominal pain.

Answer 104

1. Galactosemia is one of the few diseases
   that is a contraindication for the
   intake of breast milk or any milkbased
   formula

TEST-TAKING TIP: There are many genetic
metabolic diseases that may affect
the neonate. Galactosemia, an autosomal
recessive disease, is characterized by an
inability to digest galactose, a by-product
of lactose digestion. Since breast milk
and milk-based formulas are very high in
lactose, affected babies must be switched
to a soy-based formula.

Question 105

105. On admission to the nursery, a baby’s head and chest circumferences are 39 cm and
     32 cm, respectively. Which of the following actions should the nurse take next?
106. Assess the anterior fontanel.
107. Measure the abdominal girth.
108. Check the apical pulse rate.
109. Monitor the respiratory effort.

Answer 105

1. Because the head circumference is
   significantly larger than the chest circumference,
   the nurse should assess
   for another sign of hydrocephalus. A
   markedly enlarged or bulging fontanel
   is one of those signs.

TEST-TAKING TIP: The test taker must
remember that the head circumference
should be approximately 2 cm larger
than the chest circumference at birth.
When the head circumference is
markedly larger than expected, there is a
possibility of hydrocephalus. The nurse
should assess for other signs of the problem
like enlarged fontanel size, setting
sun sign, and bulging fontanels.

Question 106

106. A neonate is found to have choanal atresia on admission to the nursery. Which of
     the following physiological actions will be hampered by this diagnosis?
107. Feeding.
108. Digestion.
109. Immune response.
110. Glomerular filtration.

Answer 106

1. Choanal atresia will impact the baby’s
   ability to feed.

TEST-TAKING TIP: Choanal atresia, a congenital
narrowing of the nasal passages,
seriously affects babies’ ability to feed.
Babies are obligate nose breathers to enable them to suck-swallow-breathe in
a rhythmic manner during feeding. If
their nares are blocked, they are unable
to breathe through their noses and,
therefore, must stop feeding in order to
breathe.

Question 107

107. A baby is born to a mother who was diagnosed with oligohydramnios during her
     pregnancy. The nurse notifies the neonatalogist to order tests to assess the functioning
     of which of the following systems?
108. Gastrointestinal.
109. Hepatic.
110. Endocrine.
111. Renal

Answer 107

4. Some defects of the renal system can
   lead to oligohydramnios.
   TEST-TAKING TIP: The test taker must
   remember that most of the amniotic
   fluid produced during a pregnancy is
   produced by the fetal kidneys and is fetal
   urine. If there is a defect in the renal system,
   there may be a resulting decrease in
   the amount of fetal urine produced.
   Oligohydramnios would then result.

Question 108

108. A baby is born with esophageal atresia and tracheoesophageal fistula. Which of the
     following complications of pregnancy would the nurse expect to note in the
     mother’s history?
109. Preeclampsia.
110. Idiopathic thrombocytopenia.
111. Polyhydramnios.
112. Severe iron deficiency anemia

Answer 108

3. Polyhydramnios is often seen in pregnancies
   complicated by a fetus with a
   digestive blockage

TEST-TAKING TIP: Babies swallow amniotic
fluid in utero. When there is a
blockage in the digestive system, they are
unable to swallow the fluid. The fluid
builds up in the uterus and polyhydramnios
is noted.

Question 109

109. A baby is born with a diaphragmatic hernia. Which of the following signs/symptoms
     would the nurse observe in the delivery room?
110. Projectile vomiting.
111. High-pitched crying.
112. Respiratory distress.
113. Fecal incontinence

Answer 109

3. The baby will develop respiratory distress
   very shortly after delivery.

TEST-TAKING TIP: Abdominal organs are
displaced into the thoracic cavity when a
baby is born with a diaphragmatic hernia.
Because of the defect, the respiratory
tree does not develop completely. The newly delivered baby, therefore, is unable
to breathe effectively.

