chapter 23 and 24

Question 1

The nurse is teaching a group of students about the difference between a full term newborn and a preterm new born. The nurse determines that the teaching is effective when the student states that the preterm newborn has

A: Fewer visible blood vessels through the skin
B: More subcutaneous fat in the neck and abdomen
C: Well- developed muscles in the extremities
D: Greater surface area in proportion to weight

Answer 1

D: Greater surface area in proportion to weight

Question 2

When assessing a post-term newborn, which of the following would the nurse correlate with the gestational age variation?
A: moist, supple, plum skin appearance
B: abundant lanugo and vernix 
C: thin umbilical cord
D: absence of sole creases.

Answer 2

C: thin umbilical cord

Question 3

The parents of a preterm newborn being cared for in the NICU are coming to visit for the first time. The newborn is receiving mechanical ventilation and IV fluids and meds and is being monitored electronically by various devices. What action by the nurse would be most appropriate?
A: suggest that the parents stay for just a few minutes to reduce anxiety.
B: reassure them that their newborn is progressing well
C: encourage the parents to touch their preterm newborn
D: discuss the care they will be giving the newborn upon discharge

Answer 3

C: encourage the parents to touch their preterm newborn

Question 4

When performing newborn resuscitation which action would the nurse do first?
A: intubate with an appropriate sized endotracheal tube
B: give chest compressions at a rate of 80x per min
C: administer epinephrine iv
D: suction the mouth and then the nose

Answer 4

D: suction the mouth and then the nose

Question 5

The nurse frequently assess the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following?
A: inability to clear fluids
B: immaturity respiratory control center
C: deficiency of surfactant 
D: smaller respiratory passages

Answer 5

C: deficiency of sufractant

Question 6

The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with the gestational age?
A: strong brisk motor skills
B: difficulty in arousing to a quiet alert state
C: birth weight of 7lb 14oz
D: waisted appearance in extremities

Answer 6

B: difficulty in arousing to a quiet alert state

Question 7

A large gestational newborn has a blood glucose level of 30mg/dl and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do first?
A: administer IV glucose immediately
B: feed the newborn 2oz of formula
C: initiate blood by oxygen therapy
D: place the newborn under the radiant warmer

Answer 7

A: administer IV glucose immediately

Question 8

A group of pregnant women are discussing high risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk?
A: small for gestational age (SGA) newborns
B: large for gestational age (LGA) newborns
C: appropriate for gestational age (AGA) newborns
D: low birth weight newborns

Answer 8

C: appropriate for gestational age (AGA) newborns

Question 9

While caring for preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which of the following?
A: Retinopathy of prematurity 
B: Metabolic acidosis
C: infection
D: cold stress

Answer 9

A: Retinopathy of prematurity

Question 10

When planning the care for an SGA newborn, which action would the nurse determine as priority?
A: preventing hypoglycemia with early feedings
B: observing for respiratory distress syndrome
C: promoting bonding between the parents and newborn
D: monitor vital signs every 2 hours

Answer 10

A: Preventing hypoglycemia with early feedings

Question 11

A women gives birth to a newborn at 36 weeks gestation. She tells the nurse, I’, so glad that my baby isn’t preterm. Which response by the nurse would be most appropriate?
A: you are lucky to have given birth to a term newborn
B: you still need to monitor him closely for problems
C: how do you feel about delivering your baby at 36 weeks?
D: your baby is premature and needs monitoring in the NICU

Answer 11

D: you still need to monitor him closely for problems

Question 12

Which of the following would be most appropriate for the nurse to do when assisting patients who have been experienced the loss of their preterm newborn?
A: avoid using the term death or dying
B: provide opportunities for them to hold their newborn
C: refrain from initiating conversation with the parents
D: focus the parents on a more pleasant topic

Answer 12

B: provide opportunities for them to hold their newborn

Question 13

Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of a LGA newborn?
A: drug abuse
B: diabetes
C: preclampsia
D: infection

Answer 13

B: diabetes

Question 14

Which of the following would alert the nurse to suspect that a preterm newborn is in pain?
A: bradycardia
B: oxygen sat level 94%
C: decreased muscle tone
D: sudden high pitched cry

Answer 14

D: sudden high pitched cry

Question 15

When discussing newborns with birth weight variations to a group of nursing students, the instructor identifies which variation if the newborn weighs 5lb 2oz at any gestational age?
A: small for gestational age
B: low birth weight
C: very low birth weight
D: extremely low birth weight

Answer 15

B: low birth weight

Question 16

A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply).
A: waisted extremity appearance
B: increased amount of breast tissue 
C: sunken abdomen 
D: adequate muscle tone over buttocks 
E: narrow skull sutures.

Answer 16

A: waisted extremity appearance
C: sunken abdomen
E: narrow skull sutures

Question 17

The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks gestation. The nurse would classify this newborn as which of the following?
A: preterm
B: late preterm
C: full term
D: post term

Answer 17

B: late preterm

Question 18

A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborn risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborns risk? (Select all that apply)
A: surfactant deficiency
B: placental deprivation
C: immaturity of the respiratory control center
D: deceased amount of brown fat
E: depleted glycogen stores

Answer 18

A; surfactant deficiency

C: immaturity of the respiratory control center

Question 19

After determining that a newborn is in need of resuscitation, which of the following would the nurse do first?
A: dry the newborn thoroughly
B: suction the airway
C: administer ventilations
D: give volume explanders

Answer 19

A: dry the newborn thoroughly

Question 20

A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which of the following would the nurse be least likely to include in this plan?
A: stimulate the infant with frequent handling
B: keep the newborn in a warmed isolate
C: administer oxygen using oxygen hood
D: give gavage or continuous tube feeding

Answer 20

A; stimulate the infant with frequent handling

Question 21

A nurse suspects that a preterm newborn is having problems with thermal regulation. Which of the following would support the nurses suspicion. (Select all that apply)
A: Shallow, slow respirations
B: cyanotic hands and feet
C: irritability
D: hypertonicity 
E: feeble cry

Answer 21

A: shallow, slow respirations
B: Cyanotic hands and feet
E: feeble cry

Question 22

The nurse is assessing a preterm newborns fluid and hydration status. Which of the following would alert the nurse to possible overhydration?
A: decreased urine output
B: tachypnea
C: bulging fontanels 
D: elevated temperature

Answer 22

C: bulging fontanels

Question 23

The nurse is assessing a preterm newborn who is in the NICU for signs and symptoms of overstimulation. Which of the following would the nurse be least likely to assess?
A: increased respirations
B: flaying hands
C: periods of apnea
D: decreased heart rate

Answer 23

A: increased respirations

Question 24

A group of nursing students are reviewing the literature in preparation for a class presentation of newborn pain prevention and management. Which of the following would the student be most likely to find about this topic?
A: newborn pain is frequently recognized and treated
B: newborns rarely experience pain with procedures
C: pain is frequently mistaken for irritability or agitation
D: newborns may be less sensitive to pain than adults

Answer 24

C: pain is frequently mistaken for irritability or agitation

Question 25

A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development which of the following would the nurse include? (Select all that apply)
A: clustering care to promote rest
B: Positioning newborn in extension
C: using kangaroo care
D: loosely covering the newborn with blankets
E: Providing non-nutritive sucking

Answer 25

A: clustering care to promote rest
C: Using kangaroo care
E: providing non-nutritive sucking

Question 26

A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate?
A: I’ll be here to help you along the way
B: What has helped you to deal with this stressful situation in the past?
C: let me tell you about what you will see when you visit your baby
D: Forget about what happened in the past and focus on now.

Answer 26

D: forget about what happened in the past and focus on now.