Question 110

110. A woman, who has recently received Demerol (meperidine) 100 mg IM for labor
     pain, is about to deliver. Which of the following medications is highest priority
     for the nurse to prepare in case it must be administered to the baby following the
     delivery?
111. Oxytocin (Pitocin).
112. Xylocaine (Lidocaine).
113. Naloxone (Narcan).
114. Butorphanol (Stadol).

Answer 110

3. Narcan is an opiate antagonist. It may
   be administered to a depressed baby
   at delivery

TEST-TAKING TIP: It is important for the
nurse to anticipate the needs of his or
her clients. In this situation, since the
mother has recently received an opioid
analgesic, it is possible that the baby will
experience central nervous system depression.
In anticipation of this problem,
the nurse, then, should have the opioid
antagonist available for administration if
the neonatalogist should order it.

Question 111

111. A newborn in the well baby nursery is noted to have a chignon. The nurse concludes
     that the baby was born via which of the following methods?
112. Cesarean section.
113. High forceps delivery.
114. Low forceps delivery.
115. Vacuum extraction.

Answer 111

4. Babies born via vacuum extraction
   often do develop chignons.
   TEST-TAKING TIP: In common language, a
   chignon is a hairstyle that is characterized
   by a bun or knot of hair worn on the
   back of the head or nape of the neck. In
   obstetrics, a chignon is a round, bruised
   caput seen on the crown of the baby’s
   head. It results from the pressure exerted
   on the scalp during a vacuumassisted
   delivery.

Question 112

112. A baby born by vacuum extraction has been admitted to the well baby nursery. The
     nurse should assess this baby for which of the following?
113. Pedal abrasions.
114. Hypobilirubinemia.
115. Hyperglycemia.
116. Cephalhematoma.

Answer 112

4. Babies born via vacuum are at high
   risk for cephalhematoma.

TEST-TAKING TIP: Babies born either via
vacuum or via forceps are at high risk for
cephalhematoma, as well as subdural
hematoma. During mechanically assisted
births, there often is trauma to the
neonate’s head and scalp. A cephalhematoma
develops as a result of injury to
superficial blood vessels. The blood loss
accumulates in the subcutaneous space
above the periosteum. The test taker
should remember that babies born with
cephalhematomas are at high risk for hyperbilirubinemia.

Question 113

113. A macrosomic baby in the nursery is suspected of having a fractured clavicle from a
     traumatic delivery. Which of the following signs/symptoms would the nurse expect
     to see? Select all that apply.
114. Pain with movement.
115. Hard lump at the fracture site.
116. Malpositioning of the arm.
117. Asymmetrical Moro reflex.
118. Marked localized ecchymosis.

Answer 113

1, 2, 3, and 4 are correct.
1. The baby will complain of pain at
the site.
2. If not in the immediate period after
the injury, within a few days there will
be a palpable lump on the bone at the
site of the break.
3. Because of the break, the baby is
likely to position the arm in an atypical
posture.
4. Because of the injury to the bone, the
baby is unable to respond with symmetrical
arm movements.

TEST-TAKING TIP: Clavicle breaks are a
fairly common injury seen after a delivery.
They usually result from a disproportion
between the sizes of the maternal
pelvis and the fetal body. Because
shoulder dystocia is an obstetric emergency,
threatening the life of the baby,
obstetricians may purposefully break a
baby’s clavicle in order to enable the
baby to be birthed as rapidly as possible.

Question 114

114. Four babies in the well baby nursery were born with congenital defects. Which of
     the babies’ complications developed as a result of the delivery method?
115. Club foot.
116. Brachial palsy.
117. Gastroschisis.
118. Hydrocele.

Answer 114

2. Brachial palsy can result from either a
   traumatic vertex or breech delivery.

TEST-TAKING TIP: When babies are born
with unexpected findings, the nurse must
be familiar not only with the implications

of the anomalies but also with an understanding
of the etiology of the anomalies.
If the anomaly were a result of birth
trauma, the nurse must be able to clearly
and accurately communicate to the parents
the source of the birth injury without
communicating an opinion on any
potential blame for the problem.

Question 115

115. Monochorionic twins, whose gestation was complicated by twin-to-twin transfusion,
     are admitted to the neonatal intensive care unit. Which of the following characteristic
     findings would the nurse expect to see in the smaller twin?
116. Pallor.
117. Jaundice.
118. Opisthotonus.
119. Hydrocephalus

Answer 115

1. In twin-to-twin transfusion, the
   smaller twin has “donated” part of his
   or her blood supply to the larger twin.

TEST-TAKING TIP: Twin-to-twin transfusion
may occur in monochorionic twins
because they share the same placenta.
The blood from one twin, therefore, is
able to be “transfused” into the cardiovascular
system of the second twin. As a
result, because of decreased oxygenation
and nourishment, the donor develops intrauterine
growth restriction and becomes
anemic. Conversely, the recipient
grows much larger and becomes hyperemic.
Interestingly, the larger twin is the
twin at highest risk for injury because of
the potential for formation of thrombi
and/or hyperbilirubinemia.

Question 116

116. Monochorionic twins, whose gestation was complicated by twin-to-twin transfusion,
     are admitted to the neonatal intensive care unit. Which of the following characteristic
     findings would the nurse expect to see?
117. Recipient twin has petechial rash.
118. Recipient twin is 20% larger than the donor twin.
119. Donor twin has 30% higher hematocrit than recipient twin.
120. Donor twin is ruddy and plethoric.

Answer 116

2. The recipient is likely to be at least
   20% larger than the donor twin

TEST-TAKING TIP: The word plethora
refers to a red coloration. Because the
recipient twin receives a “transfusion”
from the donor, the recipient’s skin color
becomes dark pink, especially when crying.
The donor, on the other hand, is
pale and small.

Question 117

117. A nurse working with a 24-hour-old neonate in the well baby nursery has made the
     following nursing diagnosis: Risk for altered growth. Which of the following assessments
     would warrant this diagnosis?
118. The baby has lost 8% of weight since birth.
119. The baby has not urinated since birth.
120. The baby weighed 3000 grams at birth.
121. The baby exhibited signs of torticollis.

Answer 117

1. A baby who has lost 8% of his or her
   weight after only 24 hours of life is
   very high risk for altered growth.

TEST-TAKING TIP: The normal weight
loss for newborn babies is between 5%
and 10%. An 8% loss during the first 24
hours, therefore, places this baby at high
risk for altered growth. (The term “risk
for” is very important. It does not mean
that altered growth has already occurred,
but rather that there is a strong possibility
that altered growth will develop.) It is
also important for the test taker to remember
not to choose the option with
an unfamiliar term, such as torticollis,
simply because it is unfamiliar.

Question 118

118. A baby exhibits weak rooting and sucking reflexes. Which of the following nursing
     diagnoses would be appropriate?
119. Risk for deficient fluid volume.
120. Activity intolerance.
121. Risk for aspiration.
122. Feeding self-care deficit

Answer 118

1. When a baby roots and sucks poorly,
   the baby is unable to transfer milk effectively.
   Since milk intake is the
   baby’s source of fluid, the baby is high
   risk for fluid volume deficit

TEST-TAKING TIP: The obvious nursing
diagnosis related to poor rooting and
sucking is “Deficient nutrition: less than
body requirements.” The test taker,
however, is not given that choice. The
test taker, therefore, must determine, of
the 4 available options, which is the best.
Since dehydration is a consequence of altered
fluid intake, that answer is the best
response.

Question 119

119. A baby, born at 3199 grams, now weighs 2746 grams. The baby is being monitored
     for dehydration because of the following percent weight loss?
     __________%

Answer 119

14.16%
The formula for percentage of weight
loss is:
Original weight minus current weight divided
by original weight:
3199 2746 453
453/3199 0.1416 14.16%
TEST-TAKING TIP: Unless otherwise
noted, the test taker should carry the
math to the nearest hundredth place
when performing calculations for infants
and children. Because babies are very
small, a fraction of a milligram (mg),
kilogram (kg), and the like, can make a
significant difference.